The recent trend for legalization of medicinal cannabis and cannabinoid-containing products, together with their soporific effects, has led to a surge of interest of their potential therapeutic role in the management of some common sleep disorders, such as insomnia, sleep disordered breathing, and restless legs syndrome, and less common disorders such as narcolepsy and parasomnias. Although much of the pre-clinical and clinical data were derived from studies with relatively small sample sizes and limited by biases in assessment, and in clinical trials lack of allocation concealment, as a whole, the results indicate a potential therapeutic role for cannabinoids in the management of some sleep disorders. Clinical trials are underway for insomnia and obstructive sleep apnea management, but there remains a substantial need for rigorous large multi-center studies to assess the dose, efficacy, and safety of the various types of cannabinoids on sleep disorders. This review aims to summarize the modulatory effects of cannabinoids on sleep physiology and provide a critical evaluation of the research on their potential therapeutic benefit in various sleep disorders.
BackgroundA knowledge gap exists in understanding the beneficial use and duration of domiciliary supplemental oxygen (DSO) therapy among survivors of COVID-19 hospitalisations with persistent hypoxemia upon discharge. The purpose of this single center study was to begin to address this issue.MethodsIn this retrospective study we report features of U.S. military veterans residing in metropolitan Chicago with no prior DSO therapy who survived COVID-19 hospitalisation, were discharged on DSO, and were followed for 6 months.ResultsWe found that the majority of the 65 elderly patients (median age, 70 years), predominantly obese Black males, who survived COVID-19 hospitalisations at the Jesse Brown VA Medical Center and discharged on DSO did not undergo a formal 6-min walk test (6 MWT) to re-assess ongoing ambulatory supplemental oxygen requirements (46 patients or 71%). Nonetheless, DSO therapy was discontinued in most patients predominantly within 8 weeks of hospital discharge (34 patients, 52%). In addition, a large proportion of patients, obese Blacks in particular, who survived COVID-19 hospitalisations and were treated with DSO for at least 8 weeks thereafter developed post-acute sequelae of COVID-19 infection (PASC) (30 patients, 46%).ConclusionsGiven these findings, we recommend that healthcare providers be appraised about proper monitoring and evaluation, including timely performance of 6 MWT, of patients who survived COVID-19 hospitalisations and treated with DSO for persistent hypoxemia upon discharge. Whether obese Black males who survived COVID-19 hospitalisations and are treated with DSO thereafter have an elevated risk in developing PASC remains to be determined in larger, prospective studies.
Inhaled short-acting b2-adrenergic agonists (SABA) can rarely elicit paradoxical bronchospasm (PB), which may be life threatening. Prior studies have shown PB to be associated with significantly worse respiratory outcomes, including greater frequency of COPD exacerbations.Among U.S. military veterans, COPD has been reported to be of higher prevalence but the prevalence of PB is not known in this population. The purpose of our study was to determine whether paradoxical bronchospasm is recognized and reported in spirometry test results of U.S. military veterans with COPD and asthma at our tertiary care VA medical center. METHODS:We performed a retrospective review of 1,150 adequately performed pre-and post-bronchodilator spirometry test reports between years 2017 to 2020. PB was defined as at least 12%-and 200-mL decrease in forced expiratory volume in one second (FEV1) and/or forced vital capacity (FVC) from baseline after inhalation of albuterol. In addition, to pertinent demographics and comorbidities, spirometry data including pre-and post-bronchodilator FEV1 and FVC was obtained and analyzed.RESULTS: Eighteen reports were identified with post bronchodilator PB (1.5%), 12 with COPD, 4 with asthma and 2 with asthma/COPD. Noreport alluded to post-bronchodilator PB. This included 17 males and one female, 14 African Americans, 3 Caucasian and one Latinx, aged 67AE8 years (meanAESD) with BMI 28AE5 kg/m2. Thirteen were ex-tobacco smokers, 4 current smokers and one never smoked. Chest CT revealed emphysema in 8 veterans with COPD and bronchial wall thickening in 3.Chest radiographs of 4 veterans with asthma were unremarkable. All veterans were treated with inhaled b2-adrenergic agonists.Five were treated with cardioselective beta 1 blockers and 10 for gastroesophageal reflux disease (GERD). Eleven veterans were diagnosed with obstructive sleep apnea. In 12 veterans, inhaled albuterol (4 actuations)-induced decrease in FEV1 was 22AE8% and 367AE167 mL from baseline. In 6 veterans, only FVC decreased significantly from baseline (14AE3% and 448AE179 mL). No veteran reported respiratory symptoms during or after spirometry testing. Two veterans died during follow-up.CONCLUSIONS: PB displayed during spirometry testing of veterans, albeit rare, is not recognized nor reported in test results. Most identified cases of PB had history of smoking (current or prior), underlying GERD and obstructive sleep apnea history. CLINICAL IMPLICATIONS: Two large studies that investigated the prevalence of PB displayed during spirometry testing in the U.S. did not include U.S. military veterans with COPD and asthma. To the best of our knowledge, our study is the first to report PB in this population who underwent spirometry testing according to ATS/ERS guidelines. Paradoxical bronchospasm can represent a rare unrecognized phenotype of patients with COPD and asthma and should be readily recognized and reported..
Proposed novel treatment paradigm of aberrant gait and balance kinematics in patients with severe COPD Patients with severe chronic obstructive pulmonary disease (COPD; forced expiratory volume in 1 s [FEV 1 ] < 50% predicted) often report limited participation in walking and exercise activities irrespective of the severity of dyspnoea. 1,2 This, in turn, could constrain their activities of daily living, including outdoor ventures, adversely affect quality of life and increase the risk of acute exacerbations. 3 However, the pathophysiological mechanisms underlying this phenomenon have not been clearly elucidated. Addressing this knowledge gap is important because it could stimulate the development of evidence-based, innovative therapeutic interventions to enable these high-risk patients to perform regular physical activity and exercise thereby improving quality of life and health outcomes.Clinical evidence informs that lower limb muscle strength and endurance along with cognition are impaired in patients with severe COPD. [2][3][4][5] Conceivably, this could promote aberrant gait and balance kinematics which, in turn, may hinder physical activity and exercise capacity and worsen dyspnoea during activities of daily living. 6 To that end, Yentes et al. interrogated the large (n = 31,000) National Health and Nutritional Examination Survey (NHANES) III data set and a found significant correlation between the presence of altered gait and severe COPD. 7 Decreased physical activity was also significantly associated with severe COPD. In a recent review of seven studies comprising 375 elderly patients (64-75 years) with predominantly severe COPD, Zago et al. reported that gait abnormalities observed in these patients comprised of reduced step length and rhythm, and spatiotemporal inconsistency in gait patterns during ambulation. 8 In addition, Morlino et al. proposed that aberrant gait and balance kinematics observed in patients with severe COPD could be related, in part, to damaged neuronal circuits that subserve those functional outcomes in the brain. 2 Despite recent progress in medical research, the pathogenesis of aberrant gait and balance kinematics observed in patients with severe COPD remains elusive. In fact, a comprehensive, 8-week pulmonary rehabilitation programme comprising of 40 sessions of physical exercise training failed to improve stride-to-stride fluctuations (a component of the capacity to adapt walking patterns) in 44 patients with predominantly moderate COPD (mean FEV 1 % predicted, 56%). 9 However, this study did not target specific pathophysiological mechanisms that may underly aberrant gait and balance kinematics in these patients. To the best of our
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