Harnessing technology to improve sleep in frontline healthcare workers: A pilot study of electronic noise-masking earbuds on subjective and objective sleep measures

Objective: This pilot study assessed the effects of electronic noise-masking earbuds on subjective sleep perception and objective sleep parameters among healthcare workers (HCWs) reporting sleep difficulties during the COVID-19 pandemic. Methods: Using a pre-post design, 77 HCWs underwent 3 nights of baseline assessment followed by a 7-night intervention period. Participants wore an at-home sleep monitoring headband to assess objective sleep measures and completed subjective self-report assessments. The difference in mean sleep measures from baseline to intervention was estimated in linear mixed models. Results: Compared to baseline assessments, HCWs reported significant improvements in sleep quality as measured by the Insomnia Severity Index (ISI) (Cohen's d = 1.74, p < 0.001) and a significant reduction in perceived sleep onset latency (SOL) during the intervention (M = 17.2 minutes, SD = 7.7) compared to baseline (M = 24.7 minutes, SD = 16.1), (Cohen's d = -0.42, p = 0.001). There were no significant changes in objective SOL (p = 0.703). However, there was a significant interaction between baseline objective SOL (<20 minutes vs >20 minutes) and condition (baseline vs intervention) (p = 0.002), such that individuals with objective SOL >20 minutes experienced a significant decrease in objective SOL during the intervention period compared to baseline (p = 0.015). Conclusions: HCWs experienced a significant improvement in perceived SOL and ISI scores after using the electronic noise-masking earbuds. Our data provide preliminary evidence for a nonpharmacological intervention to improve the sleep quality of HCWs which should be confirmed by future controlled studies.

Palate shape is associated with Unilateral Hypoglossal Nerve Stimulation Outcomes

OBJECTIVE

The aim was to determine the potential association between palate shape and unilateral hypoglossal nerve stimulation (HNS) outcomes.

METHODS

Preoperative drug-induced sleep endoscopy (DISE) videos were reviewed and scored by 3 blinded reviewers to determine airway narrowing at the hard-soft palate junction (HP), soft palate genu, and inferior velum, as described by Woodson (2014). Scoring was as follows: 1-open airway, 2-narrow, 3-severe narrowing. Overall palate shape (oblique, intermediate, or vertical) was determined based on prior criteria. Successful surgical treatment was defined by the HNS titration polysomnogram as a reduction of ≥50% in the apnea-hypopnea index (AHI) to <15 events/h.

RESULTS

Of 332 adults, the majority was male (77%) with an average BMI of 29.2 ± 3.6 kg/m2 . Overall success rate was 73%. Success rate was lower in patients with vertical palate shape compared with the other shapes (56% vs. 75%, p = 0.029). HP score 3 compared with scores 2 and 1 was associated with lower success rates (60% vs. 76%, p = 0.028), but genu and velum scores were not associated with outcomes. Patients with both HP score 3 and complete oropharyngeal lateral wall-related obstruction had notably worse outcomes (22% vs. 74%, p = 0.026). HP score 3 (OR 0.45, 95%CI 0.22-0.92) and vertical palate shape (OR 0.33, 95%CI 0.15-0.78) were independently associated with lower odds of surgical response after adjustment for DISE findings, age, gender, and BMI.

CONCLUSION

Vertical palate shape and narrowing at the hard-soft palate junction are independently associated with lower HNS surgical success rates.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:981-986, 2024.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

A Protocol for Propofol-Infusion Drug-Induced Sleep Endoscopy

OBJECTIVE

The objective of this study was to outline a protocol utilizing propofol infusion without an initial bolus during drug-induced sleep endoscopy (DISE). We define normative values for final propofol infusion rate (P^final ) during DISE and sedation depth values at P^final .

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic hospital.

METHODS

A review of patients with obstructive sleep apnea who underwent DISE between 2016 and 2020 was performed. The following patient data were recorded: demographics; DISE procedure details, including P^final , time to P^final , frequency and cadence of infusion rate changes, depth of sedation as measured by Bispectral Index and SedLine values, and hemodynamics; and polysomnography details including apnea-hypopnea index severity and minimum oxygen saturation. A mixed linear model adjusted for age and body mass index was performed for the analysis of effects on P^final . Pearson correlation coefficients determined the strength of association between depth of sedation measured and pattern of collapse on DISE and P^final .

RESULTS

There were 246 patients who met inclusion criteria. P^final resembled a normal distribution (mean ± SD, 156.44 ± 26.69 mcg/kg/min; median, 150 mcg/kg/min). Analysis demonstrated that P^final was influenced by male sex, current smoker status, time to P^final , and number of propofol dose changes (P < .05). Depth of sedation categories measured differently between Bispectral Index and SedLine (55-65 vs 45-55, P < .001). The pattern including severity of collapse on DISE was not associated with P^final (P > .05). No patients required intra- or postoperative respiratory support beyond oxygen via nasal canula.

CONCLUSION

We describe a propofol slow-infusion DISE protocol that demonstrates safe and reproducible outcomes.

Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study

OBJECTIVES/HYPOTHESIS

To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA).

STUDY DESIGN

Cohort study.

METHODS

A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour.

RESULTS

Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m² . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042).

CONCLUSIONS

The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1676-1682, 2021.

Evaluation of Surgical Learning Curve Effect on Obstructive Sleep Apnea Outcomes in Upper Airway Stimulation

OBJECTIVE

An increasing number of facilities offer Upper Airway Stimulation (UAS) with varying levels of experience. The goal was to quantify whether a surgical learning curve exists in operative or sleep outcomes in UAS.

METHODS

International multi-center retrospective review of the ADHERE registry, a prospective international multi-center study collecting UAS outcomes. ADHERE registry centers with at least 20 implants and outcomes data through at least 6-month follow-up were reviewed. Cases were divided into two groups based on implant order (the first 10 or second 10 consecutive implants at a given site). Group differences were assessed using Mann-Whitney U-tests, Chi-squared tests, or Fisher's Exact tests, as appropriate. A Mann-Kendall trend test was used to detect if there was a monotonic trend in operative time. Sleep outcome equivalence between experience groups was assessed using the two one-sided tests approach.

RESULTS

Thirteen facilities met inclusion criteria, contributing 260 patients. Complication rates did not significantly differ between groups (P = .808). Operative time exhibited a significant downward trend (P < .001), with the median operative time dropping from 150 minutes for the first 10 implants to 134 minutes for the subsequent 10 implants. The decrease in AHI from baseline to 12-month follow-up was equivalent between the first and second ten (22.8 vs 21.2 events/hour, respectively, P < .001). Similarly, the first and second ten groups had equivalent ESS decreases at 6 months (2.0 vs 2.0, respectively, P < .001). ESS outcomes remained equivalent for those with data through 12-months.

CONCLUSIONS

Across the centers' first 20 implants, an approximately 11% reduction operative time was identified, however, no learning curve effect was seen for 6-month or 12-month AHI or ESS over the first twenty implants. Ongoing monitoring through the ADHERE registry will help measure the impact of evolving provider and patient specific characteristics as the number of implant centers increases.

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study

OBJECTIVE

To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort.

METHODS

Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression.

RESULTS

Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m² . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely).

CONCLUSION

DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique.

LEVEL OF EVIDENCE

2B Laryngoscope, 129:761-770, 2019.

Prognostic Factors in the Outcome of Invasive Fungal Sinusitis in a Pediatric Population

BACKGROUND

Pediatric invasive fungal sinusitis (IFS) is rare, and its prognosticators are poorly understood. The aim of this study was to determine important factors affecting outcome.

METHODS

A 10-year retrospective review at a tertiary academic children's hospital was performed using an International Classification of Diseases, 9th revision, and a procedure-based search after institutional review board approval. All relevant demographic and clinical information was collected.

RESULTS

Fourteen immune-compromised patients (male:female = 7:7, mean age = 10 years, range 2-16 years) were identified who had hematologic malignancies (11), diabetes mellitus (2) and unknown predisposing factors (1). Fungal species included Aspergillus (5), Mucor (5), Alternaria (2), Rhizopus (1) and Scopulariopsis (1). The cohort underwent an average of 6.1 (median = 5) endoscopic sinus surgeries and were treated with aggressive antifungal therapy. Four deaths occurred in the study population: 2 were attributable to IFS and 2 attributable to their underlying malignancies. There was a significant difference in the median absolute neutrophil count (ANC) at follow-up after treatment of IFS between the survival and the mortality subgroups, with ANC being 4290.5 and 169, respectively (P < 0.001).

CONCLUSIONS

Despite the small sample size, this study represents the largest case series in the medical literature on pediatric IFS. Age, gender, underlying cause for immunodeficiency and mycologic agent were not important prognosticators. ANC appears to be the only factor responsible for survival. The role of endoscopic sinus surgeries in survival is indeterminate.

Development of a Diagnostic Panel of Methylated MicroRNA Markers for Head and Neck Cancer

Objectives:

Early detection of head and neck squamous cell carcinoma (HNSCC) improves long-term survival. More than half of patients with HNSCC present with locoregional or metastatic disease at the time of diagnosis. MicroRNAs are promising markers for early detection, as they are stable, tissue-specific, and known to be involved in processes critical for tumor development and progression. Methylated miRNA sequences have already been studied in early detection of lung and gastrointestinal (GI) cancers.

Methods:

Genomic DNA was extracted from 30 SCC samples, 24 samples of grossly normal adjacent mucosa from those tumor patients, and 8 samples from normal controls (no cancer). The gDNA was treated with bisulfate to identify methylation patterns, and quantitative polymerase chain reaction was run for 6 miRNA markers (9-1, 9-3, 124-1, 124-2, 124-3, 137) to determine the level of expression in each sample.

Results:

Overall expression of each marker was significantly higher in the tumor group when compared to the controls ( P < 0.001) and the adjacent mucosa ( P < 0.001). Using the expression levels within the controls as a baseline, a positive cut-off value was determined for each marker to create 100% specificity. The sensitivity of each individual marker ranged from 60-76%, but when used in combination as a diagnostic panel, the sensitivity increased to 90%.

Conclusions:

We have successfully created a diagnostic panel of methylated microRNA markers that demonstrated 90% sensitivity and 100% specificity in the detection of HNSCC. This panel is currently being tested on saliva, blood, and tissue samples of tumor-positive and tumor-negative (control) patients as part of a larger early detection clinical study.

Death after adenotonsillectomy secondary to massive pulmonary embolism

Tonsillectomy is one of the most common surgical procedures performed in the United States. Although relatively safe, there is a small risk of post-operative mortality. The majority of deaths come from airway compromise or hemorrhage. The authors present a case of a 32-month-old child who underwent routine adenotonsillectomy for sleep disordered breathing and chronic pharyngitis who was found unresponsive and pulseless in his bed on the morning of postoperative day 2. The cause of death determined by post mortem autopsy was massive pulmonary embolism (PE). PE is a rare event in children and has never been reported as the cause of death following adenotonsillectomy in a child. This case is reviewed in addition to recent literature regarding obstructive sleep apnea (OSA) as a risk factor for venous thrombosis and PE.

Ontogenic development of brown adipose tissue in Angus and Brahman fetal calves

Brahman calves experience greater neonatal mortality than Angus calves if cold-stressed. To establish a developmental basis for this, three fetuses of each breed type were taken at 96, 48, 24, 14, and 6 d before expected parturition, and at parturition. Overall fetal BW tended (P = 0.08) to be greater for Angus than for Brahman fetuses. There was no difference between breed types in total brown adipose tissue (BAT) mass or grams of BAT/kg BW. Brown adipocyte density decreased 56%, whereas lipogenesis from acetate and glucose in vitro decreased 97% during the last 96 d of gestation in both breed types. Glycerolipid synthesis from palmitate declined by 85% during the last trimester but still contributed 98% to total lipid synthesis at birth. The fetal age x breed interaction was significant for lipogenesis from glucose (P = 0.05) and palmitate (P = 0.005); rates were higher at 96 d before birth in Brahman BAT but declined to similar rates by birth. Uncoupling protein-1 (UCP1) mRNA tripled during gestation in both breed types (P = 0.002), whereas mitochondrial cross-sectional area did not change (P = 0.14) during gestation. Neither the breed nor the age x breed effect was significant (P > or = 0.24) for UCP1 mRNA concentration or mitochondrial cross-sectional area. In both breed types, a marked decrease in BAT UCP1 mRNA between 24 and 14 d prepartum was associated with a similar reduction in lipogenesis from palmitate and a noticeable change in BAT mitochondrial morphology, as the mitochondria became more elongated and the cristae became more elaborate. Uncoupling protein-1 mRNA initially was elevated in Angus tailhead s.c. adipose tissue, but was barely detectable by birth, and tended to be greater overall (P = 0.09) in Angus than in Brahman BAT. If uncoupling protein activity in s.c. adipose tissue persists after birth, then s.c. adipose tissue may contribute more to thermogenesis in Angus newborn calves than in Brahman calves. In contrast, we did not observe differences in ontogenic development of perirenal BAT that could explain the documented differences in thermogenic capacity between Angus and Brahman newborn calves.