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Background: Insomnia is common in hospitalized patients. However, no study has examined new onset of insomnia in patients without a prior history of insomnia. Objectives: Incidence of new onset of insomnia in inpatients, associated factors and resolution rate after 2 weeks. Method: This is a prospective observational study conducted at a community hospital. We used the Insomnia Severity Index questionnaire to screen for insomnia in all patients located in the general medical floors from day 3 to day 5 of their hospital stay. We excluded patients with a prior insomnia history. Results: Out of the 205 patients who met the inclusion criteria, 75 patients (36%) reported insomnia. Severe insomnia was present in 3% of patients. Difficulty in maintaining sleep is the most common symptom. Frequent staff disruptions due to blood draws and vital signs checks were reported by 68% as the cause of insomnia, followed by illness associated causes (64%) and sleep disruption due to noise and or brightness (23%). Patients with insomnia had more awakenings due to noise, brightness, and staff interruptions than those without insomnia (1.35 times vs. 0.9 times, p = 0.027). Patients with respiratory symptoms, cardiac monitoring, oxygen use, private rooms, and no sedative use did not have a higher insomnia risk. Patients with insomnia had significant lower satisfaction scores than patients without insomnia (4.53 vs. 4.05, p = 0.001) but did not have a different length of stay (6.18 vs. 6.19, p = 0.97). In 31% of patients with insomnia who were able to be contacted two weeks after discharge, 75% of them had insomnia resolution. Conclusion: New onset of insomnia occurred in 36% of hospitalized patients. Most common causes are staff disruption and disease symptoms. It was usually short-term and could decrease patients’ satisfaction score.

Background: Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results. Method: A search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and metaregression analysis were performed. Results: From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO 2 / FIO 2 of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78-1.03; I 2 = 50%, p = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62-1.06; I 2 = 56%, p = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)-induced weakness. The PaO 2 /FIO 2 ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO 2 /FIO 2 ratio, positive endexpiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes. Conclusion: NMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.

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Purpose: We sought to refine the clinical picture of primary adrenal lymphoma (PAL), a rare lymphoid malignancy with predominant adrenal manifestation and risk of adrenal insufficiency. Methods: 97 patients from 14 centers in Europe, Canada and the United States were included in this retrospective analysis between 1994 and 2017. Results: Of 81 patients with imaging data, 19 (23%) had isolated adrenal involvement (iPAL), while 62 (77%) had additional extra-adrenal involvement (PAL+). Among patients who had both CT and PET scans, 18FDG-PET revealed extra-adrenal involvement not detected by CT scan in 9/18 cases (50%). The most common clinical manifestations were B symptoms (55%), fatigue (45%), and abdominal pain (35%). Endocrinological assessment was often inadequate. With a median follow-up of 41.6 months, 3-year progression-free (PFS) and overall (OS) survival rates in the entire cohort were 35.5% and 39.4%, respectively. The hazard ratios of iPAL for PFS and OS were 40.1 (95% CI: 2.63-613.7, p=0.008) and 2.69 (95% CI: 0.61-11.89, p=0.191), respectively. PFS was much shorter in iPAL versus PAL+ (median 4 months vs. not reached, p=0.006), and OS also appeared to be shorter (median 16 months vs. not reached), but the difference did not reach statistical significance (p=0.16). Isolated PAL was more frequent in females (OR=3.81; P=0.01) and less frequently associated with B symptoms (OR= 0.159; p=0.004). Conclusion: We found unexpected heterogeneity in the clinical spectrum of PAL. Further studies are needed to clarify whether clinical distinction between iPAL and PAL+ is corroborated by differences in molecular biology.