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Introduction/Purpose: Return to play (RTP) assessment and decision-making protocols are among the most discussed topics in sports medicine. Given the lack of validated guidelines, physicians and rehabilitation practitioners often rely on subjective functional evaluation to guide decisions to RTP. Biomechanical assessment using motion capture may be a useful strategy to evaluate an athlete’s post-injury functional status, and to estimate their ability to RTP with reduced risk of re-injury. The purpose of this case-study was to determine the efficacy of using marker-less 3D motion capture to provide an objective functional evaluation to tailor rehabilitation and aid RTP status for a patient who underwent syndesmotic fixation. Methods: In this case-study, a National Collegiate Athletic Association Division I collegiate football offensive lineman (Height: 1.96 m, Weight: 141 kg) performed a movement screen 5 weeks after left ankle syndesmotic fixation for purely ligamentous syndesmotic injury. Testing was performed at the anticipated time of RTP. After a standardized warm-up, the patient performed a series of 14 movements consisting of upper and lower extremity actions in all three planes of motion, including bilateral and unilateral lower extremity actions. Kinematic data was captured using an 8-camera marker-less motion capture system (MLMCS). Left and right joint-specific ranges of motion were compared for symmetry and to normative data produced by the MLMCS manufacturer. Results: The participant successfully performed all 14 movements without limitation. Ankle flexion was symmetrical during bilateral and unilateral squatting actions. However, left ankle (i.e., involved side) flexion was consistently less than right ankle flexion during more dynamic actions (Table 1). Despite the asymmetries, ankle range of motion was within normal ranges for both sides in all movements. From a performance standpoint, left-side jump heights were consistently less than the right-side efforts during the unilateral countermovement jump (left: 34.5 cm versus right: 41.1 cm; -16.0%) and consecutive hops (left: 29.5 cm versus right: 33.0 cm; -10.8%). Results were shared with the athletic trainer to focus rehabilitation efforts. The patient was able to fully RTP at 6 weeks. Conclusion: In this case-study, the patient successfully performed a movement screen without limitation at the time of RTP after left ankle syndesmotic fixation. A MLMCS detected kinematic differences that would be difficult to qualitatively recognize. Specifically, the patient expressed reduced ankle flexion and jumping performance on the operative side. No baseline screening was performed, but the observed asymmetries were consistent with what would be expected from the specific injury. Further research is needed to compare baseline measures to kinematic changes. These findings suggest that a basic movement screen using MLMCS can detect kinematic asymmetries after syndesmotic fixation. Table 1. Kinematic Assessment of Ankle Range of Motion

Purpose: Stereotactic radiosurgery (SRS) is a highly effective therapy for newly diagnosed brain metastases. Prophylactic antiepileptic drugs are no longer routinely used in current SRS practice, owing to a perceived low overall frequency of new-onset seizures and potential side effects of medications. It is nonetheless desirable to prevent unwanted side effects following SRS. Risk factors for new-onset seizures after SRS have not been well established. As such, we aimed to characterize variables associated with increased seizure risk. Methods and Materials: Patients treated with SRS for newly diagnosed brain metastases between 2013 and 2016 were retrospectively reviewed at a single institution. Data on baseline demographics, radiation parameters, and clinical courses were collected. Results: The cohort consisted of 305 patients treated with SRS without prior seizure history. Median age and baseline Karnofsky Performance Scale score were 64 years (interquartile range, 55-70) and 80 (interquartile range, 80-90), respectively. Twenty-six (8.5%) patients developed new-onset seizures within 3 months of SRS. There was no association between new-onset seizures and median baseline Karnofsky Performance Scale score, prior resection, or prior whole brain radiation therapy. There were significant differences in the combined total irradiated volume (12.5 vs 3.7 cm3, P < .001), maximum single lesion volume (8.8 vs 2.8 cm3, P = .003), lesion diameter (3.2 vs 2.0 cm, P = .003), and number of lesions treated (3 vs 1, P = .018) between patients with and without new-onset seizures, respectively. On multivariate logistic regression, total irradiated volume (odds ratio, 1.09 for every 1-cm1 increase in total volume; confidence interval, 1.02-1.17; P = .016) and pre-SRS neurologic symptoms (odds ratio, 3.08; 95% confidence interval, 1.19-7.99; P = .020) were both significantly correlated with odds of seizures following SRS. Conclusions: Our data suggest that larger total treatment volume and the presence of focal neurologic deficits at presentation are associated with new-onset seizures within 3 months of SRS. High-risk patients undergoing SRS may benefit from counseling or prophylactic antiseizure therapy.

Oxygen therapy is known to reduce loop gain (LG) in patients with obstructive sleep apnoea (OSA), yet its effects on the other traits responsible for OSA remain unknown. Therefore, we assessed how hyperoxia and hypoxia alter four physiological traits in OSA patients. Eleven OSA subjects underwent a night of polysomnography during which the physiological traits were measured using multiple 3-min 'drops' from therapeutic continuous positive airway pressure (CPAP) levels. LG was defined as the ratio of the ventilatory overshoot to the preceding reduction in ventilation. Pharyngeal collapsibility was quantified as the ventilation at CPAP of 0 cmH 2 O. Upper airway responsiveness was defined as the ratio of the increase in ventilation to the increase in ventilatory drive across the drop. Arousal threshold was estimated as the level of ventilatory drive associated with arousal. On separate nights, subjects were submitted to hyperoxia (n = 9; F iO2 ∼0.5) or hypoxia (n = 10; F iO2 ∼0.15) and the four traits were reassessed. Hyperoxia lowered LG from a median of 3.4 [interquartile range (IQR): 2.6-4.1] to 2.1 (IQR: 1.3-2.5) (P < 0.01), but did not alter the remaining traits. By contrast, hypoxia increased LG [median: 3.3 (IQR: 2.3-4.0) vs. 6.4 (IQR: 4.5-9.7); P < 0.005]. Hypoxia additionally increased the arousal threshold (mean ± s.d. 10.9 ± 2.1 l min -1 vs. 13.3 ± 4.3 l min -1 ; P < 0.05) and improved pharyngeal collapsibility (mean ± s.d. 3.4 ± 1.4 l min -1 vs. 4.9 ± 1.3 l min -1 ; P < 0.05), but did not alter upper airway responsiveness (P = 0.7). This study demonstrates that the beneficial effect of hyperoxia on the severity of OSA is primarily based on its ability to reduce LG. The effects of hypoxia described above may explain the disappearance of OSA and the emergence of central sleep apnoea in conditions such as high altitude. © 2014 The Physiological Society.

RATIONALE: Patients with heart failure (HF) and Cheyne-Stokes respiration or periodic breathing (PB) often demonstrate improved cardiac function when treatment with continuous positive airway pressure (CPAP) resolves PB. Unfortunately, CPAP is successful in only 50% of patients, and no known factor predicts responders to treatment. Because PB manifests from a hypersensitive ventilatory feedback loop (elevated loop gain [LG]), we hypothesized that PB persists on CPAP when LG far exceeds the critical threshold for stable ventilation (LG = 1). OBJECTIVES: To derive, validate, and test the clinical utility of a mathematically precise method that quantifies LG from the cyclic pattern of PB, where LG = 2[pi]/(2[pi]DR - sin2[pi]DR) and DR (i.e., duty ratio) = (ventilatory duration)/(cycle duration) of PB. METHODS: After validation in a mathematical model of HF, we tested whether our estimate of LG changes with CPAP (n = 6) and inspired oxygen (n = 5) as predicted by theory in an animal model of PB. As a first test in patients with HF (n = 14), we examined whether LG predicts the first-night CPAP suppression of PB. MEASUREMENTS AND MAIN RESULTS: In lambs, as predicted by theory, LG fell as lung volume increased with CPAP (slope = 0.9 ± 0.1; R(2) = 0.82; P < 0.001) and as inspired-arterial PO(2) difference declined (slope = 1.05 ± 0.12; R(2) = 0.75; P < 0.001). In patients with HF, LG was markedly greater in 8 CPAP nonresponders versus 6 responders (1.29 ± 0.04 versus 1.10 ± 0.01; P < 0.001); LG predicted CPAP suppression of PB in 13/14 patients. CONCLUSIONS: Our novel LG estimate enables quantification of the severity of ventilatory instability underlying PB, making possible a priori selection of patients whose PB is immediately treatable with CPAP therapy. [ABSTRACT FROM AUTHOR]

Aim The clinical nurse leader (CNL(R)) is a new nursing role introduced by the American Association of Colleges of Nursing (AACN). This paper describes its potential impact in practice. Background Significant pressures are being placed on health care delivery systems to improve patient care outcomes and lower costs in an environment of diminishing resources. Method A naturalistic approach is used to evaluate the impact the CNL has had on outcomes of care. Case studies describe the CNL implementation experiences at three different practice settings within the same geographic region. Results Cost savings, including improvement on Centers for Medicare and Medicaid Services (CMS) core measures, are realized quickly in settings where the CNL role has been integrated into the care delivery model. Conclusions With the growing calls for improved outcomes and more cost-effective care, the CNL role provides an opportunity for nursing to lead innovation by maximizing health care quality while minimizing costs. Implications for nursing management Nursing is in a unique position to address problems that plague the nation's health system. The CNL represents an exciting and promising opportunity for nursing to take a leadership role, in collaboration with multiple practice partners, and implement quality improvement and patient safety initiatives across all health care settings. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is now recognized to be a multifactorial disorder caused by several endotypes that differ between individuals and patient populations. In order to understand the current clinical implications of OSA endotypes, this review aims to examine the current state of play in endotype measurements, endotype modification and their impact on clinical outcomes/prognosis. In summary, the field has developed multiple techniques to measure the endotypes over the last few decades. There is now good proof-of-concept evidence that a priori knowledge of an individual's OSA endotype traits may be useful in helping to guide treatment decisions. However, in order to truly deliver a personalized medicine approach to the treatment of OSA, we need to address critical gaps in: understanding OSA endotype treatment thresholds, and the impact of OSA modification on patient centred outcomes and hard clinical endpoints. Such efforts will benefit from a united, collaborative approach that involve partnerships between academics and consumers (i.e. patients, healthcare providers, industry)., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Bradley Edwards reports a relationship with Apnimed Inc, Myofunctional Research Co, and Incannex that includes: funding grants; and a relationship with Signifier Medical and EQT Partners Netherlands B.V. that includes: consulting or advisory. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Study Objectives: There is substantial night-to-night variability (NtNV) in obstructive sleep apnea (OSA) severity in some individuals, however predictors for this remain incompletely understood. This study aims to quantify the degree of NtNV in the apnea-hypopnea index (AHI), hypoxic burden, airflow limitation, and OSA endotypes; to determine if a relationship exists between the degree of NtNV in AHI and in endotype expression; to assess whether the degree of flow limited breathing is predictive of the degree of NtNV of the AHI., Methods: 71 patients with OSA underwent two polysomnograms (PSGs). OSA endotypes, hypoxic burden and flow limitation frequency were extracted from PSG data. Intra-individual agreement was assessed and associations with the NtNV of the AHI were calculated. Patients were grouped into High Variability vs Low Variability based on the degree of difference in AHI between each night., Results: Despite wide limits of agreement, at the group level most PSG and endotype variables were not statistically different between first and second night. Flow limitation frequency was 7.7% (2.1 to 13, P<0.01) higher on the second night compared to baseline. There were weak linear associations between NtNV of endotypes and NtNV of the AHI. In sub-group analysis, there was greater difference between nights for Vactive (5%eupnea, P=0.01), Vpassive (3.1%eupnea, P=0.03), Vcomp (3.2%eupnea, P=0.01) and arousal threshold (4.1%eupnea, P=0.04) in the High Variability compared to the Low Variability group., Conclusions: There is high NtNV in AHI, OSA endotypes and flow limitation in some individuals, however no strong linear relationship exists between these changes., (© The Author(s) 2024. Published by Oxford University Press on behalf of Sleep Research Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

The impersonal nature of high-enrollment science courses makes it difficult to build student-instructor relationships, which can negatively impact student learning and engagement, especially for members of marginalized groups. In this study, we explored whether an instructor collecting and sharing aggregated student demographics could positively impact student-instructor relationships. We surveyed students in a high-enrollment physiology course about their perceptions of their instructor 1 ) distributing a demographic survey, and 2 ) sharing aggregated survey results in class. We found that 72% of students appreciated the demographic survey, and 91% thought it helped their instructor get to know them. Further, 73% of students expressed that the instructor sharing aggregated demographic data in class positively impacted their overall course experience, and over 90% thought both the collection and sharing of demographic data were appropriate. Most students felt both parts of the intervention increased their sense of belonging in class, increased how connected they felt to their instructor, and made their instructor seem more approachable and inclusive, although the intervention also made some students feel more different from their peers. Women and nonbinary students felt the demographic survey increased instructor approachability more than men, and liberal students felt the survey increased instructor approachability more than nonliberal students. Compared to men, women and nonbinary students were more likely to report that taking the survey increased instructor inclusivity and made them feel less different from their peers. Based on these results, collecting student demographic information and sharing it in aggregate may be a practical, effective way to enhance student-instructor relationships. NEW & NOTEWORTHY This study examined undergraduate student perceptions of a high-enrollment physiology instructor collecting student demographics and sharing aggregated results to promote course inclusion. Most students perceived the collection and sharing positively, with women and nonbinary students, as well as liberal students, perceiving greater benefits from the data collection than their counterparts. Our results indicate that collecting and sharing in aggregate student demographics may be an effective way to enhance student-instructor relationships in high-enrollment science courses.

Study Objectives: The comorbidity of insomnia and obstructive sleep apnea (COMISA) is common and associated with adverse clinical consequences. While insomnia is often underdiagnosed among individuals with OSA, the identification of insomnia among these individuals may lead to improved medical care. Our objective was to assess the performance of two simplified tools (insomnia severity index-2 (ISI-2) and ISI-3) to identify insomnia among individuals with OSA. We hypothesized that the ISI-2 and ISI-3 perform well to diagnose insomnia among individuals with OSA., Methods: Four different cohorts of individuals with sleep disorders were studied. Cohorts 1,2 and 3 included individuals with OSA. Cohort 4 included individuals with insomnia only. The performance of ISI-2 and ISI-3 was compared to ISI-7-based diagnosis of insomnia using receiving operating characteristic curve analysis., Results: Cohorts 1, 2, 3 and 4 included 490, 124, 39 and 118 individuals, respectively. Individuals from cohorts 1, 2 and 3 were middle-aged, obese and had severe OSA on average. Individuals from cohort 2 were predominantly male while from cohorts 3 and 4 were predominantly female. Individuals from cohort 4 were slightly younger, and eutrophic on average. Cohorts 3 and 4 had higher insomnia severity (ISI-7) than cohorts 1 and 2. Using cohort 1, the best cut-offs for ISI-2 and ISI-3 were ≥6 and ≥8, respectively. Area under the curve (AUC) for ISI-2 was .900, .951 and .893 among cohorts 1, 2 and 4, respectively. AUC for ISI-3 was .924, .961 and .936 among cohorts 1, 2 and 4, respectively., Conclusion: ISI-2 and ISI-3 are accurate screening tools for insomnia among individuals with sleep disorders. Easy recognition of insomnia among individuals with COMISA may improve clinical outcomes., Competing Interests: Declaration of competing interest The named authors have no conflicts of interest, financial or otherwise., (Copyright © 2024 Elsevier B.V. All rights reserved.)

The WHAM-F TOX β model describes the toxic effects of mixtures of protons and metal cations towards biological species, using a set of intrinsic parameters for the cations (α H , α M *) and a sensitivity parameter (β) for each species. We applied the model to extensive water chemistry and zooplankton species occurrence data for four lakes contaminated with acidity and metals (Al, Ni, Cu, Zn) at Sudbury, Ontario, over the period 1973-2018, during which cation contamination declined, and zooplankton species numbers increased. Assuming that the appearance of a species resulted solely from decreases in water toxicity, and that α H and α M * values previously derived from laboratory toxicity test data could be applied in the field, we used the field data to estimate values of β for individual lake zooplankton species. Results for lake-species pairs with 20 or more species occurrences (from six samplings per year) were analysed. In most cases, the number of occurrences increased over time from zero to five or six per year, then remained at the high level. For a minority of pairs, occurrences per year increased initially, but subsequently declined, and so data only from the initial period were used to estimate β. The β values derived for the lake zooplankton are reasonably consistent with values derived from laboratory data for a range of other species. The findings support the application of WHAM-F TOX β to describe toxic effects of mixtures of cations in the field, and the toxicity model might be combined with ecological theory to interpret natural population responses., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Mercury (Hg) is naturally released by volcanoes and geothermal systems, but the global flux from these natural sources is highly uncertain due to a lack of direct measurements and uncertainties with upscaling Hg/SO 2 mass ratios to estimate Hg fluxes. The 2021 and 2022 eruptions of Fagradalsfjall volcano, southwest Iceland, provided an opportunity to measure Hg concentrations and fluxes from a hotspot/rift system using modern analytical techniques. We measured gaseous Hg and SO 2 concentrations in the volcanic plume by near-source drone-based sampling and simultaneous downwind ground-based sampling. Mean Hg/SO 2 was an order of magnitude higher at the downwind locations relative to near-source data. This was attributed to the elevated local background Hg at ground level (4.0 ng m -3 ) likely due to emissions from outgassing lava fields. The background-corrected plume Hg/SO 2 mass ratio (5.6 × 10 -8 ) therefore appeared conservative from the near-source to several hundred meters distant, which has important implications for the upscaling of volcanic Hg fluxes based on SO 2 measurements. Using this ratio and the total SO 2 flux from both eruptions, we estimate the total mass of gaseous Hg released from the 2021 and 2022 Fagradalsfjall eruptions was 46 ± 33 kg, equivalent to a flux of 0.23 ± 0.17 kg d -1 . This is the lowest Hg flux estimate in the literature for active open-conduit volcanoes, which range from 0.6 to 12 kg d -1 for other hotspot/rift volcanoes, and 0.5-110 kg d -1 for arc volcanoes. Our results suggest that Icelandic volcanic systems are fed from an especially Hg-poor mantle. Furthermore, we demonstrate that the aerial near-source plume Hg measurement is feasible with a drone-based active sampling configuration that captures all gaseous and particulate Hg species, and recommend this as the preferred method for quantifying volcanic Hg emissions going forward., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024. Published by Elsevier B.V. All rights reserved.)

Background: Approximately 60% of veterans living with posttraumatic stress disorder (PTSD) experience obstructive sleep apnoea (OSA). Why OSA is so prevalent in individuals with PTSD remains unknown, though PTSD may influence the underlying endotypes known to cause OSA. We examined whether these endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) differ between those with comorbid OSA and PTSD relative to their counterparts with OSA-only., Methods: Using the ventilatory flow pattern from diagnostic polysomnography, the OSA endotypes were measured in a retrospective cohort of 21 OSA patients with PTSD and 27 OSA-only patients. All participants were trauma exposed elderly male Australian Vietnam War veterans with mild-to-severe OSA (median Apnoea-Hypopnea index: 20.2 vs. 23.6 events/h). Age and BMI were similar between groups (70.7 vs. 71.7 years, and 28.4 vs. 28.4 kg/m 2 )., Results: There were no significant differences in the OSA endotype traits between PTSD + OSA and OSA-only patients for upper airway collapsibility (76.68 [71.53-83.56] vs. 78.35 [72.81-83.82] %V eupnea, median [IQR]), muscle compensation (4.27 [0.34-9.18] vs. 5.41 [1.83-7.21] %V eupnea ), loop gain (0.56(0.17) vs. 0.60(0.14)), and arousal threshold (135.76 [126.59-147.54] vs. 146.95 [128.64-151.28] %V eupnea )., Conclusion: The OSA endotypes in veterans with PTSD were similar to their trauma exposed OSA-only counterparts. PTSD appears to exert little influence on the OSA endotypes beyond the effect that age and trauma exposure may have. The aetiology of increased prevalence of OSA in PTSD remains unclear. Further work examining OSA endotypes using larger and more diverse samples is needed before robust conclusions can be made., Competing Interests: Declaration of competing interest EJB is supported by an Australian Government Research Training Program (RTP) Scholarship. SAL received project grant funds from the Monash Lung and Sleep Institute. SPAD has active grant funding from the National Health and Medicine Research Council. He serves as a consultant to Avecho Biotechnology, LTD and Philia Labs. SAL, SPAD, and BAE are recipients of a São Paulo Research Foundation-Monash University Seed Grant. BAE has received grant support from Apnimed and the National Health and Medicine Research Council, as well as personal fees from Signifier Medical outside the current work., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

The tension between religion and science as a long-standing barrier to science education has led researchers to explore ways of improving the experiences of Christian students in biology who can experience their Christianity as stigmatized in academic biology environments. As undergraduate science classes become student-centered, interactions among students increase, and Christians may feel a need to conceal their religious identities during peer discussions. In this interview study, we used the social psychology framework of concealable stigmatized identities to explore 30 Christian students' experiences during peer interactions in undergraduate biology courses to find potential ways to improve those experiences. We found that students felt their religious identity was salient during peer interactions in biology, and students thought revealing their religious identity to peers in their biology courses could be beneficial, yet few actually did so. Additionally, though most students anticipated stigma, comparatively few had experienced stigma from other students in their biology courses, despite the prior documented cultural stigma against Christians in biology. These results indicate a need for future studies exploring the impact of learning environments in which students are given the opportunity to share their religious identities with one another, which could reduce their anticipated and perceived stigma.

Rationale: Acetazolamide and atomoxetine-plus-oxybutynin ('AtoOxy') can improve obstructive sleep apnoea (OSA) by stabilising ventilatory control and improving dilator muscle responsiveness respectively. Given the different pathophysiological mechanisms targeted by each intervention, we tested whether AtoOxy-plus-acetazolamide would be more efficacious than AtoOxy alone., Methods: In a multicentre randomised crossover trial, 19 patients with moderate-to-severe OSA received AtoOxy (80/5 mg), acetazolamide (500 mg), combined AtoOxy-plus-acetazolamide or placebo at bedtime for three nights (half doses on first night) with a 4-day washout between conditions. Outcomes were assessed at baseline and night 3 of each treatment period. Mixed model analysis compared the reduction in Apnoea-Hypopnoea Index (AHI) from baseline between AtoOxy-plus-acetazolamide and AtoOxy (primary outcome). Secondary outcomes included hypoxic burden and arousal index., Results: Although AtoOxy lowered AHI by 49 (33, 62)% baseline (estimate (95% CI)) vs placebo, and acetazolamide lowered AHI by+34 (14, 50)% baseline vs placebo, AtoOxy-plus-acetazolamide was not superior to AtoOxy alone (difference: -2 (-18, 11)% baseline , primary outcome p=0.8). Likewise, the hypoxic burden was lowered with AtoOxy (+58 (37, 71)% baseline ) and acetazolamide (+37 (5, 58)% baseline ), but no added benefit versus AtoOxy occurred when combined (difference: -13 (-5, 39)% baseline ). Arousal index was also modestly reduced with each intervention (11% baseline -16% baseline ). Mechanistic analyses revealed that similar traits (ie, higher baseline compensation, lower loop gain) were associated with both AtoOxy and acetazolamide efficacy., Conclusions: While AtoOxy halved AHI, and acetazolamide lowered AHI by a third, the combination of these leading experimental interventions provided no greater efficacy than AtoOxy alone. Failure of acetazolamide to further increase efficacy suggests overlapping physiological mechanisms., Trial Registration Number: NCT03892772., Competing Interests: Competing interests: The combination intervention under investigation in the current study was protected by a patent ('Combination pharmacological interventions for multiple mechanisms of obstructive sleep apnoea', WO-2021091902-A1, Sands co-inventor) licensed to Apnimed from the Brigham and Women’s Hospital. SS has received grant funding from Apnimed, Prosomnus and Dynaflex, and has served as a consultant for Apnimed, Nox Medical, Inspire, Eli Lilly, Merck, Forepont, LinguaFlex, Achaemenid. He is also co-inventor on a patent related to wearable oximetry technology. He has received royalties from licensed intellectual property. AA served as a consultant for Somnifix, Respicardia and Apnimed; SS and AA’s industry interactions are managed by the Brigham and Women’s Hospital. SJ and GH has received equipment to support research projects from Resmed, Philips Respironics and Air Liquide Healthcare. BE has received grant funding from Apnimed and Incannex, and received personal fees from Signifier Medical outside the current work., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Supine related obstructive sleep apnea (OSA) is the most common clinical and physiological phenotype of OSA. This condition is recognizable by patients, their families and through polysomnographic recordings. Commonly used definitions distinguish the presence of supine related OSA when respiratory events occur at twice the frequency when the patient lies in the supine compared to non-supine sleeping positions. Recent physiology studies have demonstrated that airway obstruction arises more commonly in the supine position particularly at the level of the soft palate and epiglottis. Increased airway collapsibility is reliability observed supine relative to lateral position. To a lesser extent, changes in control of breathing favour less stable ventilation when the supine sleeping posture is adopted. Many treatments have been developed and trialled to help patients avoid sleeping on their back. The last 10 years has seen the emergence of vibrotactile warning devices that are worn on the patients' neck or chest. High quality randomized controlled trial data is accumulating on the efficacy and common pitfalls of the application of these treatments., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Purpose: To determine the effect of exercise interventions on quality of life in adults with multiple myeloma., Methods: A literature search of 10 sources was performed in June 2022 to identify eligible studies for synthesis., Inclusion Criteria: randomised controlled trials comparing the effect of exercise interventions with usual care in adults with a diagnosis of multiple myeloma. The risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. Meta-analysis was performed using a random-effects model with inverse variance and 95% confidence intervals. Forest plots were constructed to present pooled data., Results: Five RCTs, which included a total of 519 participants, were selected for inclusion. Four of the five studies were included in the meta-analysis. The mean participant age ranged from 55 to 67 years old. All studies included an aerobic exercise component. Intervention length ranged from 6 to 30 weeks. Meta-analysis of 118 participants showed that exercise interventions had no impact on global quality of life (MD = 2.15, 95% CI: - 4.67, 8.97, p = 0.54, I 2  = 0%). Exercise interventions negatively impacted participant grip strength (MD: - 3.69, 95% CI: - 7.12, -0.26, p = 0.03, I 2  = 0%) according to pooled data from 186 participants., Conclusion: Exercise interventions have no positive impact on the quality of life of patients with multiple myeloma. The analysis is limited by a high risk of bias across included studies and low certainty evidence. Further high-quality trials are needed to assess the role of exercise in patients with multiple myeloma., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Rationale: With up to 40% of individuals with either insomnia or obstructive sleep apnea (OSA) demonstrating clinically significant symptoms of the other disorder, the high degree of comorbidity among the two most common sleep disorders suggests a bidirectional relationship and/or shared underpinnings. Although the presence of insomnia disorder is believed to influence the underlying pathophysiology of OSA, this influence is yet to be examined directly. Objectives: To investigate whether the four OSA endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) are different in patients with OSA with and without comorbid insomnia disorder. Methods: Using the ventilatory flow pattern captured from routine polysomnography, the four OSA endotypes were measured in 34 patients with OSA who met the diagnostic criteria for insomnia disorder (COMISA) and 34 patients with OSA without insomnia (OSA only). Patients demonstrated mild-to-severe OSA (apnea-hypopnea index, 25.8 ± 2.0 events/h) and were individually matched according to age (50.2 ± 1.5 yr), sex (42 male: 26 female), and body mass index (29.3 ± 0.6 kg/m 2 ). Results: Compared with patients with OSA without comorbid insomnia, patients with COMISA demonstrated significantly lower respiratory arousal thresholds (128.9 [118.1 to 137.1] vs. 147.7 [132.3 to 165.0] % eupneic ventilation ([Formula: see text]); U  = 261; 95% confidence interval [CI], -38.3 to -13.9; d  = 1.1; P  < 0.001), less collapsible upper airways (88.2 [85.5 to 94.6] vs. 72.9 [64.7 to 79.2] %[Formula: see text]; U  = 1081; 95% CI, 14.0 to 26.7; d  = 2.3; P  < 0.001), and more stable ventilatory control (i.e., lower loop gain: 0.51 [0.44 to 0.56] vs. 0.58 [0.49 to 0.70]; U  = 402; 95% CI, -0.2 to -0.01; d  = 0.05; P  = 0.03). Muscle compensation was similar between groups. Moderated linear regression revealed that the arousal threshold moderated the relationship between collapsibility and OSA severity in patients with COMISA but not in patients with OSA only. Conclusions: A low arousal threshold is an overrepresented endotypic trait in individuals with COMISA and may exhibit a greater relative contribution to OSA pathogenesis in these patients. Contrastingly, the prevalence of a highly collapsible upper airway in COMISA was low, suggesting that anatomical predisposition may contribute less to OSA development in COMISA. Based on our findings, we theorize that conditioned hyperarousal perpetuating insomnia may translate to a reduced arousal threshold to respiratory events, thereby increasing the risk or severity of OSA. Therapies that target increased nocturnal hyperarousal (e.g., through cognitive behavior therapy for insomnia) may be effective in individuals with COMISA. Clinical trial registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12616000586415).