Temporary extracorporeal life support: single-centre experience with a new concept

OBJECTIVES

The combination of veno-arterial extracorporeal membrane oxygenation with a micro-axial flow pump (ECMELLA) is increasingly used for cardiogenic shock (CS) therapy. We report our experience with a novel single-artery access ECMELLA setup with either femoral (2.0) or jugular venous cannulation (2.1), respectively.

METHODS

Data from 67 consecutive CS patients treated with ECMELLA 2.0 (n = 56) and 2.1 (n = 11) from December 2020 and December 2022 in a tertiary cardiac center were retrospectively analyzed.

RESULTS

The mean age was 60.7 ± 11 years, 56 patients (84%) were male. CS aetiology was acute on chronic heart failure (n = 35, 52%), myocardial infarction (n = 13, 19.5%), postcardiotomy syndrome (n = 16, 24%) and myocarditis (n = 3, 4.5%). Preoperatively 31 patients (46%) were resuscitated, 53 (79%) were on a ventilator and 60 (90%) were on inotropic support. The median vasoactive inotropic score was 32, and the mean arterial lactate was 8.1 mmol/l. In 39 patients (58%), veno-arterial extracorporeal membrane oxygenation was explanted after a median ECMELLA support of 4 days. Myocardial recovery was achieved in 18 patients (27%), transition to a durable left ventricular assist device in 16 (24%). Thirty-three patients (n = 33; 49%) died on support (25 on ECMELLA and 8 on Impella after de-escalation), 9 (13%) of whom were palliated. Axillary access site bleeding occurred in 9 patients (13.5%), upper limb ischaemia requiring surgical revision in 3 (4.5%). Axillary site infection occurred in 6 cases (9%), and perioperative stroke in 10 (15%; 6 hemorrhagic, 4 thromboembolic).

CONCLUSIONS

ECMELLA 2.0/2.1 is a feasible and effective therapy for severe CS. The single-artery cannulation technique is associated with a relatively low rate of access-related complications.

Factors contributing to U.S. parents' decisions to administer melatonin to children

OBJECTIVE

Pediatric melatonin use is increasingly prevalent in the U.S. despite limited research on its efficacy and long-term safety. The current study investigated factors contributing to parents' decisions whether to give children melatonin.

METHODS

Parents of children 1.0-13.9 years completed an online questionnaire on children's health, sleep, and melatonin use. Parents who reported giving melatonin to their child were asked open-ended follow-up questions on why their child takes melatonin and why they stopped (if applicable). Responses were assigned to categories through thematic coding.

RESULTS

Data were analyzed on 212 children who either consumed melatonin in the past 30 days (n = 131) or took melatonin previously (n = 81). Among children who recently took melatonin, 51.1 % exhibited bedtime resistance and 46.2 % had trouble falling asleep. Parents most commonly gave children melatonin to: help them fall asleep (49.3 %), wind down before bedtime (22.7 %), facilitate changes in their sleep routine (17.5 %), and/or change their circadian rhythm (11.4 %). Parents stopped giving melatonin because their child did not need it anymore (32.0 %), experienced negative side effects (9.3 %), and/or concerns about health and safety (13.3 %). Finally, parents initiated melatonin use on their own (50.0 %), were encouraged by a friend or family member (27.4 %), and/or followed the recommendation of a health provider (48.1 %).

CONCLUSIONS

Parents administered melatonin to children for a number of reasons and discontinued melatonin based on their own observations of a variety of effects. Parents frequently initiated use without the recommendation of a medical professional. Further research on indications and efficacy of melatonin and wider dissemination of guidelines are needed to help parents make informed decisions regarding children's sleep health.

A novel voice interactive sleep log: concurrent validity with actigraphy and sleep diaries

This is a preliminary validation study of a novel approach to an interactive sleep data collection platform. We compared actigraphy, paper and pencil logs, and the novel voice interactive sleep log in a sample of 17 breast cancer survivors with insomnia symptoms and also report qualitative data on acceptability. We used correlation coefficients and Bland Altman plots to evaluate convergent validity across these measures and report means for acceptability ratings. The sleep log data collected via paper and pencil vs the voice interactive measure had comparable mean values and variable validity coefficients across key sleep variables compared to actigraphy except for wake after sleep onset, where the voice-interactive system had fair concurrent validity with actigraphy. The voice interactive sleep log has several advantages over pencil and paper logs and actigraphy as it reduces patient burden, automatically calculates sleep variables, documents the timeliness of response and provides daily feedback to respondents on calculated sleep metrics.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Identifier: NCT05233800.

CITATION

Lewin D, Starling CM, Zhou ES, Greenberg D, Shaw C, Arem H. A novel voice interactive sleep log: concurrent validity with actigraphy and sleep diaries. J Clin Sleep Med. 2024;20(2):309-312.

Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance

Obstructive sleep apnea (OSA) is the most common respiratory sleep disorder in the United States in preschool and school-aged children. In an effort to continue addressing gaps and variations in care in this patient population, the American Academy of Sleep Medicine (AASM) Quality Measures Task Force performed quality measure maintenance on the Quality Measures for the Care of Pediatric Patients with Obstructive Sleep Apnea (originally developed in 2015). The Quality Measures Task Force reviewed the current medical literature, including updated clinical practice guidelines and systematic literature reviews, existing pediatric OSA quality measures, and performance data highlighting remaining gaps or variations in care since implementation of the original quality measure set to inform any potential revisions to the quality measures. These revised quality measures have been implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous quality improvement, specifically in outcomes associated with diagnosing and managing OSA in the pediatric population.

CITATION

Lloyd RM, Crawford T, Donald R, et al. Quality measures for the care of pediatric patients with obstructive sleep apnea: 2023 update after measure maintenance. J Clin Sleep Med. 2024;20(1):127-134.

Characteristics of Melatonin Use Among US Children and Adolescents

This survey study describes parent-reported sleep practices, such as prevalence, frequency, and timing of melatonin use, among young people aged 1 to 13 years.

Temporary Mechanical Circulatory Support in Cardiogenic Shock Patients after Cardiac Procedures: Selection Algorithm and Weaning Strategies

Mechanical circulatory support has proven effective in managing postcardiotomy cardiogenic shock by stabilizing patients' hemodynamics and ensuring adequate organ perfusion. Among the available device modalities, the combination of extracorporeal life support and a microaxial flow pump for left ventricular unloading has emerged as a valuable tool in the surgical armamentarium. In this publication, we provide recommendations for the application and weaning of temporary mechanical circulatory support in cardiogenic shock patients, derived from a consensus among leading cardiac centers in German-speaking countries.

Outcome of patients supported with the HeartMate 3 after extracorporeal life support: On behalf of the Durable Mechanical Circulatory Support After Extracorporeal Life Support Study Group

OBJECTIVES

The Durable Mechanical Circulatory Support System After Extracorporeal Life Support registry is a multicenter registry of patients who were bridged from extracorporeal life support to a durable mechanical circulatory support system. Although numerous studies have highlighted the favorable outcomes after implantation of the HeartMate 3 (Abbott), the objective of our study is to examine the outcomes of patients who received HeartMate 3 support after extracorporeal life support.

METHODS

Data of patients undergoing HeartMate 3 implantation from January 2016 to April 2022 at 14 centers were collected and evaluated. Inclusion criteria were patients with extracorporeal life support before HeartMate 3 implantation. The outcome was reported and compared with patients receiving other types of pumps.

RESULTS

A total of 337 patients were bridged to durable mechanical circulatory support system after extracorporeal life support in the study period. Of those patients, 140 were supported with the HeartMate 3. The other types of pumps included 170 HeartWare HVADs (Medtronic) (86%), 14 HeartMate II devices (7%), and 13 (7%) other pumps (7%). Major postoperative complications included right heart failure requiring temporary right ventricular assist device in 60 patients (47%). Significantly lower postoperative stroke (16% vs 28%, P = .01) and pump thrombosis (3% vs 8%, P = .02) rates were observed in the patients receiving the HeartMate 3. The 30-day, 1-year, and 3-year survivals in patients receiving the HeartMate 3 were 87%, 73%, and 65%, respectively.

CONCLUSIONS

In this critically ill patient population, the survivals of patients who were transitioned to the HeartMate 3 are deemed acceptable and superior to those observed when extracorporeal life support was bridged to other types of durable mechanical circulatory support systems.

Pediatric sleep: current knowledge, gaps, and opportunities for the future

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

Automatic Detection of Chronic Insomnia from Polysomnographic and Clinical Variables Using Machine Learning

Insomnia is defined subjectively by the presence and frequency of specific clinical symptoms and an association with distress. Although sleep study data has shown some weak associations, no objective test can currently be used to predict insomnia. The purpose of this study was to use previously reported and relatively crafted insomnia-related polysomnographic variables in machine learning models to classify groups with and without insomnia. Demographics, diagnosed depression, Epworth Sleepiness Scale (ESS), and features derived from electroencephalography (EEG), arousals, and sleep stages from 3,407 sleep clinic patients (2,617 without insomnia and 790 insomnia patients based on responses to a set of questions) were included in this analysis. The number of features were reduced using pair-wise correlation and recursive feature elimination. Predictive value of three machine learning models (logistic regression, neural network, and support vector machine) was investigated, and the best performance was achieved with logistic regression, yielding a balanced accuracy of 71%. The most important features in predicting insomnia were depression, age, sex, duration of longest arousal, ESS score, and EEG power in theta and sigma bands across all sleep stages. Results indicate potential of machine learning-based screening for insomnia using clinical variables and EEG.

Impact of preoperative mitral regurgitation on left ventricular assist device patients: propensity score-matched analysis of the EUROMACS dataset

OBJECTIVES

Mitral regurgitation (MR) is frequently observed in patients undergoing left ventricular assist device implantation. We investigated the impact of preoperative MR on left ventricular assist device patients.

METHODS

A retrospective propensity score-matched analysis of adult patients enrolled in the EUROMACS registry between 1 January 2011 and 30 November 2021 was performed. Patients were divided into 2 groups according to the grade of preoperative MR: none-to-mild (MR 0-II) or moderate-to-severe (MR III-IV).

RESULTS

Following 1:1 propensity score matching, each group consisted of 914 patients. Incidence of postoperative temporary right ventricular support, reoperation for bleeding and dialysis was similar. MR III-IV demonstrated shorter median intensive care unit stay [14 days (6; 27.8) vs 10 days (5; 22), P = 0.004] and ventilation time [72 h (22, 320) vs 31 h (18, 150), P < 0.001]. Mortality was lower for MR III-IV patients [subdistribution hazard ratio: 0.66, 95% confidence interval (CI): 0.59-0.73, P < 0.001]. The 1-year survival was 68.1% (95% CI: 65.1-71.3%) in MR 0-II and 75% (95% CI: 72.1-78%) in MR III-IV. A lower incidence of total complications [odds ratio (OR): 0.93 (0.89-0.98), P = 0.003] and trend towards a lower risk of neurological dysfunction (subdistribution hazard ratio: 0.79; 95% CI: 0.61-1.01, P = 0.063) and sustained ventricular tachycardia [OR: 0.93 (0.54-1.03), P = 0.074] were demonstrated for MR III-IV. The risk of fatal stroke and pump thrombosis was similar.

CONCLUSIONS

Moderate-to-severe MR in patients undergoing left ventricular assist device implantation is associated with better mid-term survival and lower incidence of total major adverse events and complications. The incidence of severe postoperative complications including fatal stroke and device thrombosis was similar.

Complications related to the access site after transaxillary implantation of a microaxial left ventricular assist device

BACKGROUND

Impella 5.0 and 5.5 (summarized as Impella 5+) are microaxial, catheter-based left ventricular assist devices (LVAD) that are implanted via a vascular graft sutured to the axillary artery and provide blood flow of up to 5.5 liter/min. This study aims to investigate the incidence of long-term complications following circulatory support with Impella 5+.

METHODS

A single-center retrospective analysis of 203 consecutive adult patients treated between January 2017 and September 2021 with a surgically implanted Impella 5.0 or 5.5 via a vascular graft sutured to the axillary artery.

RESULTS

The median Impella support duration was 8 days. Of 203 patients, 78 (38.4%) died while on temporary mechanical circulatory support. Fifty-five (27.1%) were successfully weaned from Impella 5+ and 70 (34.5%) were bridged to a durable LVAD with a median follow-up time of 232 (IQR 68.5, 597) days after Impella 5+ explantation. In 119 of these patients, the Impella was explanted and the vascular graft was shortened, ligated, and pushed under the pectoralis muscle; in 6 patients early graft infection prompted complete graft removal during explantation. In addition, 13 patients (10.9%) developed a late-onset graft infection after a median of 86 days, requiring complete (n = 10) or partial (n = 2) explantation of the retained graft. In 1 patient, the graft infection was successfully treated by conservative therapy. Our analysis identified no specific risk factors for graft infections. Of the 203 patients, 5 (2.5%) developed a brachial plexus injury resulting in neurological dysfunction.

CONCLUSIONS

In 10.9% of patients, retaining the vascular graft was complicated by a late graft infection. Complete explantation of the graft prosthesis may decrease the infection rate, but may in turn increase the risk of brachial plexus injury. On the other hand, this method offers the possibility of bedside explantation.

HeartWare to HeartMate 3 left ventricular assist device exchange via a left lateral thoracotomy

A continuous-flow left ventricular assist device implant is a well-established therapy for patients with end-stage heart failure. Currently, the HeartMate 3 device is the only commercially available durable left ventricular assist device. Therefore, patients on HeartWare HVAD support who require a pump exchange must have a HeartMate 3 implanted.

Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance

Obstructive sleep apnea (OSA) remains a highly prevalent disorder that can lead to multiple adverse outcomes when undiagnosed and/or when left untreated. There continue to be gaps and variations in the provision of care for the adult patient population with OSA, which emphasizes the importance of the measure maintenance initiative for The Quality Measures for the Care of Adult Patients with Obstructive Sleep Apnea (originally developed in 2015). The American Academy of Sleep Medicine (AASM) convened the Quality Measures Task Force in 2018 to review the current medical literature, other existing quality measures focused on the same patient population, and any performance data or data in the medical literature that show gaps or variations in care, to inform potential revisions to the quality measure set. These revised quality measures will be implemented in the AASM Sleep Clinical Data Registry (Sleep CDR) to capture performance data and encourage continuous improvement in outcomes associated with diagnosing and managing OSA in the adult population.

CITATION

Lloyd R, Morgenthaler TI, Donald R, et al. Quality measures for the care of adult patients with obstructive sleep apnea: 2022 update after measure maintenance. J Clin Sleep Med. 2022;18(11):2673-2680.

Longitudinal associations between high school sleep characteristics and young adult health outcomes

STUDY OBJECTIVES

Short sleep duration and evening chronotype are independently associated with negative health outcomes. However, it is unclear how adolescent sleep duration and chronotype are longitudinally associated with health outcomes during early adulthood.

METHODS

Participants from the NEXT Generation Health Study (n = 2,783; 54.5% female) completed measures of sleep duration (scheduled day and unscheduled day) and chronotype in high school. Sleep duration, chronotype, general health, depressive symptoms, and psychosomatic symptoms were also assessed 4 years after high school. Latent variables estimated high school scheduled-day sleep duration, unscheduled-day sleep duration, and chronotype using the during high school measures. Two path analyses tested the prospective associations between high school sleep duration (separate models for scheduled and unscheduled days) and chronotype with 4 years after high school health outcomes as mediated by concurrent sleep duration and chronotype.

RESULTS

In the scheduled-day model, longer high school sleep duration and later chronotype were associated with longer duration and later chronotype in early adulthood. Longer high school sleep duration was directly associated with fewer psychosomatic symptoms and indirectly associated with fewer depressive and psychosomatic symptoms through longer sleep duration in early adulthood. Later chronotype in high school was indirectly associated with poorer general health, greater depressive symptoms, and greater psychosomatic symptoms in early adulthood through later chronotype.

CONCLUSIONS

Findings highlight the roles of scheduled-day sleep duration and evening chronotype in shaping health outcomes and suggest the importance of chronotype and optimal sleep habits among adolescents.

CITATION

Maultsby KD, Temmen CD, Lewin D, et al. Longitudinal associations between high school sleep characteristics and young adult health outcomes. J Clin Sleep Med. 2022;18(11):2527-2536.

Transcatheter Aortic Valve Replacement in a Patient With Criss-Cross Heart

This paper presents the first transcatheter management of severe aortic regurgitation in a 77-year-old woman with a criss-cross heart—an extremely rare and complex congenital heart disease. The procedure achieved an elimination of aortic regurgitation and resulted in a remarkable improvement of the patient’s physical condition. (Level of Difficulty: Advanced.)

Testing delivery of components of cognitive behavioral therapy for insomnia to breast cancer survivors by smart speaker: a study protocol

BACKGROUND

Insomnia is common in breast cancer survivors (BCS), affecting an estimated 30-50% of the 3.8 million BCS in the US. Insomnia is associated with health consequences for cardiometabolic and immune systems, neurobehavioral function, depression, fatigue, and quality of life and may put BCS at particular risk. While pharmacotherapy for insomnia may address symptoms in the short-term, cognitive behavioral therapy for insomnia (CBT-I) is considered the gold standard insomnia treatment. We describe our protocol to determine the efficacy of voice-activated delivery of CBT-I components on insomnia symptoms compared to a sleep education control among BCS.

METHODS

We will conduct a 6-week, randomized controlled trial with two arms. Intervention arm participants will receive a smart speaker device and will be asked to engage with the program daily, using a voice-activated speaker with an accompanying smart-phone app. Control participants will have access to a website with basic information about CBT-I, sleep, and breast cancer survivorship and will be asked to engage with the website as desired.

DISCUSSION

Our primary outcome is the Insomnia Severity Index total score. Secondary outcomes include sleep diary outcomes (sleep efficiency, wake after sleep onset, sleep onset latency, total sleep time, and sleep quality). This study will provide evidence on a promising modality to deliver elements of CBT-I for BCS experiencing insomnia. Trial Registration ClinicalTrials.gov NCT05233800 Released 3/25/2022.

Impact of left ventricular inspection employing cardiopulmonary bypass on outcome after implantation of left ventricular assist device

BACKGROUND

Cardiopulmonary bypass (CPB) during left ventricular assist device (LVAD) implantation provides circulatory support and allows for safe inspection of the left ventricle (LV), whereas circulatory support by veno-arterial extracorporeal life support (va-ECLS) or off-pump implantation may reduce postoperative bleeding and inflammatory response.

METHODS

Retrospective analysis of 616 consecutive adult patients who received an LVAD via median sternotomy between January 1, 2015 and December 31, 2019. All patients undergoing concomitant intracardiac procedures other than closure of persistent foramen ovale or atrial septal defect and redo surgeries were excluded from the analysis. The remaining patients (n = 222) were divided into two groups and 1:1 propensity score-matched regarding preoperative parameters: patients who underwent LVAD implantation with LV inspection employing CPB (CPB group, n = 62) and without LV inspection on va-ECLS or off-pump (non-CPB group, n = 62).

RESULTS

The groups were well balanced with regard to preoperative baseline characteristics (standard difference <0.1). Patients in the CPB group required more blood transfusions (median 2 vs. 0 units, p = 0.031) during surgery and in the first 24 h afterwards. The median intensive care unit stay was longer in the CPB group (18 vs. 11 days, p = 0.021). The CPB group showed an absence of perioperative stroke and a smaller number of events per patient-year for postoperative ischemic stroke (0.02 vs. 0.12, p = 0.003). 30-day survival (87% vs. 87.1%) and 1-year survival (80.3% vs. 74%) were similar in both groups (p = 0.78).

CONCLUSION

Visual LV inspection on CPB may reduce the risk of postoperative ischemic stroke. Despite the negative effects of employing CPB in lieu of other intraoperative strategies, survival was similar in both groups.

Hepatic Hyaline Arteriolosclerosis in Patients with Chronic Hyperglycemia

Introduction/Objective

Hyaline arteriolosclerosis is a common feature of diabetic microangiopathy. It results from hyperglycemia-induced endothelial cell dysfunction and can be found in many sites including the retina, kidney, and skin. This histologic finding is important because studies have shown that in the kidney it is an independent risk factor for cardiovascular complications. To our knowledge, an association between hyperglycemia and hyaline arteriolosclerosis in the liver has not be studied. We aimed to investigate whether chronic hyperglycemia is associated with this histologic finding in liver arterioles.

Methods/Case Report

The first 50 liver biopsies performed at our institution starting January 1, 2020 were scanned into a digital pathology system (Philips, Cambridge, MA). For each biopsy, the patient’s highest recorded hemoglobin A1c (HbA1c) up to one year from the date of biopsy was recorded. The biopsies were then grouped into two groups: those from patients with a HbA1c greater than 6.5%, and those with a HbA1c value less than 6.5 %. Next, the digested periodic acid Schiff (DPAS) intensity of the arteriolar vessels in each biopsy was graded 0 to 3 by a single pathology resident who was blinded to its corresponding HbA1c group. Grade 0 to 1 was considered negative staining. Grade 2 to 3 was considered positive staining and indicative of hyaline arteriolosclerosis. By the end of the data collection, each case had been given a staining category and a HbA1c group. A 2 x 2 contingency table was constructed.

Results (if a Case Study enter NA)

37 of 50 patients had a recorded HbA1c meeting the study criteria. Of these 37 patients, 11 had an HbA1c greater than 6.5 % while 26 had an HbA1c less than 6.5%. Seven of the 11 biopsies from patients with an elevated HbA1c showed positive staining. Six of the 26 biopsies from patients with an HbA1c less than 6.5% showed positive staining.

Conclusion

We hypothesized that patients living with hyperglycemia may be more likely to exhibit hepatic hyaline arteriolosclerosis. A chi-squared test of independence was performed to examine the association between a liver biopsy’s HbA1c group and staining category. The relation between these variables was significant at p = &lt; .05, χ 2 (2, N= 36) = 5.57, p = .0182, indicating liver biopsies with a HbA1c greater than 6.5 % are more likely to have this histologic finding. Future studies are needed to characterize diabetic hepatopathy, and its relatedness to macrovascular complications.

Percutaneous mitral valve repair assisted by a catheter-based circulatory support device in a heart transplant patient

BACKGROUND

Systemic infections and chronic graft rejection represent common causes of mortality and morbidity in heart transplant patients. In severe cases, cardiogenic shock (CS) may occur and require hemodynamic stabilization with temporary mechanical circulatory support (tempMCS). Under these devastating circumstances, treatment of sequelae of left ventricular dysfunction, such as secondary mitral regurgitation (MR) is challenging, especially when surgical repair is deemed futile. In nontransplant patients, interventional mitral valve repair strategies such as the MitraClip system (Abbott Cardiovascular) have been used to successfully treat secondary MR and allow for weaning from tempMCS.

CASE SUMMARY

We report about the first patient in whom profound CS after heart transplantation was stabilized with tempMCS followed by interventional elimination of secondary MR.

Three Dimensions of Sleep, Somatic Symptoms, and Marijuana Use in U.S. High School Students

PURPOSE

This study aimed to investigate potential bidirectional relations between key sleep characteristics and somatic symptoms with past 30-day marijuana use in high school students.

METHODS

Participants from the NEXT Generation Health Study (n = 2,770) reported on 10th and 11th grade (W1 and W2) sleep characteristics and somatic symptoms and 12th grade (W3) past 30-day marijuana. Multivariate logistic regressions and path analyses were conducted.

RESULTS

Sleep duration was not associated with marijuana use. However, later W1 chronotype, greater W1 social jetlag, W1 trouble falling asleep, W1 trouble staying asleep, and W1 somatic symptoms were associated with increased odds of W3 past 30-day marijuana use. Path models indicated direct associations between W1 chronotype and W3 past 30-day marijuana use, and W1 social jetlag and W3 past 30-day marijuana use.

CONCLUSIONS

Later sleep timing was longitudinally associated with past 30-day marijuana use. Improved understanding of sleep health, specifically chronotype and social jetlag as risk factors for marijuana use is warranted, which may inform additional screening targets and interventions that address these associated domains.

Propensity score-based analysis of long-term follow-up in patients supported with durable centrifugal left ventricular assist devices: the EUROMACS analysis

 

OBJECTIVES

The HeartWare HVAD (HW) and the HeartMate3 (HM3) are presently the most commonly used continuous-flow left ventricular assist devices worldwide. We compared the outcomes of patients supported with either of these 2 devices based on data from the EUROMACS (European Registry for Patients with Mechanical Circulatory Support).

METHODS

A retrospective analysis of the survival and complications profile in propensity score-matched adult patients enrolled in the EUROMACS between 01 January 2016 and 01 September 2020 and supported with either an HW or HM3. Matching included demographic parameters, severity of cardiogenic shock and risk-modifying end-organ parameters that impact long-term survival. Survival on device and major postoperative adverse events were analysed.

RESULTS

Following 1:1 propensity score matching, each group consisted of 361 patients. Patients were well balanced (<0.1 standardized mean difference). The median follow-up was similar in both groups [396 (interquartile range (IQR) 112-771) days for HW and 376 (IQR 100-816) days for HM3]. The 2-year survival was similar in both groups [HW: 61% 95% confidence interval (CI) (56-67%) vs HM3: 68% 95% CI (63-73%) (stratified hazard ratio for mortality: 1.13 95% CI (0.83-1.54), P = 0.435].The cumulative incidence for combined major adverse events and unexpected readmissions was similar in both groups [subdistribution hazard ratio (SHR) 1.0 (0.84-1.21), P = 0.96]. Patients in the HW group demonstrated a higher risk of device malfunction [SHR 2.44 (1.45-3.71), P < 0.001], neurological dysfunction [SHR 1.29 (1.02-1.61), P = 0.032] and intracranial bleeding [SHR 1.76 (1.13-2.70), P = 0.012].

CONCLUSIONS

Mid-term survival in both groups was similar in a propensity-matched analysis. The risk of device malfunction, neurological dysfunction and intracranial bleeding was significantly higher in HW patients.

Impact of a surgical approach for implantation of durable left ventricular assist devices in patients on extracorporeal life support

BACKGROUND

The aim of this study was to evaluate the impact of the surgical approach on the postoperative outcome in patients who underwent left ventricular assist device (LVAD) implantation after having received veno-arterial extracorporeal life support (va-ECLS) using data from a European registry (ECLS-VAD). Five hundred and thirty-one patients were included.

METHODS

A propensity score-adjusted outcome analysis was performed, resulting in 324 patients in the full sternotomy (FS) group and 39 in the less invasive surgery (LIS) group.

RESULTS

The surgery lasted in median 236 min in the FS group versus 263 min in the LIS group (p = 0.289). The median chest tube output during the first 24 h was similar in both groups. Patients who underwent implantation with an FS required more blood products during the first 24 postoperative hours (median 16 vs. 12, p = 0.033). The incidence of revision due to bleeding was also higher (35.5 vs. 15.4%, p = 0.016). A temporary postoperative right ventricular assist device was necessary in 45.1 (FS) versus 23.1% (LIS) of patients, respectively (p = 0.067). No stroke occurred in the LIS group during the first 30 days after surgery (7.4% in the FS group). The incidence of stroke and of renal, hepatic, and respiratory failure during the follow-up was similar in both groups. The 30-day and one-year survival were similar in both groups.

CONCLUSION

LIS for implantation of a durable LVAD in patients on va-ECLS implanted for cardiogenic shock is associated with less revision due to bleeding, less administration of blood products and absence of perioperative stroke, with no impact on survival.

Assessing Breast Cancer Survivors' Perceptions of Using Voice-Activated Technology to Address Insomnia: Feasibility Study Featuring Focus Groups and In-Depth Interviews

Background

Breast cancer survivors (BCSs) are a growing population with a higher prevalence of insomnia than women of the same age without a history of cancer. Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be effective in this population, but it is not widely available to those who need it.

Objective

This study aimed to better understand BCSs’ experiences with insomnia and to explore the feasibility and acceptability of delivering CBT-I using a virtual assistant (Amazon Alexa).

Methods

We first conducted a formative phase with 2 focus groups and 3 in-depth interviews to understand BCSs’ perceptions of insomnia as well as their interest in and comfort with using a virtual assistant to learn about CBT-I. We then developed a prototype incorporating participant preferences and CBT-I components and demonstrated it in group and individual settings to BCSs to evaluate acceptability, interest, perceived feasibility, educational potential, and usability of the prototype. We also collected open-ended feedback on the content and used frequencies to describe the quantitative data.

Results

We recruited 11 BCSs with insomnia in the formative phase and 14 BCSs in the prototype demonstration. In formative work, anxiety, fear, and hot flashes were identified as causes of insomnia. After prototype demonstration, nearly 79% (11/14) of participants reported an interest in and perceived feasibility of using the virtual assistant to record sleep patterns. Approximately two-thirds of the participants thought lifestyle modification (9/14, 64%) and sleep restriction (9/14, 64%) would be feasible and were interested in this feature of the program (10/14, 71% and 9/14, 64%, respectively). Relaxation exercises were rated as interesting and feasible using the virtual assistant by 71% (10/14) of the participants. Usability was rated as better than average, and all women reported that they would recommend the program to friends and family.

Conclusions

This virtual assistant prototype delivering CBT-I components by using a smart speaker was rated as feasible and acceptable, suggesting that this prototype should be fully developed and tested for efficacy in the BCS population. If efficacy is shown in this population, the prototype should also be adapted for other high-risk populations.

Sexual Orientation and Sleep Behaviors in a National Sample of Adolescents Followed Into Young Adulthood

STUDY OBJECTIVES

Sexual minority adolescents experience mental and physical health disparities attributable to increased discrimination and minority stress. These same factors may also impair sleep health, although available literature on this topic is limited. This study examined longitudinal associations between adolescent sexual minority status and seven sleep behaviors in young adulthood and tested depressive symptoms and overweight as mediators.

METHOD

Data were drawn from Waves 2 (11th grade) to 7 (4 years after high school) of the NEXT Generation Health Study, a national longitudinal cohort study of US adolescents (n = 1946; 6.3% sexual minorities).

RESULTS

There were no significant sexual orientation disparities in sleep duration, trouble falling asleep, trouble staying asleep, or trouble waking up during young adulthood. Relative to heterosexual females, sexual minority females had higher odds of snoring/stop breathing (36.6% versus 19.2%; adjusted odds ratio = 2.57; 95% confidence interval = 1.30, 5.09) and reported more frequent daytime sleepiness (b = 0.66, 95% confidence interval = 0.05, 1.27). Mediation analyses revealed that female sexual minority status was associated with increased risk of snoring/stop breathing though overweight status (mediated 43.6% of total effect) and was also associated with increased daytime sleepiness through higher depressive symptoms (mediated 70.8% of total effect).

CONCLUSIONS

Among US youth, no sexual orientation disparities were found except for snoring/stop breathing and daytime sleepiness among females. Sexual orientation disparities in these aspects of sleep are partially due to worse mental and physical health among sexual minority females, highlighting depressive symptoms and overweight problems as potential intervention targets.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Health Behavior in School-Aged Children: NEXT Longitudinal Study 2009-2016; Identifier: NCT01031160.

Beyond Sleep Duration: Bidirectional Associations Among Chronotype, Social Jetlag, and Drinking Behaviors in a Longitudinal Sample of US High School Students

Inadequate sleep and problematic drinking are prevalent among high school students and are significant public health issues. Inadequate sleep may contribute to alcohol use through impairments in emotion regulation or cognitive functioning, whereas alcohol use may lead to inadequate sleep through the biological effects of alcohol or social influences. However, the directionality of the associations between sleep and drinking variables remains unclear as most prior studies were cross-sectional. This study utilizes longitudinal data from the NEXT Generation Health Study to examine bidirectional associations between alcohol use and sleep adequacy in a nationally representative sample across 3 years of high school. Students reported usual bedtimes and waketimes for scheduled- and free-days, alcohol use, and heavy episodic drinking. Estimates of sleep duration, chronotype, and social jetlag were calculated. Cross-lagged autoregressive models revealed evidence of alcohol use predicting subsequent sleep duration and timing, and sleep timing predicting subsequent alcohol use. Specifically, previous-wave alcohol use predicted shorter free-day sleep duration and later chronotype at 11th and 12th grade, and more social jetlag at 12th grade; similar results were obtained for heavy episodic drinking. Eleventh grade social jetlag predicted subsequent year current alcohol use; eleventh grade chronotype and social jetlag predicted subsequent year heavy episodic drinking. Bidirectional findings suggest that alcohol use and sleep may reflect mutually reinforcing life style choices. Understanding these bidirectional associations could inform risk prevention interventions. Given the implications of poor sleep for adolescents, further research on possible social influences on the alcohol-sleep relations is merited. Clinical Trial Registration: NCT01031160.

Relationships Between Smoking and Sleep Problems in Black and White Adolescents

Study Objectives

The relationship between sleeping and smoking during adolescence remains unclear and is likely complex. We aim to evaluate the longitudinal reciprocal associations between sleep problems, sleep duration, and smoking among non-Hispanic white (NHW) and non-Hispanic black (NHB) youth.

Design

Prospective cohort study.

Setting

NEXT Generation Health Study.

Participants

A national sample (N = 1394) of NHB and NHW 10th graders were surveyed annually between 2009 (Wave 1) and 2012 (Wave 3).

Interventions

N/A.

Measurements and Results

Past 30-day smoking, chronic difficulty falling asleep, recent difficulty falling asleep, difficulty staying asleep, and weekday and weekend sleep duration were measured at each wave. Using structural equation models, we observed significant autocorrelations over time for sleep problems and sleep duration. We found significant reciprocal, prospective relationships between smoking and sleep problems. The strengths of the relationships differed by race, with a stronger association between sleep problems and subsequent smoking for NHB than NHW youth. Conversely, a stronger association between smoking and subsequent sleep problems for NHW than NHB youth was observed. These association were independent of demographics, snoring or sleep apnea, body mass index, depressive symptoms, alcohol use, and soda consumption.

Conclusions

Reciprocal and prospective relationships exist for youth smoking and sleep problems and duration in both NHW and NHB youth. Further research is needed to unravel the complex relationship between the direct effects of nicotine, lifestyle choices that may link smoking and sleep problems, and racial differences.

Association Between Short Sleep Duration and Risk Behavior Factors in Middle School Students

Study Objectives

To examine the association between self-reported sleep duration (SD) and peer/individual factors predictive of risky behaviors (risk behavior factors) in a large socioeconomically diverse school-based sample of early adolescents.

Design, Setting, and Participants

Survey data collected from 10718 and 11240 eighth-grade students in 2010 and 2012, respectively, were analyzed.

Intervention

N/A.

Measurements and Results

Self-reported school night SD was grouped as ≤4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, and ≥10 hours. Scores on 10 peer/individual risk behavior factor scales were dichotomized according to national eigth-grade cut points. The percentage of students reporting an "optimal" SD of 9 hours was 14.8% and 15.6% in 2010 and 2012, respectively; 45.6% and 46.1% reported <7 hours. Adjusted for covariates of gender, race, and SES, multilevel logistic regression results showed that odds ratios (ORs) for 9 of 10 risk factor scales increased with SD <7 hours, with a dose-response effect for each hour less sleep compared to an SD of 9 hours. For example, ORs for students sleeping <7 hours ranged from 1.3 (early initiation of antisocial behavior) to 1.8 (early initiation of drug use). The risk factor scale ORs for <5 hours SD ranged from 3.0 (sensation seeking) to 6.4 (gang involvement).

Conclusions

Middle school students are at high risk of insufficient sleep; in particular, an SD <7 hours is associated with increased risk behavior factors.

Relationships Between Smoking and Sleep Problems in Black and White Adolescents

Study Objectives

The relationship between sleeping and smoking during adolescence remains unclear and is likely complex. We aim to evaluate the longitudinal reciprocal associations between sleep problems, sleep duration, and smoking among non-Hispanic white (NHW) and non-Hispanic black (NHB) youth.

Design

Prospective cohort study.

Setting

NEXT Generation Health Study.

Participants

A national sample (N = 1394) of NHB and NHW 10th graders were surveyed annually between 2009 (Wave 1) and 2012 (Wave 3).

Interventions

N/A.

Measurements and Results

Past 30-day smoking, chronic difficulty falling asleep, recent difficulty falling asleep, difficulty staying asleep, and weekday and weekend sleep duration were measured at each wave. Using structural equation models, we observed significant autocorrelations over time for sleep problems and sleep duration. We found significant reciprocal, prospective relationships between smoking and sleep problems. The strengths of the relationships differed by race, with a stronger association between sleep problems and subsequent smoking for NHB than NHW youth. Conversely, a stronger association between smoking and subsequent sleep problems for NHW than NHB youth was observed. These association were independent of demographics, snoring or sleep apnea, body mass index, depressive symptoms, alcohol use, and soda consumption.

Conclusions

Reciprocal and prospective relationships exist for youth smoking and sleep problems and duration in both NHW and NHB youth. Further research is needed to unravel the complex relationship between the direct effects of nicotine, lifestyle choices that may link smoking and sleep problems, and racial differences.

Self-Regulation and Sleep Duration, Sleepiness, and Chronotype in Adolescents

OBJECTIVE

To determine whether shorter school-night sleep duration, greater daytime sleepiness, and greater eveningness chronotype were associated with lower self-regulation among adolescents.

METHODS

An online survey of 7th- to 12th-grade students in 19 schools in Fairfax County, Virginia Public Schools was conducted in 2015. Self-regulation was measured with the Behavior Rating Inventory of Executive Function, 2nd edition, Screening Self-Report Form. Sleep measures included school night-sleep duration (hours between usual bedtime and wake time), daytime sleepiness (Sleepiness Scale in the Sleep Habits Survey, tertiles), and chronotype (Morningness-Eveningness Scale for Children, continuous score and tertiles). Sociodemographic factors and mental health conditions were analyzed as potential confounders.

RESULTS

Among 2017 students surveyed, the mean age was 15.0 years (range, 12.1-18.9 years), and 21.7% slept <7 hours on school nights. In regression models adjusted for confounders, there was a significant independent association between self-regulation and both chronotype (P < .001) and daytime sleepiness (P < .001) but not sleep duration (P = .80). Compared with those in the lowest tertile of daytime sleepiness, those in the highest tertile had lower (0.59 SD units; 95% confidence interval, 0.48-0.71) self-regulation, as did those in the eveningness tertile of chronotype compared with those in the morningness tertile (0.35 SD units lower; 95% confidence interval, 0.24-0.46).

CONCLUSIONS

Among adolescents, greater daytime sleepiness and greater eveningness chronotype were independently associated with lower self-regulation, but shorter sleep duration was not. Aspects of sleep other than school-night sleep duration appear to be more strongly associated with self-regulation.

Pilot Study of Massage to Improve Sleep and Fatigue in Hospitalized Adolescents With Cancer

BACKGROUND

Adolescents with cancer experience many troubling symptoms, including sleep disruptions that can affect mood and quality of life. Massage is a safe and popular intervention that has demonstrated efficacy in pediatric and adult patients with cancer. This study aimed to assess the feasibility of conducting a massage intervention to help with sleep in hospitalized adolescent oncology patients.

PROCEDURE

Adolescents ages 12-21 with cancer who were expected to be hospitalized for at least four consecutive nights were recruited from the inpatient unit at Children's National Health System and randomized to either massage intervention or a waitlist control. Patients in the intervention group received one massage per night, for two or three nights. Sleep was measured with actigraphy and patient and proxy reported instruments were used to measure fatigue, mood, and anxiety.

RESULTS

The majority (78%) of patients approached for the study consented, and almost all patients in the intervention group (94%) received at least one massage, 69% received two, and rates of completion of instruments among adolescents were high demonstrating feasibility. There were trends toward increased night time and overall sleep in the intervention group compared with standard of care, but no differences between groups in the patient reported outcome measures. Participant and parent feedback on the intervention was positive and was the impetus for starting a clinical massage service at the hospital.

CONCLUSIONS

Massage for hospitalized adolescents with cancer is feasible, well received, and can potentially improve patients' sleep. A randomized multicenter efficacy study is warranted.

Summer activity patterns among teenage girls: harmonic shape invariant modeling to estimate circadian cycles

BACKGROUND

Physical activity as measured by activity counts over short time intervals across a 24 h period are often used to assess circadian variation. We are interested in characterizing circadian patterns in activity among adolescents and examining how these patterns vary by obesity status. New statistical approaches are needed to examine how factors affect different features of the circadian pattern and to make appropriate covariate adjustments when the outcomes are longitudinal count data.

METHODS

We develop a statistical model for longitudinal or repeated activity count data that is used to examine differences in the overall activity level, amplitude (defined as the difference between the lowest and highest activity level over a 24 hour period), and phase shift. Using seven days of continuous activity monitoring, we characterize the circadian patterns and compare them between obese and non-obese adolescent girls.

RESULTS

We find a statistically significant phase delay in adolescent girls who were obese compared with their non-obese counterparts. After the appropriate adjustment for measured potential confounders, we did not find differences in mean activity level between the two groups.

CONCLUSION

New statistical methodology was developed to identify a phase delay in obese compared with non-obese adolescents. This new approach for analyzing longitudinal circadian rhythm count data provides a useful statistical technique to add to the repertoire for those analyzing circadian rhythm data.

L-Dopa improves Restless Legs Syndrome and periodic limb movements in sleep but not Attention-Deficit-Hyperactivity Disorder in a double-blind trial in children

BACKGROUND

In a previous open-label study, dopaminergic agents improved Restless Legs Syndrome (RLS) and Periodic Limb Movements in Sleep (PLMS), as well as Attention-Deficit-Hyperactivity Disorder (ADHD) in children with both disorders. We therefore conducted a double-blind placebo-controlled trial of L-DOPA in ADHD children with and without RLS/PLMS.

METHODS

Two groups of patients (total n = 29), those with ADHD only or those with ADHD and RLS/PLMS, were randomized to L-DOPA or placebo therapy. At baseline and after therapy patients were assessed with Conners' parent and teacher rating scales; polysomnography; RLS rating scale; and neuropsychometric measures of memory, learning, attention, and vigilance.

RESULTS

L-DOPA improved RLS/PLMS symptoms in all patients with those disorders compared with placebo (p = .007). When assessed by the Conners' Scales before therapy, ADHD was more severe in children without RLS/PLMS than in children with RLS/PLMS (p = 0.006). L-DOPA had no effect on Conners' scales, sleep, or neuropsychometric tests when all patients treated with the drug were compared to those on placebo or when patients with ADHD only were compared to those with ADHD and RLS/PLMS.

CONCLUSIONS

In this first double-blind study of a dopaminergic therapy in children with RLS/PLMS, L-Dopa significantly improved RLS/PLMS but not ADHD. These results, however, should be interpreted carefully since they may have been influenced by the relatively small sample size and the baseline differences in severity of ADHD symptoms. Further work needs to be done to elucidate the relationship between dopamine, ADHD and RLS/PLMS.

Polysomnographic abnormalities in succinic semialdehyde dehydrogenase (SSADH) deficiency

OBJECTIVES

Patients with SSADH deficiency, a disorder of chronically elevated endogenous GABA and GHB, were studied for sleep symptoms and polysomnography. We hypothesized that patients would have excessive daytime somnolence and decreased REM sleep.

DESIGN

Polysomnography and MSLT were performed on patients enrolled for comprehensive clinical studies of SSADH deficiency.

SETTING

Sleep studies were obtained in the sleep laboratories at CNMC and NIH.

PATIENTS

Sleep recordings were obtained in 10 patients with confirmed SSADH deficiency.

INTERVENTIONS

Thirteen overnight polysomnograms were obtained in 10 patients (7 male, 3 female, ages 11-27 y). Eleven MSLT studies were completed in 8 patients.

MEASUREMENTS AND RESULTS

Polysomnograms showed prolongation of REM stage latency (mean 272 +/- 89 min) and decreased percent stage REM (mean 8.9%, range 0.3% to 13.8%). Decreased mean sleep latency was present in 6 of 11 MSLTs.

CONCLUSIONS

SSADH deficiency is associated with prolonged latency to stage REM and decreased percent stage REM. This disorder represents a model of chronic GABA and GHB accumulation associated with suppression of REM sleep.

Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety

OBJECTIVE

To mitigate the risks of fatigue-related medical errors, the Accreditation Council for Graduate Medical Education introduced work hour limits for resident physicians in 2003. Our goal was to determine whether work hours, sleep, and safety changed after implementation of the Accreditation Council for Graduate Medical Education standards.

METHODS

We conducted a prospective cohort study in which residents from 3 large pediatric training programs provided daily reports of work hours and sleep. In addition, they completed reports of near-miss and actual motor vehicle crashes, occupational exposures, self-reported medical errors, and ratings of educational experience. They were screened for depression and burnout. Concurrently, at 2 of the centers, data on medication errors were collected prospectively by using an established active surveillance method.

RESULTS

A total of 220 residents provided 6007 daily reports of their work hours and sleep, and 16 158 medication orders were reviewed. Although scheduling changes were made in each program to accommodate the standards, 24- to 30-hour shifts remained common, and the frequency of residents' call remained largely unchanged. There was no change in residents' measured total work hours or sleep hours. There was no change in the overall rate of medication errors, and there was a borderline increase in the rate of resident physician ordering errors, from 1.06 to 1.38 errors per 100 patient-days. Rates of motor vehicle crashes, occupational exposures, depression, and self-reported medical errors and overall ratings of work and educational experiences did not change. The mean length of extended-duration (on-call) shifts decreased 2.7% to 28.5 hours, and rates of resident burnout decreased significantly (from 75.4% to 57.0%).

CONCLUSIONS

Total hours of work and sleep did not change after implementation of the duty hour standards. Although fewer residents were burned out, rates of medication errors, resident depression, and resident injuries and educational ratings did not improve.