The authors conducted an open-label trial of modafinil for excessive daytime sleepiness in myotonic dystrophy. Eleven patients were evaluated: two were not treated because of obstructive sleep apnea, and nine received 200 to 400 mg modafinil/day for an average of 16.4 weeks. There were no major side effects. Average sleep latency as measured by the Multiple Sleep Latency Test increased from 7.3 to 22.7 minutes ( p = 0.00013), and average Epworth Sleepiness Scale score decreased from 13.25 to 7.75 (p = 0.01028). Modafinil shows evidence of effectiveness for excessive daytime somnolence in myotonic dystrophy and should be investigated further.

Aim: To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM). Methods: This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment. Results: 50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 ± 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0-2. The overall intra-hospital mortality was 50% (n = 25). Conclusions: It is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

Mild therapeutic hypothermia (MTH 33°C) post out-of-hospital cardiac arrest (OHCA) is widely accepted as standard of care. However, uncertainty remains around the dose and therapy duration. OHCA patients are usually kept sedated±paralyzed and ventilated for the first 24-36 hours, which allows for targeted temperature management, but makes neurological prognostication challenging. The aim of this study is to investigate the feasibility and safety of assessing the unconscious OHCA patient after 12 hours for early waking/extubation while continuing to provide MTH for 24 hours, and fever prevention for 72 hours by using an intravenous temperature management (IVTM) system and established conscious MTH anti-shiver regimens. This is a single-center, prospective, non-randomized observational study that will compare the results of early awakening (at 12 hours) with historical controls. A total of 50 consecutive unconscious survivors of OHCA, treated with MTH, who meet the Therapeutic Hypothermia and eArly Waking (THAW) inclusion criteria will be enrolled. The patient will receive MTH by using IVTM. After 12 hours of MTH, patients will be assessed by using strict clinical criteria to determine suitability for early waking and extubation. Once awake and extubated, MTH will continue for 24 hours with skin counter-warming and anti-shiver regimen followed fever prevention up to 72 hours. All patients will have serial electroencephalogram (EEG), somatic sensory potential, and neuro-biomarkers performed on admission to intensive care unit, 6 and 12 hours, then every 24 hours until 72 hours. The study has been approved by the National Research Ethics Service, Health Research Authority.

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Out of hospital cardiac arrest (OHCA) is a major healthcare chal-13 lenge. In 2020, in England, the ambulance service attended 93,920 14 calls for OHCA, with just 8.3% of patients conveyed to hospital sur-15 viving to discharge. 1 Many patients suffer poor outcomes due to 16 hypoxic-ischaemic brain injury occurring prior to admission. 2 The 17 International Liaison Committee on Resuscitation (ILCOR) suggests 18 a multi-modality approach to neurological prognostication, including 19 clinical examination, neurophysiology, biomarkers and neuro-imag-20 ing to be performed no earlier than 72 hours when targeted temper-21 ature management and sedation have been safely discontinued. 3 22 However, utilization is poor; one study from Denmark suggests that 23 just 32% of OHCA patients underwent an electroencephalogram 24 (EEG) and 14% somatosensory evoked potential test (SSEP). 4 25 The Essex Cardiothoracic Centre, in the South East of the United 26 Kingdom delivers cardiac care to a population of 1.7 million people. 27 Typically, we see over 100 OHCA admissions per annum. One of the 28 many challenges has been how to deliver guideline directed neuro-29 prognostication in a stand-alone cardiac centre, whilst not having 30 access to the diagnostics and specialist staff essential for neurolog-31 ical-prognostication available to centres that exist within larger 32 hospitals. 33We have a unique nurse lead approach that ensures our patients 34 receive cutting edge neurological prognostication. We have previ-35 ously shown the feasibility of setting up a neurophysiology service 36 in standalone cardiac centre 5 and we now employ a highly specialist 37 cardiac nurse specifically for this purpose. Following acute treat-38 ment, OHCA patients are admitted to intensive care or the coronary 39 care unit. Our OHCA nurse then takes a clinical history and docu-40 ments and a MIRACLE-2 score. 6 They are responsible for a detailed 41 neurological assessment, including quantitative pupillometry and 42 brainstem reflexes. In addition, the nurse ensures that blood is drawn 43 at 72 hours for Neuronal Specific Enolase (NSE) levels. For patients 44 remaining comatose at 72 hours the nurse performs an SSEP and 45 EEG as well as ensuring a CT head has been done. The clinical pic-46 ture, neuro-physiology tests, and CT imaging are live-screened via 47 tele-conferencing software to a neurologist with a special interest 48 in neurological-prognostication, based off site. The results are veri-49 fied and discussed in a twice weekly neuro-prognostication MDT with 50 attending cardiologist and ICU consultant. Early neurological-prog-51 nostication may signal: poor outcomes instigating a palliative strat-52 egy, indeterminate results requiring continued supportive therapies 5. Watson N, Damian M, Potter M, et al. Increasing cardiac arrest 91 survivor access to advanced neuromonitoring and 92 neuroprognostication, as recommended in international guidelines -A 93