The response to nasal continuous positive airways pressure (nCPAP) of a wide variety of symptoms recognized to be associated with obstructive sleep apnoea syndrome (OSAS) was examined.Fifty-six consecutive patients with OSAS, confirmed by polysomnography (mean (SD) apnoea±hypopnoea index (AHI) 49.6 (22.6) events . h -1 , Epworth score 15.4 (5.0)), were asked to complete paired symptom evaluation questionnaires, before treatment and again after 4 months of nCPAP. The response rate was 80%. A control group of 21 consecutive OSAS patients of similar age, body mass index (BMI), AHI and Epworth score to the treated group but managed with conservative measures, completed the same questionnaires on two occasions, 4 months apart.The nCPAP-treated group showed significant reductions (Wilcoxon matched pairs test) in the symptoms of daytime sleepiness, restless sleep, heartburn, nocturia, enuresis, headache and nocturnal sweating, whereas controls showed no significant changes in these symptoms. There were no changes in BMI, smoking, alcohol consumption or exercise habits in either group.It was concluded that, in addition to improvements in symptoms of daytime sleepiness and restless sleep, a wide range of other symptoms may improve significantly with nasal continuous positive airways pressure therapy. Eur Respir J 1999; 13: 1086±1090. Obstructive sleep apnoea syndrome (OSAS) affects 1± 4% of adults in Europe and North America [1,2]. Treatment with nasal continuous positive airways pressure (nCPAP) can abolish apnoeas during sleep and has been shown to greatly reduce the excessive daytime sleepiness (EDS) [3,4] that is a major symptom of OSAS. However, OSAS has been reported to be associated with a wide variety of other symptoms, including heartburn [5], nocturia [6], adult nocturnal enuresis [7], and nocturnal sweating [8], but there are little data available on the impact of nCPAP on these. Therefore, a prospective assessment of the subjective impact of nCPAP therapy on a wide range of symptoms in patients with moderate to severe OSAS was performed.The response to nCPAP was compared with a control group of patients with OSAS and similar clinical features, managed with conservative measures. MethodsFifty-six consecutive patients, with a diagnosis of OSAS previously established by full overnight polysomnography (PSG) using standard techniques [9], and who were admitted from the hospital waiting list for nCPAP therapy, completed a written pretreatment questionnaire. This questionnaire contained 23 multiple part questions aimed to assess sleep quality perception and symptoms of OSAS such as snoring, nocturnal choking and witnessed apnoeas. A range of other questions were asked, relating to abnormal motor activity during sleep; changes in personality including mood, irritability and depression; nocturnal sweating; hypnagogic hallucinations; sexual problems including libido and impotence; sleeping position in bed, oesophageal reflux; nocturia and enuresis; nasal symptoms; menstrual status (in women); headache; hearin...

Introduction COVID-19 has spread globally to now be considered a pandemic by the World Health Organisation. Initially patients appeared to have a respiratory limited disease but there are now increasing reports of multiple organ involvement including renal disease in association with COVID-19. We studied the development and outcomes of acute kidney injury (AKI) in patients with COVID-19, in a large multicultural city hospital trust in the UK, to better understand the role renal disease has in the disease process. Methods This was a retrospective review using electronic records and laboratory data of adult patients admitted to the four Manchester University Foundation Trust Hospitals between March 10 and April 30 2020 with a diagnosis of COVID-19. Records were reviewed for baseline characteristics, medications, comorbidities, social deprivation index, observations, biochemistry and outcomes including mortality, admission to critical care, mechanical ventilation and the need for renal replacement therapy. Results There were 1032 patients included in the study of whom 210 (20.3%) had AKI in association with the diagnosis of COVID-19. The overall mortality with AKI was considerably higher at 52.4% compared to 26.3% without AKI (p-value <0.001). More patients with AKI required escalation to critical care (34.8% vs 11.2%, p-value <0.001). Following admission to critical care those with AKI were more likely to die (54.8% vs 25.0%, p-value <0.001) and more likely to require mechanical ventilation (86.3% vs 66.3%, p-value 0.006). Discussion We have shown that the development of AKI is associated with dramatically worse outcomes for patients, in both mortality and the requirement for critical care. Patients with COVID-19 presenting with, or at risk of AKI should be closely monitored and appropriately managed to prevent any decline in renal function, given the significant risk of deterioration and death.

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Background and aims Manual laboratory continuous positive airway pressure (CPAP) titration for obstructive sleep apnoea (OSA) is costly, time intensive and delays access to treatment. Automatic positive airway pressure (APAP) titration has the potential to reduce cost and improve access to treatment. The aim of this study was to assess the clinical efficacy and costs of APAP titration compared with manual titration in moderateesevere OSA. Methods Patients with moderateesevere OSA (apnoea/ hypopnoea index >15 and Epworth Sleepiness Score $8) who were free of co-morbidities that could impair APAP titration were eligible. 249 participants were randomised to manual titration, home APAP or laboratory APAP titration to determine a fixed pressure for CPAP. Clinical and direct cost outcomes were assessed after 4 weeks of treatment. Results Average nightly CPAP use, subjective sleepiness, SF36 quality of life, Trails A and B cognitive function and polysomnographic outcomes were similar among the per-protocol groups. Non-hypertensive patients had a lower resting heart rate (and greater reduction in heart rate) at 4 weeks after laboratory APAP titration compared with home APAP titration. Costs per patient were highest in manual (AU$817.84), followed by laboratory (AU$647.56) and home (AU$132.09) APAP titration. An intention-to-treat analysis confirmed the effectiveness of APAP titration compared with manual titration in the standard clinical setting. Conclusions Among patients with moderateesevere OSA without serious co-morbidities, outcomes at 1 month indicate that APAP titration is more cost-effective than manual laboratory titration to determine an appropriate pressure for CPAP for long-term use; with the largest savings occurring in the home APAP patients. Australian New Zealand Clinical Trials Registry Number ACTRN12608000054314.

Background Coronavirus-19 (COVID-19) has been declared a global pandemic by the World Health Organisation. Severe disease typically presents with respiratory failure but Acute Kidney Injury (AKI) and a hypercoagulable state can also occur. Early reports suggest that thrombosis may be linked with AKI. We studied the development of AKI and outcomes of patients with COVID-19 taking chronic anticoagulation therapy. Methods Electronic records were reviewed for all adult patients admitted to Manchester University Foundation Trust Hospitals between March 10 and April 302,020 with a diagnosis of COVID-19. Patients with end-stage kidney disease were excluded. AKI was classified as per KDIGO criteria. Results Of the 1032 patients with COVID-19 studied,164 (15.9%) were taking anticoagulant therapy prior to admission. There were similar rates of AKI between those on anticoagulants and those not anticoagulated (23.8% versus 19.7%) with no difference in the severity of AKI or requirement of renal replacement therapy between groups (1.2% versus 3.5%). Risk factors for AKI included hypertension, pre-existing renal disease and male sex. There was a higher mortality in those taking anticoagulant therapy (40.2% versus 30%). Patients taking anticoagulants were less likely to be admitted to the Intensive Care Unit (8.5% versus 17.4%) and to receive mechanical ventilation (42.9% versus 78.1%). Conclusion Patients on chronic anticoagulant therapy did not have a reduced incidence or severity of AKI suggesting that AKI is unlikely to be thrombotic in nature. Therapeutic anticoagulation is currently still under investigation in randomised controlled studies to determine whether it has a potential role in COVID-19 treatment.