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IntroductionSubjective sleep disturbance is common in chronic obstructive pulmonary disease (COPD) and is related to hyperinflation when supine and tidal expiratory flow limitation (EFL). We hypothesised that abnormalities in supine lung mechanics disturb sleep and impair gas exchange in COPD. We aimed to assess relationships between supine lung derecruitment, EFL and hyperinflation, and polysomnographic measures of sleep disturbance and gas exchange in COPD.MethodsIn this prospective, observational study, supine oscillometry was performed in stable COPD patients to assess lung derecruitment (reactance at 5 Hz (Xrs5) z-score) and EFL (difference between mean inspiratory and expiratory reactance (∆Xrs5)). Hyperinflation was assessed by supine inspiratory capacity (ICsupine) z-score. In-laboratory polysomnography was used to assess sleep disturbance, measured by Apnoea-Hypopnoea Index (AHI), Oxygen Desaturation Index (ODI) and AHI during rapid eye movement sleep (AHI REM). Monitoring of transcutaneous carbon dioxide (TcCO2), and measurements of partial pressure of arterial carbon dioxide (PaCO2) and HCO3− were performed in a subgroup.Results28 COPD patients were enrolled (13 female, mean age (SD) 67.5 (8.71) years and mean forced expiratory volume in 1second (FEV1) z-scores (SD) −2.61 (1.06)). Worse Xrs5(supine) correlated with greater respiratory arousals (AHI rs =0.47, p=0.01; ODI rs=−0.58, p=0.001), as did greater ∆Xrs5(supine) (AHI REM rs=0.53, p=0.005). Xrs5(supine) correlated with peripheral oxygen saturation nadir (rs=0.43, p=0.02). ICsupine correlated negatively with hypoventilation (PaCO2 rs=−0.77, p=0.001; HCO3− rs=−0.78, p=0.001, n=15), as did Xrs5(supine) (rise in TcCO2 rs=−0.65, p=0.009).ConclusionLung derecruitment, EFL and supine hyperinflation likely contribute to sleep disturbance and sleep-related gas exchange impairment in COPD.

Large reductions in diabetes complications have altered diabetes-related morbidity in the USA. It is unclear whether similar trends have occurred in causes of death. Using data from the National Health Interview Survey Linked Mortality files from 1985 to 2015, we estimated age-specific death rates and proportional mortality from all causes, vascular causes, cancers, and non-vascular, non-cancer causes among US adults by diabetes status. From 1988–94, to 2010–15, all-cause death rates declined by 20% every 10 years among US adults with diabetes (from 23·1 [95% CI 20·1–26·0] to 15·2 [14·6–15·8] per 1000 person-years), while death from vascular causes decreased 32% every 10 years (from 11·0 [9·2–12·2] to 5·2 [4·8–5·6] per 1000 person-years), deaths from cancers decreased 16% every 10 years (from 4·4 [3·2–5·5] to 3·0 [2·8–3·3] per 1000 person-years), and the rate of non-vascular, non-cancer deaths declined by 8% every 10 years (from 7·7 [6·3–9·2] to 7·1 [6·6–7·5]). Death rates also declined significantly among people without diagnosed diabetes for all four major mortality categories. However, the declines in death rates were significantly greater among people with diabetes for all-causes (pinteraction<0·0001), vascular causes (pinteraction=0·0214), and non-vascular, non-cancer causes (pinteration<0·0001), as differences in all-cause and vascular disease death between people with and without diabetes were reduced by about a half. Among people with diabetes, all-cause mortality rates declined most in men and adults aged 65–74 years of age, and there was no decline in death rates among adults aged 20–44 years. The different magnitude of changes in cause-specific mortality led to large changes in the proportional mortality. The proportion of total deaths among adults with diabetes from vascular causes declined from 47·8% (95% CI 38·9–58·8) in 1988–94 to 34·1% (31·4–37·1) in 2010–15; this decline was offset by large increases in the proportion of deaths from non-vascular, non-cancer causes, from 33·5% (26·7–42·1) to 46·5% (43·3–50·0). The proportion of deaths caused by cancer was relatively stable over time, ranging from 16% to 20%. Declining rates of vascular disease mortality are leading to a diversification of forms of diabetes-related mortality with implications for clinical management, prevention, and disease monitoring. None.

Nurse practitioners (NPs) provide an increasing proportion of home-based primary care, despite restrictive scope of practice laws in approximately one half of states. We examined the relationship between scope of practice laws and state volume of NP-provided home-based primary care by performing an analysis of 2018 to 2019 Medicare claims. For each state we calculated the proportion of total home-based primary care visits by NPs and the proportion of all NPs providing home-based primary care. We used the 2018 American Association of Nurse Practitioners classification of state practice environment. We performed chi-square tests to assess the significance between volume and practice environment. We found that 42% of home-based primary care is delivered by NPs nationally, but substantial variation exists across states. We did not find a discernible or statistically significant pattern of uptake of NP-provided home-based primary care across full, reduced, or restricted states. [Journal of Gerontological Nursing, 49(5), 11–17.]

Amiodarone is a highly effective antiarrhythmic drug, but can have serious adverse effects, particularly in older patients. If possible it should not be used purely for controlling the heart rate If a prescription for amiodarone is contemplated, particularly for an older patient, consult a cardiologist. Avoid amiodarone in patients with significant conduction system disease, significant liver or pulmonary disease, or hyperthyroidism Regular monitoring of the patient, clinically and biochemically, is required to identify complications at an early, treatable stage. Maintain a high level of suspicion if a patient taking amiodarone is experiencing adverse reactions and presents with new symptoms Consider potential drug interactions when other drugs are prescribed with amiodarone. The effects and toxicities of amiodarone may persist weeks after it is stopped

PurposeObstructive sleep apnoea (OSA) is a common condition with a range of short- and long-term health implications. Providing patient-centred care is a key principle to ensure patients are well informed and empowered to participate in clinical decision making. This study aimed to develop a patient-centred sleep study report for patients with obstructive sleep apnoea and to determine whether or not its implementation led to improved patient understanding of their disease.MethodsThe study was performed in two phases. The first phase utilised the Delphi-survey technique to develop and critically appraise a patient-centred sleep study report (PCSR) for patients with OSA, to accurately and simply convey key components of the patient’s diagnosis and management. The second phase was a prospective, randomised controlled trial to assess the effect of the PCSR on patient knowledge, self-efficacy, and understanding as measured through validated patient questionnaires.ResultsThe PCSR was developed on key concepts deemed to be important by the surveyed physicians, senior sleep scientists and patients. This included ensuring the results were customised, highlighting the patient’s apnoea-hypopnea index, oxygen desaturation index and arousal index and limiting technical information to a few key pieces. Patients randomised to receive the PCSR had improved understanding and perceived patient-physician interaction compared to those randomised to standard care.ConclusionThe development and implementation of the PCSR was feasible and improved patient understanding and perceived patient-physician interaction in patients with moderate to severe OSA. Whether or not use of the PCSR will translate to improved compliance with therapy will require further evaluation.

Diabetes affects approximately 12% of the U.S. adult population and approximately 25% of adults aged ≥65 years. From 2009 to 2017, there was no significant change in diabetes prevalence overall or among persons aged 65-79 years (1). However, these estimates were based on survey data with <5,000 older adults. Medicare administrative data sets, which contain claims for millions of older adults, afford an opportunity to explore both trends over time and heterogeneity within an older population. Previous studies have shown that claims data can be used to identify persons with diagnosed diabetes (2). This study estimated annual prevalence and incidence of diabetes during 2001-2015 using Medicare claims data for beneficiaries aged ≥68 years and found that prevalence plateaued after 2012 and incidence decreased after 2006. In 2015 (the most recent year estimated) prevalence was 31.6%, and incidence was 3.0%. Medicare claims can serve as an important source of data for diabetes surveillance for the older population, which can inform prevention and treatment strategies.

NEURONS in the central nervous system (CNS) often store more than one neurotransmitter 1,2 , but as yet the functional significance of this type of coexistence is poorly understood. 5-Hydroxytrypta-mine (5-HT) modulates calcium-dependent K + channels (K Ca ) responsible for the postspike afterhyperpolarization in different regions of the CNS 3,4 . In lamprey, 5-HT neurons control apamine-sensitive K Ca channels in spinal locomotor network interneurons 4–6 , thereby in addition regulating the duration of locomotor bursts 7,8 . We report here that these spinal 5-HT neurons also contain dopamine. Like 5-HT, dopamine causes a reduction of the afterhyperpolarization, but in this case it is due to a reduction of calcium entry during the action potential, which results in a reduced activation of K Ca . 5-HT and dopamine are both released from these midline neurons, and both reduce the afterhyperpolarization through two distinctly different, but complementary cellular mechanisms. The net effect of dopamine (10–100 µM) on the locomotor network is similar to that of 5-HT, and the effects of dopamine and 5-HT are additive at the network level.