EClinicalMedicine
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Complex insomnia, the comorbidity of chronic insomnia and obstructive sleep apnea (OSA), is a common sleep disorder, but the OSA component, whether presenting overtly or covertly, often goes unsuspected and undiagnosed due to a low index of suspicion. Among complex insomniacs, preliminary evidence demonstrates standard CPAP decreases insomnia severity. However, CPAP causes expiratory pressure intolerance or iatrogenic central apneas that may diminish its use. An advanced PAP mode-adaptive servo-ventilation (ASV)-may alleviate CPAP side-effects and yield superior outcomes. ⋯ PAP therapy was highly efficacious in decreasing insomnia severity in chronic insomnia patients with previously undiagnosed co-morbid OSA. ASV proved superior to CPAP in this first efficacy trial to compare advanced to traditional PAP modes in complex insomnia. Future research must determine the following: pathophysiological mechanisms to explain how OSA causes chronic insomnia; general population prevalence of this comorbidity; and, cost-effectiveness of ASV therapy in complex insomnia. Last, efforts to raise awareness of complex insomnia are urgently needed as patients and providers appear to disregard both overt and covert signs and symptoms of OSA in the assessment of chronic insomnia.
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In obese patients, preoxygenation with non-invasive ventilation (NIV) was reported to improve outcomes compared with facemask. In this setting, high-flow nasal cannulae (HFNC) used before and during intubation has never been studied against NIV. ⋯ Institutional funding, additional grant from Fisher & Paykel. Clinicaltrials.gov identifier: NCT03106441 N°ID RCB: 2017-A00305-48. Institutional review Board: CPP Nord-Ouest I, registration number 019/2017. URL registry:https://clinicaltrials.gov/ct2/show/NCT03106441.
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Self-harm is the leading risk factor for suicide, with elevated rates reported amongst older populations. This study explores how older adults experience self-harm, identifying factors leading to self-harm. ⋯ Self-harm is often concealed due to stigma and shame, being further accentuated amongst older adults, which may result in low levels of medical help-seeking behaviour for self-harm. Self-harm occurred along a spectrum of no-suicidal intent to high-levels of intent, suggesting self-harm holds different functions to older adults. Clinicians should be aware of the existence of self-harm in this age-group, and the heightened risk amongst those with comorbidities so adequate assessment, support and/or referral is provided.
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Clostridioides (Clostridium) difficile ranks first among the pathogens of hospital-acquired infections with hospital-based preventive strategies being only partially successful in containing its spread. ⋯ These results outline the association of HO-CDI with community practice and characteristics of the healthcare delivery system and support the need to further study the effect of community and nursing home-based antimicrobial and acid suppressant stewardship programs in the rate of HO-CDI in geographic areas that may cross state lines.
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Despite explicit policies and reporting mechanisms in academia designed to prevent harassment and ensure respectful environments, sexual harassment persists. We report on a national survey of Canadian medical students' experiences of sexual harassment perpetrated by faculty, patients and peers, their responses to harassment, and their suggestions for improving the learning environment. ⋯ Sexual harassment is a part of the Canadian medical education environment where most who reported harassment are subject to the dual vulnerabilities of being learners and women. Although survey respondents recognised the systemic nature of the problem, as individuals they often described shame and self-blame when victimised, came up with solutions that implied they were the problem, and often reported thinking silence was less risky than confrontation or official reporting. Many participants believed in the transformative power of education - of themselves and faculty - as a means of improving the medical environment whilst we await social change.