Fall Prevalence and Associated Risk Factors in the Hospitalised Adult Population: A Crucial Step Towards Improved Hospital Care

Background Falls among the adult population are a major global health concern with severe repercussions for individuals and healthcare systems. The purpose of this study was to investigate the prevalence and associated risk factors of falls in hospitalized patients in order to improve hospital care for elderly adults. Materials and methods The research was conducted at two institutions of tertiary care in Abbottabad, Pakistan. After extensive screening and obtaining informed consent, a total of 210 participants aged 50 and older were enrolled in the study. Mental status, history of falls, ambulation/elimination status, vision, gait/balance, systolic blood pressure, medication use, and predisposing diseases were evaluated using the Long Term Care Fall Risk Assessment Form. Additionally, the Dynamic Gait Index was utilized to evaluate various aspects of gait. Results 58.6% of participants reported a history of falls in the previous year, according to the findings. BMI, imbalance, vertigo, and fear of falling were significantly associated with an increased risk of falls in older individuals. The Long-Term Care Fall Risk Assessment, the Montreal Cognitive Assessment (MoCA), the Dynamic Gait Index (DGI), and the Mini-BESTest scores revealed that patients with a history of falls had inferior functional and cognitive outcomes. Falls were more common among individuals with a robust BMI, especially men. Conclusions The study results highlight the multifactorial nature of falls in the adult population and the need for targeted interventions to address modifiable risk factors. To enhance hospital care for high-risk patients, proactive fall prevention strategies, including regular risk assessments and individualized interventions, should be implemented. This study provides important insights into the prevalence and causes of accidents among hospitalized patients, particularly in developing nations such as Pakistan. ​​​​​​.

In vitro analysis of PI3K pathway activation genes for exploring novel biomarkers and therapeutic targets in clear cell renal carcinoma

OBJECTIVES

The regulation of various cellular functions such as growth, proliferation, metabolism, and angiogenesis, is dependent on the PI3K pathway. Recent evidence has indicated that kidney renal clear cell carcinoma (KIRC) can be triggered by the deregulation of this pathway. The objective of this research was to investigate 25 genes associated with activation of the PI3K pathway in KIRC and control samples to identify four hub genes that might serve as novel molecular biomarkers and therapeutic targets for treating KIRC.

METHODS

Multi-omics in silico and in vitro analysis was employed to find hub genes related to the PI3K pathway that may be biomarkers and therapeutic targets for KIRC.

RESULTS

Using STRING software, a protein-protein interaction (PPI) network of 25 PI3K pathway-related genes was developed. Based on the degree scoring method, the top four hub genes were identified using Cytoscape's Cytohubba plug-in. TCGA datasets, KIRC (786-O and A-498), and normal (HK2) cells were used to validate the expression of hub genes. Additionally, further bioinformatic analyses were performed to investigate the mechanisms by which hub genes are involved in the development of KIRC. Out of a total of 25 PI3K pathway-related genes, we developed and validated a diagnostic and prognostic model based on the up-regulation of TP53 (tumor protein 53) and CCND1 (Cyclin D1) and the down-regulation of PTEN (Phosphatase and TENsin homolog deleted on chromosome 10), and GSK3B (Glycogen synthase kinase-3 beta) hub genes. The hub genes included in our model may be a novel therapeutic target for KIRC treatment. Additionally, associations between hub genes and infiltration of immune cells can enhance comprehension of immunotherapy for KIRC.

CONCLUSION

We have created a new diagnostic and prognostic model for KIRC patients that uses PI3K pathway-related hub genes (TP53, PTEN, CCND1, and GSK3B). Nevertheless, further experimental studies are required to ascertain the efficacy of our model.

An Unrecognized Cause of Elevated Procalcitonin Level

Diabetic Ketoacidosis (DKA) is a preventable yet serious complication of diabetes that is commonly associated with type 1 diabetes but can also occur in other forms of diabetes, including type 2. Infection is a primary cause of DKA and can lead to elevated levels of procalcitonin (PCT), which is a biomarker used to differentiate bacterial infections from non-infectious inflammation. However, some cases of DKA have shown increased PCT levels even in the absence of bacterial infection, and the underlying mechanism of this observation is not fully understood. To gain a better understanding of how non-infectious inflammation affects PCT levels, further research is needed. While PCT is a helpful biomarker, it should be interpreted in the context of the patient's overall clinical picture, including signs and symptoms of infection or inflammation and underlying medical conditions that may be contributing to their presentation. A systematic approach to evaluating and managing patients with DKA can minimize the risk of unnecessary antibiotic use and ensure optimal treatment. We present a 31-year-old male who was admitted to the ICU with DKA, and further investigations revealed elevated PCT levels. Despite conducting several studies and cultures, including blood and urine, no infections were detected. The patient was treated for DKA with hydration and insulin administration without the use of antibiotics, and his PCT levels subsequently decreased.

Ampreloxetine Versus Droxidopa in Neurogenic Orthostatic Hypotension: A Comparative Review

Neurogenic orthostatic hypotension (nOH) is a disabling problem of autonomic dysfunction in patients with Parkinson's disease, which is associated with poor quality of life and higher mortality rates. The purpose of this literature review was to explore and compare the efficacy and safety of droxidopa (an existing treatment) and ampreloxetine (a newer medication) in the treatment of nOH. We used a mixed-method literature review that addresses the epidemiology, pathophysiology, and pharmacological and non-pharmacological management of nOH in Parkinson's disease in a general way, with a more exploratory approach to droxidopa- and ampreloxetine-controlled trial studies. We included a total of 10 studies of randomized controlled trials with eight studies focused on droxidopa and two studies focused on ampreloxetine. These two drugs were analyzed and compared based on the collected individual study results. Treatment of nOH in Parkinson's disease patients with droxidopa or ampreloxetine showed clinically meaningful and statistically significant improvements relative to placebo on the components of the OHSA (Orthostatic Hypotension Symptom Assessment) composite score and OHDAS (Orthostatic Hypotension Daily Activity Scale composite scores) composite score. Droxidopa had an improved effect on daily activities, with an associated increase in standing systolic blood pressure (BP), but the long-term efficacy of droxidopa has not been documented. Standing systolic BP was maintained by ampreloxetine and worsened after the withdrawal phase. This highlights the importance of conducting further research which will help us to improve the therapeutic approach for patients with nOH and Parkinson's disease.

Virtual and Augmented Reality in Post-stroke Rehabilitation: A Narrative Review

Virtual reality (VR) and augmented reality (AR) are noble adjunctive technologies currently being studied for the neuro-rehabilitation of post-stroke patients, potentially enhancing conventional therapy. We explored the literature to find if VR/AR improves neuroplasticity in stroke rehabilitation for a better quality of life. This modality can lay the foundation for telerehabilitation services in remote areas. We analyzed four databases, namely Cochrane Library, PubMed, Google Scholar, and Science Direct, by searching the following keywords: ("Stroke Rehabilitation" [Majr]) AND ("Augmented Reality" [Majr]), Virtual Augmented Reality in Stroke Rehabilitation. All the available open articles were reviewed and outlined. The studies conclude that VR/AR can help in early rehabilitation and yield better results in post-stroke patients in adjunct to conventional therapy. However, due to the limited research on this subject, we cannot conclude that this information is absolute. Moreover, VR/AR was seldom customized according to the needs of stroke survivors, which would have given us the full extent of its application. Around the world, stroke survivors are being studied to verify the accessibility and practicality of these innovative technologies. Observations conclude that further exploration of the extent of the implementations and efficacy of VR and AR, combined with conventional rehabilitation, is fundamental.

Effect of Thymectomy on Outcomes of Myasthenia Gravis Patients: A Case-Control Study at a Tertiary Care Hospital

Background and objective Myasthenia gravis (MG) is an acquired autoimmune disease mediated by antibodies affecting the neuro-muscular junction on the postsynaptic membrane, resulting in neuromuscular transmission obstruction and, consequently, muscle weakening. It is believed that the thymus gland plays a critical role in the production of these antibodies. Screening patients for thymoma and surgical excision of the thymus gland is a crucial part of the treatment. To compare the odds of good outcomes in Myasthenia Gravis patients with or without thymectomy. Material and methods A retrospective case-control study was conducted at the Department of Medicine and Neurology, Ayub Teaching Hospital, Abbottabad, Pakistan, from October 2020 to September 2021. A purposive sampling technique was employed. Thirty-two MG patients with thymectomy and 64 MG patients without thymectomy were selected for investigation. Controls and cases were matched on the basis of sex and age (1:2). A positive EMG study, acetylcholine receptor antibodies, and a pyridostigmine test were used to make the diagnosis of MG. Patients were called to the outpatient department for assessment of treatment outcomes. Primary outcome evaluation was done using the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS) tool at the last follow-up after one year. Results A sample of 96 patients was evaluated, of which 63 (65%) were females and 33 (34%) were males. The mean age for Group 1 (cases) was 35 years ±8.9 and for Group 2 (controls) was 37± 11.1. Age and Osserman stages were shown to be the two most crucial prognostic factors in our study. However, there are several other factors in our study that are linked to a poor response, such as a greater BMI, dysphagia, thymoma, older age, and a longer duration of disease. Conclusions Our findings indicate that none of the analysed groups had significantly worse outcomes as a result of the current clinical practice of thymectomy patient selection.

Prevalence of Non-adherence to Antiepileptic Drugs in Patients With Epilepsy Presenting to Emergency With Fits

Background

Epilepsy is considered when a patient has at least two unprovoked seizures that occurred more than a day apart. Seizure control depends upon several factors, including adequate treatment and its dosage, patients' daily activities, and adherence to antiepileptic medications. The study aimed to assess the rate of adherence to antiepileptic drugs (AED) in patients with epilepsy.

Methodology

A cross-sectional study was conducted at the Department of Neurology, Ayub Teaching Hospital, Abbottabad, Pakistan, between November 2019 and October 2020. All participants who presented to the emergency room with complaints of seizures, had a known diagnosis of epilepsy, aged above 18 years, with no cognitive dysfunction or severe psychiatric disorders were included in the study. Patients with other neurological disabilities (brain tumors, cerebral palsy, neuromuscular disorder) or severe psychotic episodes and those with undiagnosed cases of epilepsy were excluded from the study. A predefined proforma was used to assess the level of adherence and non-adherence among patients and they were then divided into their respective groups.

Results

A total of 150 participants were included in the study. Of patients, 110 were adherent to AED treatment while 40 were non-compliant. It was found that the most frequent cause of non-adherence was that patients forgot their pills (72.5%). Of patients, 7.5% stopped taking the medication when symptoms were relieved. About 12.5% reported affordability to be the reason for non-adherence. The rate of poor seizure control was significantly higher in non-adherent patients as compared to adherent patients (77.5% vs. 49.1%, p = 0.001). It was also found that a greater number of non-adherent patients experienced convulsive seizures in the past year as compared to those who were adherent to their medications (p = 0.006).

Conclusion

To enhance treatment adherence, the practice of prescribing more simpler treatment regimens among physicians can result in better seizure control, as the complexity of the regimen is found to be a major challenge for adjustment of AED regimens in this regard.

Organizing Pneumonia Following Recombinant Zoster Vaccination: A Rare Adverse Reaction

We describe a case of a severe but rare adverse reaction to recombinant varicella-zoster virus (VZV) vaccination: a 67-year-old female admitted with gradual onset of shortness of breath, hypoxia, and fever following VZV vaccination. The clinical picture and radiologic presentation mimicked COVID-19 pneumonia. However, repeated testing for COVID-19 by PCR was negative. A diagnosis of organizing pneumonia was made on transbronchial biopsies. The patient responded well to steroids and improved both clinically and radiographically. This case illustrates not only a rare and unreported complication from vaccination but also raises the awareness during the COVID-19 pandemic that other etiologies can mimic COVID-19 pneumonia. Physicians should be aware of other diagnoses that can mimic COVID-19 infection.

693 Are Virtual Clinics the New ‘Normal’? – A Single-Institution Comparative Analysis of Outcomes and Cost-Effectiveness of Virtual and Face-To-Face Clinics

Introduction

The coronavirus (COVID-19) pandemic has had a profound impact on clinicians, hospital resources and patients. Urology Virtual clinics (VCs) were initiated at our institution to ensure continued provision of service during the pandemic. The study aim was to analyse outcomes and cost-effectiveness of VCs compared to pre-COVID-19 face-to face (F2F) clinics.

Method

We retrospectively analysed the VCs from 18^th March 2020 to 1st July 2020 and compared them to F2F clinics in the same period in 2019. Clinical outcomes were compared, and potential financial savings were estimated to see if VCs can be incorporated into future practice.

Results

1317 patients were reviewed in 2020 as compared to 1941 in 2019. We noted similar rates of discharges [25.4% (2020) v/s 24.1% (2019)], follow-ups (48.7% (2020) v/s 48.4% (2019)] and patients who did not attend/answer (6.8% (2020) v/s 6.6% (2019)]. Potentially, over £100,000 can be saved by changing 50% appointments to VCs.

Conclusions

Our data shows that VCs are non-inferior to F2F clinics and have allowed continued effective service provision during the COVID-19 pandemic. There is potential to incorporate VCs into future practice without compromising on efficacy. Further data collection and analysis is ongoing at our institution on a larger scale.

Iron Deficiency Anemia as a Rare Risk Factor for Recurrent Pulmonary Embolism and Deep Vein Thrombosis

Iron deficiency is a well-known cause of anemia. However, it is an under-recognized cause of venous thromboembolism (VTE). Iron deficiency predisposes to VTE mainly by inducing thrombocytosis, which can lead to a hypercoagulable state. Identifying iron deficiency as a possible cause of thromboembolic phenomena has clinical significance since this is a potentially avoidable risk factor. This case report serves as a reminder that iron deficiency is an important risk factor for VTE that should be considered in the evaluation of patients. This is particularly true in patients like ours who have recurrent venous thromboembolic disease.

Can charcoal improve outcomes in COVID-19 infections?

COVID-19 infection causes considerable morbidity and mortality, especially to those who are aged, have impaired renal function and are obese. We propose to examine the potential utility of oral activated charcoal with the hypothesis that such treatment would lower absorption of microbiome derived toxins and ameliorate systemic oxidant stress and inflammation.

Vitamin B12 Deficiency: A Rare Cause of Excessive Daytime Sleepiness

None

Excessive daytime sleepiness (EDS) is one of the leading reasons that patients present to sleep clinics. Approximately 10% to 14% of the adults report that excessive sleepiness interferes with their daily lives. Common causes of EDS include obstructive sleep apnea, sleep deprivation, circadian rhythm disorders, medication effects, psychiatric conditions especially depression, and primary hypersomnia such as narcolepsy or central idiopathic hypersomnia. Vitamin B12 deficiency is a rare cause of EDS. We are presenting a case of severe vitamin B12 deficiency as an unusual and rare cause of hypersomnia.

CITATION

Khawaja I, Yingling K, Bukamur H, Abusnina W. Vitamin B12 deficiency: a rare cause of excessive daytime sleepiness. J Clin Sleep Med. 2019;15(9):1365-1367.

Applied Uses of Extracorporeal Membrane Oxygenation Therapy

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

Global Initiative for Chronic Obstructive Lung Disease: The Changes Made

Chronic obstructive pulmonary disease or COPD is one of the conditions that physicians frequently see in both the hospital and outpatient setting. In order to improve diagnostic and treatment outcomes, the Global Strategy for the Diagnosis, Management and Prevention of COPD, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was created in 2001. Every year, a new report is generated based on an analysis of published studies which attempts to improve the way physicians handle COPD. GOLD reports are considered to be essential evidence-based reference tools for the implementation of effective management plans, and represent the current best practices for the care of patients with COPD. The 2017 report greatly revised the guidelines and added a few components that changed the system of COPD diagnosis and treatment. This review article addresses those changes, explains the current guidelines, and draws attention to areas that still require improvement.

The Association of Obstructive Sleep Apnea and Hypertension

Obstructive sleep apnea (OSA) is a condition characterized by recurrent episodes of partial or complete upper airway obstruction during sleep. Hypertension (HTN) is defined by the presence of a chronic elevation of systemic arterial pressure above a certain threshold value (≥140 mm Hg systolic or ≥90 mm Hg diastolic). On the surface, OSA and HTN appear very different from one another. Despite this, they share several common risk factors including obesity, male gender, and advancing age. In 2003, the Seventh Joint National Committee (JNC VII) recognized OSA as a secondary cause of HTN. As physicians, our goal is to understand the OSA-HTN association better through academic study regarding its epidemiology, its pathophysiology, and its treatment. 

Central Line Catheters and Associated Complications: A Review

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Cardiac Ultrasound in the Intensive Care Unit: A Review

Transthoracic echocardiography (TTE) is an incredibly valuable tool in today’s emergency rooms and intensive care units (ICUs). It has the ability to provide a complete evaluation of the structure and function of the heart, the valves, stroke volume, ejection fraction, and much more. Previous academic studies have also determined that point-of-care TTE done by non-cardiologist physicians can also provide higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. The aim of this review article is to examine further these point-of-care evaluations, what they entail, their benefits, and where further research would better our own understanding.

Diagnosing Allergic Bronchopulmonary Aspergillosis: A Review

Dr. Hinson and his colleagues first described allergic bronchopulmonary aspergillosis (ABPA) in 1952. Later in 1977, Rosenberg proposed a diagnostic criteria for ABPA that even today remains widely acknowledged. Despite these steps taken, there still isn't a standardized diagnostic criteria set for ABPA although many have been proposed by various physicians over the years. ABPA is a condition caused by hypersensitivity to Aspergillus fumigatus antigens. It is seen most commonly in patients with either asthma or cystic fibrosis. In susceptible hosts, repeated inhalation of Aspergillus spores can cause an allergic response. Although a standardized diagnostic criteria is re­quired, there is no single test that establishes the diagnosis oth­er than a demonstration of central bronchiectasis (CB) with nor­mal tapering bronchi, a feature that is still considered pathognomonic of ABPA. Because of lack of standardized diagnostic criteria and screening, even today ABPA is under diagnosed and often times treatment for it is delayed. This can lead to complications in patients like pulmonary fibrosis, bronchiectasis with chronic sputum production, and increasingly severe persistent asthma with loss of lung function. For this alone, it becomes imperative that the diagnostic criteria guidelines need to be reviewed and standardized preferably with the help of larger research studies. In the following review article, we address the epidemiology, pathophysiology, and the current cumulative view regarding the diagnosis of ABPA.

Treating Allergic Bronchopulmonary Aspergillosis: A Review

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that results from a hypersensitivity reaction to the fungi Aspergillus fumigatus (Af). It presents with pulmonary infiltrates and bronchiectasis. Past research studies on ABPA have led to the conclusion that it is both underdiagnosed and much more prevalent than previously assumed. The underdiagnosing of ABPA is due to a lack of consensus regarding diagnosis and treatment. Complications that result from delay in treatment for ABPA are pulmonary fibrosis, bronchiectasis with chronic sputum production, and severe persistent asthma with loss of lung function. Because of this, it becomes imperative that ABPA treatment guidelines are reviewed and more thoroughly evaluated regarding their efficacy. The following article addresses the epidemiology, the pathophysiology, and the treatment of ABPA. The treatment is studied in detail regarding the types of medications used and their proven clinical impact on patients according to past research studies. The aim of this article is to address the current need for larger clinical trials in order to learn more and establish more formal treatment protocols for ABPA.

The Association Between Obstructive Sleep Apnea and Arrhythmias

Obstructive sleep apnea (OSA) is caused by intermittent episodes of partial or complete closure of the upper airway, leading to apneic episodes while the patient is asleep. Atrial fibrillation (AF) leads to more than 750,000 hospitalizations per year and accounts for an estimated 130,000 deaths each year. The death rate from AF as the primary or a contributing cause of death has been rising for more than two decades. The material reviewed in this paper focuses on the association between OSA and arrhythmias. It goes into the details of the epidemiology, pathophysiology, and types of arrhythmias and the therapies seen in association with OSA.

Parasomnias: A Comprehensive Review

Parasomnias are a group of sleep disorders characterized by abnormal, unpleasant motor verbal or behavioral events that occur during sleep or wake to sleep transitions. Parasomnias can occur during non-rapid eye movement (NREM) and rapid eye movement (REM) stages of sleep and are more commonly seen in children than the adult population. Parasomnias can be distressful for the patient and their bed partners and most of the time, these complaints are brought up by their bed partners because of the possible disruption in their quality of sleep. As clinicians, it is crucial to understand the characteristics of various parasomnias and address them with detailed sleep history and essential diagnostic approach for proper evaluation.

The review aims to highlight the epidemiology, pathophysiology and clinical features of various types of parasomnias along with the appropriate diagnostic and pharmacological approach.

Basic Insights of Lung Ultrasonography in Critical Care Setting

Lung ultrasonography has a tailored diagnostic and therapeutic approach in the critical care setting. Lung ultrasonography in critically ill (LUCI) is a helpful modality for the early detection and assessment of various lung pathologies and guides the management protocol for the same. The aim of this review was to highlight the basics of an ultrasound machine, the fundamentals of a lung ultrasound and the importance of lung artifacts in detecting the anatomy and pathology of the lung disease. In addition, we have also discussed regarding the effective approach to lung ultrasonography through the two protocols: the Bedside Lung Ultrasound in Emergency (BLUE) protocol and the Fluid Administration Limited by Lung Sonography (FALLS) protocol.

The Overlap Syndrome

The overlap syndrome (OS) was first coined by David C. Flenley in 1985 to describe the coexistence of obstructive sleep apnea (OSA) in patients with chronic obstructive pulmonary disease (COPD). Patients with OS experience more profound nocturnal oxygen desaturation (NOD) than patients with OSA or COPD alone. This underlying hypoxia in OS increases the risk of cardiovascular disease including atrial fibrillation, right heart failure, and pulmonary hypertension, thereby increasing the mortality associated with the disease. Keeping in mind the risk of mortality, it is crucial for clinicians to clinically evaluate the patients with OSA or COPD for the occurrence of OS and provide effective treatment options for the same. This review aims to highlight the pathophysiology and the risks associated with the OS along with early detection and appropriate management protocols to reduce the mortality associated with it.

Correlates of daytime sleepiness in patients with posttraumatic stress disorder and sleep disturbance

OBJECTIVE

To assess the correlates of daytime sleepiness in patients with a lifetime diagnosis of posttraumatic stress disorder (PTSD) and ongoing sleep disturbance not due to sleep apnea or other diagnosed sleep disorders.

METHOD

The sample consisted of 26 veterans receiving mental health care at the Minneapolis VA Medical Center, Minneapolis, Minnesota. The Epworth Sleepiness Scale was the primary outcome measure. Other sleep-related instruments consisted of the Pittsburgh Sleep Quality Scale, a daily sleep log, and daily sleep actigraphy. In addition, data included 3 symptom ratings (Posttraumatic Stress Disorder Checklist, Clinician Administered PTSD Scale [CAPS], and Beck Depression Inventory). Data were collected from 2003 to 2005. Current and lifetime PTSD diagnoses were based on DSM-IV criteria and were obtained by experienced psychiatrists using the CAPS interview.

RESULTS

Univariate analyses showed that daytime sleepiness on the Epworth Sleepiness Scale was associated with daytime dysfunction on the Pittsburgh Sleep Quality Index (P < .001), less use of sleeping medication (P = .02), and more self-rated posttraumatic symptoms (P = .05). Within posttraumatic symptom categories, hypervigilance symptoms were more correlated with daytime sleepiness (P = .03) than were reexperiencing and avoidance symptoms (P = .09 for both).

CONCLUSION

In this selected sample, daytime sleepiness was most strongly and independently associated with daytime dysfunction.