Prevention of malnutrition in cystic fibrosis Purpose of review Malnutrition is one of the major burdens of disease in cystic fibrosis. The prevention of malnutrition remains a priority throughout the life of a patient with cystic fibrosis. Literature and guidelines on the management of nutrition in cystic fibrosis have been published; however, here we review updated findings in cystic fibrosis nutrition as well as the role of novel treatments. Recent findings We review the latest studies on the importance and consequences of nutrition in cystic fibrosis. Novel findings on specific nutrients such as vitamin D and sodium can improve our care and thereby health and growth outcomes. The role of exercise has been further studied. In the field of new treatments, we review the role of cystic fibrosis transmembrane-conductance regulator potentiators and modulators in cystic fibrosis nutrition. A new feeding tube fat-digesting device has been developed and shows promise in cystic fibrosis enteral nutrition. Summary Advances in the nutritional care of cystic fibrosis are forming and believed to further develop in the near future, adding to the recent progress in cystic fibrosis patients’ health, survival, and quality of life. Correspondence to Mordechai Slae, MD, Department of Pediatrics, Hadassah Medical Center, Kiryat Hadassah, POB 12000 Jerusalem, Israel. Tel.: +972 26778960;. fax: +972 26778966; e-mail: mord@hadassah.org.il Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Ecological interactions in asthma: from environment to microbiota and immune responses Purpose of review Asthma is a heterogeneous condition shaped not only by genetics but also host conditioning by environmental factors. Recognizing the ecological context of microbe-immune interactions across environments and body sites is a necessary step toward better understanding how human microbiota influence or drive the pathogenesis and pathophysiology of asthma in its various presentations. Recent findings There is increasing evidence of a critical role for microbiota in asthma pathogenesis and outcomes across various body compartments, including the upper and lower airways, and gut. We discuss recent studies from this area including: development of a method to quantify microbial farm-effect in nonfarm environments, relationships between environmental microbial exposures and asthma prevalence across different geographies, microbiome-mediated responses to ozone, and microbiome-immune interactions within and across body compartments. Beyond bacteria, recent reports of asthma-associated differences in archaea and fungal organisms also are highlighted. Summary Collective evidence warrants application of an ecological framework to advance mechanistic insights into microbiota-immune interactions in asthma. This is necessary to achieve goals of developing successful therapeutic interventions targeting modification of microbiomes. Correspondence to Yvonne J. Huang, MD, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI 48109-5642, USA. Tel: +1 734 936 5047; e-mail: yvjhuang@umich.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Ethical, philosophical, and practical considerations in adherence to therapy in sleep medicine Purpose of review We consider a series of linked philosophical issues created by non-adherence to therapy in sleep medicine. Recent findings First, the difficulty of measuring rates of adherence creates an epistemic problem regarding the efficacy of prescribed treatments. Secondly, as diseases are often classified as refractory based on apparent failure of standard medicines, the validity of this classification faces a similar epistemic crisis. This in turn produces ethical issues when therapies are restricted to cases deemed refractory. It also calls into question, if the patient does not take the medicines as prescribed, what they do with them; and the prospect of potential drug diversion arises. Education of patients seems to be of limited help in addressing these issues; what may be needed is a revision of the patient–prescriber relationship to move away from blame when nonadherence occurs. We close by revisiting an ancient debate in the philosophy of action, which may shed light on what such a revised relationship would require. Summary More honest and trusting patient–physician relationships, and a much more accurate sense of when nonadherence is occurring and why, may result from a better practical and philosophical understanding of the patient's decision-making. Correspondence to Shane N. Glackin, Department of Sociology, Philosophy & Anthropology, University of Exeter, Amory B350, Rennes Drive, Exeter EX4 4RJ, UK. Tel: +44 1392 723302; e-mail: s.n.glackin@exeter.ac.uk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Prevention of osteoporosis in cystic fibrosis Purpose of review The increased life span of patients with cystic fibrosis has lead to the detection of new complications. Osteopenia is present in up to 50% of adult patients with cystic fibrosis, and osteoporosis in 10–34% and can cause a difficult management problem.. Recent findings In children, defects in bone health become apparent generally at adolescence because of suboptimall bone peak mass achievement. Malnutrition, inflammation, vitamin D and vitamin K deficiency, altered sex hormone production, glucocorticoid therapy, and physical inactivity potentiate poor bone health. Summary Monitoring bone mineral density and preventive care of osteoporosis are necessary from childhood to minimize cystic fibrosis-related bone disease in adult cystic fibrosis patients. Correspondence to Isabelle Sermet-Gaudelus, Hôpital Necker Enfants Malades, 149 rue de Sévres, 75015 Paris, France. Tel: +33 144494887/33 140615681; e-mail: isabelle.sermet@aphp.fr Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Obesity and sleep: a growing concern Purpose of review The ‘obesity epidemic’ is a growing concern globally, and obesity trends are projected to continue increasing in both prevalence and overall mean BMI. Cardiovascular and metabolic comorbidities have historically been well described; however, obesity-related respiratory disease is now increasingly prevalent, in particular, sleep disordered breathing. The surge in clinically significant obstructive sleep apnoea and obesity hypoventilation syndrome is associated with increased cardiopulmonary morbidity, quality-of-life impairment, and a potential rise in the frequency of road traffic accidents. Recent findings We discuss recent trends in obesity and obesity-related sleep disordered breathing. We also discuss recently published international guidelines regarding the diagnosis and management of sleep disordered breathing, and in particular, the role of weight management interventions, such as bariatric surgery, in this area. We discuss possible approaches to meet the growing demand for sleep assessment and management in the future. Summary Obesity-related respiratory disease reflects an increasing proportion of patients in both inpatient and outpatient settings. It is important to recognize the impact of obesity on pulmonary physiology in order to appropriately care for this population, as well as plan for the future. Correspondence to Dr John F. Garvey, MB BCh, BAO, PhD, Department of Respiratory Medicine, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland. Tel: +353 221 3702; fax: +353 221 3576; e-mail: j.garvey@svhg.ie Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A contemporary review of obstructive sleep apnea with emphasis on definitions, epidemiology, and consequences Purpose of review This review provides a contemporary review of sleep apnea with emphasis on definitions, epidemiology, and consequences. Recent findings Amyloid β-42 is one of the main peptides forming amyloid plaques in the brains of Alzheimer patients. Poorer sleep quality and shorter sleep duration have been associated with a higher amyloid burden. Decreased sleep time in the elderly is a precipitating factor in amyloid retention. Studies have shown that the dysregulation of the homeostatic balance of the major inhibitory and excitatory amino acid neurotransmitter systems of gamma-aminobutyric acid (GABA) and glutamate play a role in sleep disordered breathing (SDB). Summary Untreated sleep disordered breathing (obstructive sleep apnea and/or central sleep apnea) are an important cause of medical mortality and morbidity. OSA is characterized by recurrent episodes of partial or complete collapse of the upper airway during sleep followed by hypoxia and sympathetic activation. Apneic events are terminated by arousal, followed by increases in pulse and blood pressure, and re-oxygenation and the release of inflammatory factors. Individuals with OSA have an increased risk of developing atrial fibrillation. Hypoxemia and poor sleep quality because of OSA increase the risk of cognitive decline in the elderly. Correspondence to Frank Ralls, MD, Associate Professor of Internal Medicine, University of New Mexico, Program Director: UNM Sleep Medicine Fellowship, Medical Director, University Hospital Sleep Disorders Center, 1101 Medical Arts Avenue NE, Building 2, Albuquerque, NM 87102, USA. Tel: +1 505 272 6110; fax: +1 505 272 6112; e-mail: FRalls@salud.unm.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Prevention of drug-related complications in cystic fibrosis Purpose of review Due to continuous development of new drugs and better treatment strategies, survival of patients with cystic fibrosis has changed dramatically. Recently, targeted therapy of cystic fibrosis transmembrane conductance regulator (CFTR) modulators have become available. Despite these promising developments, treatment of this complex multiorgan disease constitutes a high and variable amount of other drugs. Complications of pharmacotherapeutic treatment are, therefore, expected to become more prevalent. This gives cause to review drug-related side effects in this new era in cystic fibrosis treatment. Recent findings We will discuss cystic fibrosis-related pharmacotherapies with a focus on indication of treatment, side effects and their complications, drug--drug interactions, and options to monitor and prevent drug-induced toxicity. Many recent publications about pharmacotherapy in cystic fibrosis, focus on antifungal therapy and CFTR modulators. We will give an overview of the most important studies. Summary With increased life expectancy which is, in part, because of better treatment options, the burden of pharmacotherapy in cystic fibrosis patients will increase. This has a high impact on quality of life as pharmacotherapy is time consuming and may cause side effects. Therefore, it is very important to be aware of possible pharmacotherapy-related side effects and their complications, drug--drug interactions, and options to monitor and prevent drug-induced toxicity. Correspondence to Renske van der Meer, Haga Ziekenhuis, Els Borst-Eilersplein 275, 2545 AA Den Haag, The Netherlands. Tel: +31 641319642; e-mail: r.vandermeer@hagaziekenhuis.nl Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Phenotypic approach to pharmacotherapy in the management of obstructive sleep apnoea Purpose of review To provide a concise synthesis of the current knowledge of obstructive sleep apnoea (OSA) phenotyping concepts and how this information is being used to develop and direct targeted pharmacotherapy for OSA. Recent findings The causes of OSA vary between patients and therefore so too does the optimal therapy or therapies. Key phenotypic causes include impaired upper airway anatomy and non-anatomical contributors such as ineffective pharyngeal dilator muscles during sleep, waking up too easily to minor airway narrowing (low arousal threshold) and unstable respiratory control (high loop gain). Traditionally, heterogeneity of OSA pathophysiology was not considered in pharmacotherapy approaches for OSA. However, recent study has focussed on targeted pharmacotherapies directed towards specific OSA phenotypes. This, combined with advances in knowledge of the neurobiology of pharyngeal muscle control from animal studies that have recently been translated to human proof-of-concept studies by repurposing existing drugs that target the desired mechanisms, have opened up exciting new lines of investigation for OSA pharmacotherapy. Summary There have been major recent advances in the development of new targeted approaches to pharmacotherapy for OSA. This study shows considerable promise for a viable and much needed pathway to drug therapy for this common chronic health condition. Correspondence to Danny J. Eckert, AISH, Flinders University, Box 6, Mark Oliphant Building, 5 Laffer Drive, Bedford Park, South Australia 5042, Australia. E-mail: danny.eckert@flinders.edu.au Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Sleep and interstitial lung disease Purpose of review There is an increasing recognition of the impact of sleep and sleep disorders on respiratory disease. Recent years have seen a new focus on the relationship between sleep and outcomes in patients interstitial lung disease (ILD). Recent findings Recent studies suggest a high prevalence of sleep issues in ILD cohorts, which seem to have a meaningful negative impact on quality of life, disease progression, and survival. Summary Sleep disordered breathing is common in ILD patients: obstructive sleep apnoea (OSA) is found in 44–72% of ILD patients, and nocturnal hypoxemia is relatively common even in the absence of OSA. Sleep disorders are associated with worse quality of life in ILD, and may also predict more rapid disease progression and increased mortality. It remains unknown if nocturnal hypoxemia may itself cause progression of ILD. Uncontrolled and retrospective studies have suggested that treating OSA may improve ILD-related outcomes, but prospective studies are lacking in this field. Correspondence to Dr Brian D. Kent, Sleep Disorders Centre, Guy's Hospital, London SE1 9RT, United Kingdom. E-mail: briankent@physicians.ie Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Rapid eye movement sleep and neuronal development Purpose of review To understand the importance of rapid eye movement (REM) sleep in the cognitive and sensorimotor development via neural plasticity during embryonic development and infants. Recent findings REM sleep has remained a mystery as many of the underlying mechanisms of REM sleep remain unclear. Recent findings have demonstrated that REM sleep selectively prunes newly formed dendritic spines in the developing brain as well as strengthening new synapses in the developing brain. This process is critical for normal neuronal circuit development and behavioral improvement after learning. Summary Although many mechanisms of REM sleep remain unclear, recent findings strongly suggest that REM sleep is vitally important in pruning synapses as well as maintaining new synapses for the development of a healthy brain. Developmental neuroplasticity refers to the continuous change of the developing brain during fetal development. Lack of plasticity may result in reduced intellectual ability, reduced learning and memory consolidation, and mental illness. Correspondence to Frank M. Ralls, MD, Associate Professor Internal Medicine, Program Director: UNM Sleep Medicine Fellowship, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico, Board Certified: Sleep Medicine, Family Medicine, Geriatric Medicine, and Hospice and Palliative Care, Medicine, 1101 Medical Arts Ave NE, Albuquerque, NM 87131, USA. Tel: +1 505 272 6110; fax: +1 505 272 6112; e-mail: fralls@salud.unm.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.