Heather Ward

Outcomes of Home-Based Diagnosis and Treatment of Obstructive Sleep Apnea

BACKGROUND Home diagnosis and therapy for obstructive sleep apnea (OSA) may improve access to testing and continuous positive airway pressure (CPAP) treatment. We compared subjective sleepiness, sleep quality, quality of life, BP, and CPAP adherence after 4 weeks of CPAP therapy in subjects in whom OSA was diagnosed and treated at home and in those evaluated in the sleep laboratory. METHODS A randomized trial was performed consisting of home-based level 3 testing followed by 1 week of auto-CPAP and fixed-pressure CPAP based on the 95% pressure derived from the auto-CPAP device, and in-laboratory polysomnography (PSG) (using mostly split-night protocol) with CPAP titration; 102 subjects were randomized (age, 47.4 +/- 11.4 years; 63 men; BMI, 32.3 +/- 6.3 kg/m(2); Epworth Sleepiness Scale [ESS]: 12.5 +/- 4.3). The outcome measures were daytime sleepiness (ESS), sleep quality (Pittsburgh Sleep Quality Index [PSQI]), quality of life (Calgary Sleep Apnea Quality of Life Index [SAQLI], 36-Item Short-Form Health Survey [SF-36], BP, and CPAP adherence after 4 weeks. RESULTS After 4 weeks of CPAP therapy, there were no significant differences in ESS (PSG 6.4 +/- 3.8 vs home monitoring [HM] 6.5 +/- 3.8, P = .71), PSQI (PSG 5.4 +/- 3.1 vs HM 6.2 +/- 3.4, P = .30), SAQLI (PSG 4.5 +/- 1.1 vs HM 4.6 +/- 1.1, P = .85), SF-36 vitality (PSG 62.2 +/- 23.3 vs HM 64.1 +/- 18.4, P = .79), SF-36 HM (PSG 84.0 +/- 10.4 vs HM 81.3 +/- 14.9, P = .39), and BP (PSG 129/84 +/- 11/0 vs HM 125/81 +/- 13/9, P = .121). There was no difference in CPAP adherence (PSG 5.6 +/- 1.7 h/night vs HM 5.4 +/- 1.0 h/night, P = .49). CONCLUSIONS Compared with the home-based protocol, diagnosis and treatment of OSA in the sleep laboratory does not lead to superior 4-week outcomes in sleepiness scores, sleep quality, quality of life, BP, and CPAP adherence. TRIAL REGISTRATION clinicaltrials.gov; Identifier: NCT00139022.

Pregnant women with gestational hypertension may have a high frequency of sleep disordered breathing.

BACKGROUND Gestational hypertension is a common complication of pregnancy. Recent evidence suggests that women with gestational hypertension have a high rate of sleep disordered breathing (SDB). Using laboratory-based polysomnography, we evaluated for the frequency of SDB in women with gestational hypertension compared to healthy women with uncomplicated pregnancies. METHODS In this single-center cross-sectional study, women with the diagnosis of gestational hypertension were screened in the Fetal Assessment Unit and Antepartum ward. Healthy subjects were recruited by local advertising. Subjects completed a series of questionnaires addressing sleep quality and daytime sleepiness, followed by full night polysomnography. The primary outcome was frequency of SDB (defined as a respiratory disturbance index ≥ 5) in the gestational hypertension and healthy groups. RESULTS A total of 34 women with gestational hypertension and singleton pregnancies and 26 healthy women with uncomplicated singleton pregnancies consented to participate in the study. The mean ages and gestational ages, but not the body mass indices, of the 2 groups were similar. The frequencies of SDB in the more obese gestational hypertension group and the healthy group were 53% and 12%, respectively (P < 0.001). INTERPRETATION Women with gestational hypertension may have a significantly higher frequency of SDB than do healthy women with uncomplicated pregnancies of similar gestational age. The relative causal contributions, if any, of SDB and obesity remain to be determined.

Putting the ‘patient’ back into patient-centred care: An education perspective

Patient-centred care is a value espoused by most healthcare systems and a concept taught in nursing education programs as a fundamental concept of patient care. In this study, we focused on the patients experience of patient-centredness, interviewing eighteen patients and eight family members about their experiences as patients on an in-patient acute care medical unit in a large hospital in Canada. Approximately half of the patients expressed satisfaction with their experiences and their involvement in decisions about their healthcare. The remainder expressed concerns about their care that jeopardized their experiences of patient-centredness. These areas concerned issues of communication with and among healthcare professionals, relationships with these care providers, trust and respect in the professional relationships, and general satisfaction with care. Participants provided advice to professional students about ways to interact more effectively with their patients to establish caring, empathetic, patient-centred relationships as the basis for care. We address patient recommendations to support learner understanding of the patient experience both in classrooms and clinical experiences throughout educational programs as a means to enhance their patient-centredness.

Constrictive Bronchiolitis and Ulcerative Colitis

Pulmonary complications occur in an estimated 0.21% of patients with inflammatory bowel disease. The most common presentation of pulmonary manifestations is large airway disease, such as tracheobronchitis, chronic bronchitis or bronchiectasis. Small airway disease, such as constrictive bronchiolitis or bronchiolitis obliterans with organizing pneumonia, is less frequently reported, and is described as occurring in isolation from large airway disease. A case of a postcolectomy ulcerative colitis in a patient who has both large airway involvement, tracheobronchitis and bronchiectasis, and constrictive bronchiolitis is presented.

An empirical continuous positive airway pressure trial for suspected obstructive sleep apnea

BACKGROUND Standard practice in obstructive sleep apnea (OSA) management requires that a positive diagnostic, overnight polysomnography (PSG) test be obtained before initiating treatment. However, long waiting times due to lack of access to PSG testing facilities may delay the initiation of definitive treatment for OSA. OBJECTIVES To evaluate the response of patients who had a high clinical suspicion for OSA and who were waiting for a PSG test to an empirical continuous positive airway pressure (CPAP) trial. METHODS A retrospective study of all patients who had been offered empirical CPAP therapy for suspected OSA was conducted. After outpatient assessment, 183 patients with a high pretest probability of having OSA began empirical CPAP testing using an arbitrary CPAP pressure. The presence of OSA, the accuracy of empirical CPAP pressure prescription, the adherence to empirical CPAP and the improvement in daytime somnolence were evaluated at the time of PSG. RESULTS Of 183 patients on a CPAP trial, 91% had OSA, which was at least moderate (more than 15 apneas and hypopneas per hour of sleep) in 75% of the patients. Eighty per cent of the patients had significant daytime somnolence (Epworth Sleepiness Scale [ESS] greater than 10, mean +/- SD ESS 14+/-5), which improved with CPAP (ESS 9.0+/-5, P<0.01). In 40% of the patients, the arbitrary CPAP pressure was lower than that determined by manual titration. Adherence to a trial of CPAP (longer than 2 h/night) predicted OSA with a sensitivity of 82% and a specificity of 41%; the positive and negative predictive values were 92% and 22%, respectively. CONCLUSIONS At the time of PSG testing, OSA was present in 91% of the patients who had received empirical CPAP. An empirical CPAP provided satisfactory interim treatment for excessive somnolence, despite the fact that the CPAP pressure was suboptimal in 40% of the patients.

Postgraduate internal medicine residents' roles at patient discharge - do their perceived roles and perceptions by other health care providers correlate?

Abstract Knowing one’s own role is a key collaboration competency for postgraduate trainees in the Canadian competency framework (CanMEDS®). To explore methods to teach collaborative competency to internal medicine postgraduate trainees, baseline role knowledge of the trainees was explored. The perceptions of roles (self and others) at patient discharge from an acute care internal medicine teaching unit amongst 69 participants, 34 physicians (25 internal medicine postgraduate trainees and 9 faculty physicians) and 35 health care professionals from different professions were assessed using an adapted previously validated survey (Jenkins et al., 2001). Internal medicine postgraduate trainees agreed on 8/13 (62%) discharge roles, but for 5/13 (38%), there was a substantial disagreement. Other professions had similar lack of clarity about the postgraduate internal medicine residents’ roles at discharge. The lack of interprofessional and intraprofessional clarity about roles needs to be explored to develop methods to enhance collaborative competence in internal medicine postgraduate trainees.

A case study of healthcare providers’ goals during interprofessional rounds

ABSTRACT Daily interprofessional rounds enhance collaboration among healthcare providers and improve hospital performance measures. However, it is unclear how healthcare providers’ goals influence the processes and outcomes of interprofessional rounds. The purpose of this case study was to explore the goals of healthcare providers attending interprofessional rounds in an internal medicine ward. The second purpose was to explore the challenges encountered by healthcare providers while pursuing these goals. Three focus groups were held with healthcare providers of diverse professional backgrounds. Focus group field notes and transcripts were analysed using thematic analysis. The data indicated that there was no consensus among healthcare providers regarding the goals of interprofessional rounds. Discharge planning and patient care delivery were perceived as competing priorities during rounds, which limited the participation of healthcare providers. Nevertheless, study participants identified goals of rounds that were relevant to most care providers: developing shared perspectives of patients through direct communication, promoting collaborative decision making, coordinating care, and strengthening interprofessional relationships. Challenges in achieving the goals of interprofessional rounds included inconsistent attendance, exchange of irrelevant information, variable participation by healthcare providers, and inconsistent leadership. The findings of this study underscore the importance of shared goals in the context of interprofessional rounding.

Asbestosis and probable microscopic polyangiitis.

Several inorganic dust lung diseases (pneumoconioses) are associated with autoimmune diseases. Although autoimmune serological abnormalities are common in asbestosis, clinical autoimmune/collagen vascular diseases are not commonly reported. A case of pulmonary asbestosis complicated by perinuclear-antineutrophil cytoplasmic antibody (myeloperoxidase) positive probable microscopic polyangiitis (glomerulonephritis, pericarditis, alveolitis, multineuritis multiplex) is described and the possible immunological mechanisms whereby asbestosis fibres might be relevant in induction of antineutrophil cytoplasmic antibodies are reviewed in the present report.

Interprofessional Skills Learning Guide: A Multimedia E-Book for Small-Group or Individual Learning

Introduction Redefining learning space beyond physical classrooms with fixed resources is necessary to address challenges of interprofessional learning in a clinical setting. This multimedia e-book introduces recognized team skills of shared mental models, situational awareness, and the SBAR (situation, background, assessment, and recommendation) communication tool for individual or small-group learning. The e-book was derived from work done to develop an interprofessional small-group interactive learning tool for use in a clinical environment where resources, including meeting space, time, and facilitators, were limited. It is designed for individuals early in their clinical training but who have had previous clinical experience. Methods Utilizing readings, a series of videos, and reflective questions, a virtual narrator guides learners through an interactive case regarding a virtual chronic obstructive pulmonary disease patient preparing for discharge. Results Thirty-two responders evaluated the learning content as being clinically relevant. Comments encouraged all health care providers to become familiar with these interprofessional tools. Discussion Electronic, human, and space resources are often limited, especially in the clinical/education interface of the hospital or clinic environment for embedded interprofessional learning opportunities. The multimedia e-book provides a stand-alone learning resource for individuals or small groups of the same or different professions, with the opportunity for interactive learning with minimal space and human resource requirements.

Accessing Information on a General Internal Medicine Consultation Service: The Value of a GIM Online Guide

The advent of copyright law changes made it difficult for the authors’ Division of General Internal Medicine to continue providing their internal medicine learners with a compilation of key articles on general internal medicine for the consultative rotation. This was seen as an opportunity for collaboration with the library to develop an online guide to key articles for general internal medicine. This guide has been very useful and well received by both faculty and learners.