Prospective Analyses of Cytokine Mediation of Sleep and Survival in the Context of Advanced Cancer.

OBJECTIVE: The aims of this study were to examine the potential association between sleep problems, symptom burden, and survival in patients with advanced cancer. METHODS: A prospective study of 294 patients with gastrointestinal cancer administered questionnaires assessing sleep, depression, anxiety, stress, pain, fatigue, and health-related quality of life. Serum levels of cytokines including interleukin (IL)-1α, IL-1ß, tumor necrosis factor α, IL-10, IL-2, and interferon-γ were measured to assess biological mediation between sleep and survival. Survival was measured as time from diagnosis to death. RESULTS: Fifty-nine percent of patients reported poor sleep quality, 53% reported poor sleep efficiency, 39% reported sleep latency greater than 30 minutes, and 45% reported sleeping less than 6 hours or greater than 10 hours. We found a significant association between sleep duration and symptom burden. Shorter sleep duration was significantly associated with higher levels of fatigue (r = -0.169, p = .01), pain (r = -0.302, p = .01), anxiety (r = -0.182, p = .01), depression (r = -0.172, p = .003), and lower levels of quality of life (r = 0.240, p = .01). After adjustment for demographic, psychological, and disease-specific factors, short sleep duration was associated with reduced survival (hazard ratio [HR] linear = 0.485, 95% confidence interval = 0.275-0.857) and there was also evidence for a quadratic pattern (HR quadrati = 1.064, 95% confidence interval = 1.015-1.115) suggesting a curvilinear relationship between sleep duration and survival. Interleukin 2 was the only cytokine significantly related to survival (HR = 1.01, p = .003) and sleep duration (ß = -30.11, p = .027). When of IL-2 was added to the multivariable model, short and long sleep (ß = -0.557, p = .097; ß = 0.046, p = .114) were no longer significantly related to survival, suggesting mediation by IL-2. CONCLUSION: Sleep duration was associated with symptom burden and poorer survival and IL-2 was found to mediate the association between sleep and survival. Screening and treatment of sleep problems in patients diagnosed with cancer are warranted.

Students' Attitudes Towards Patient Smoking Status During Enrollment in a Pulmonary Rehabilitation Program.

The harmful effects of nicotine products are well documented, especially cigarettes. Due to the addictive nature of nicotine, it is often difficult for people who smoke to quit. This study was performed to assess the attitudes of healthcare students regarding enrollment of patients who smoke into a pulmonary rehabilitation program. Public colleges and universities in Texas offering health professions programs were asked to participate if they offered a baccalaureate degree and student enrollment was >5,000. Results were obtained from 114 participants, the majority of whom were from the fields of respiratory therapy and physical therapy. The results revealed that older student participants, >37 yrs old, were less likely to agree to allow a patient who smokes to enroll in a pulmonary rehabilitation program when compared to younger student participants. Students who were more likely to allow patients who smoke to enroll in a pulmonary rehabilitation program were 18- to 22-yr-old women. Females were more likely to agree/strongly agree with allowing a patient who smokes to enroll in a pulmonary rehabilitation program. There was little difference in the attitudes of students who had any history vs no history of smoking.

Pediatric Patients Discharged from the Emergency Department with Abnormal Vital Signs.

INTRODUCTION: Children often present to the emergency department (ED) with minor conditions such as fever and have persistently abnormal vital signs. We hypothesized that a significant portion of children discharged from the ED would have abnormal vital signs and that those discharged with abnormal vital signs would experience very few adverse events. METHODS: We performed a retrospective chart review encompassing a 44-month period of all pediatric patients (aged two months to 17 years) who were discharged from the ED with an abnormal pulse rate, respiratory rate, temperature, or oxygen saturation. We used a local quality assurance database to identify pre-defined adverse events after discharge in this population. Our primary aim was to determine the proportion of children discharged with abnormal vital signs and the frequency and nature of adverse events. Additionally, we performed a sub-analysis comparing the rate of adverse events in children discharged with normal vs. abnormal vital signs, as well as a standardized review of the nature of each adverse event. RESULTS: Of 33,185 children discharged during the study period, 5,540 (17%) of these patients had at least one abnormal vital sign. There were 24/5,540 (0.43%) adverse events in the children with at least one abnormal vital sign vs. 47/27,645 (0.17%) adverse events in the children with normal vital signs [relative risk = 2.5 (95% confidence interval, 1.6 to 2.4)].However, upon review of each adverse event we found only one case that was related to the index visit, was potentially preventable by a 23-hour hospital observation, and caused permanent disability. CONCLUSION: In our study population, 17% of the children were discharged with at least one abnormal vital sign, and there were very few adverse (0.43%) events associated with this practice. Heart rate was the most common abnormal vital sign leading to an adverse event. Severe adverse events that were potentially related to the abnormal vital sign(s) were exceedingly rare. Additional research is needed in broader populations to better determine the rate of adverse events and possible methods of avoiding them.

Sleep duration is associated with survival in advanced cancer patients.

OBJECTIVE: Sleep problems have been linked to increased risk of mortality in the general population. Limited evidence suggests similar relationships among people diagnosed with cancer. The aims of the present study were to investigate the type and rates of sleep problems in advanced cancer patients and examine whether sleep problems are associated with survival. METHODS: A prospective study of 292 patients with advanced cancers affecting the hepatobiliary and pancreatic systems were administered a battery of questionnaires measuring sociodemographic information, sleep, and depression. Descriptive statistics, ANOVA, Chi-square, Kaplan-Meier survival, and Cox regression analyses were performed to test the aims. RESULTS: The majority of patients were male (64%) and the mean age was 62 years (SD = 11). Fifty-nine percent of patients reported poor sleep quality; 43% reported sleeping ≤6 h and 2% ≥10 h; 40% reported sleep latency of 30 min or greater; average sleep efficiency was 80%. Of the 292 patients, 58% reported clinically levels of depression and depressive symptoms were related to shorter sleep duration (p = 0.02). After adjusting for factors known to contribute to survival, a curvilinear relationship was observed between sleep duration and mortality: short and long sleep duration were associated with increased mortality [linear term: hazard ratio (HR) = 0.485, 95% confidence interval (CI) = 0.275-0.857; quadratic term: HR = 1.064, 95% CI = 1.015-1.115]. CONCLUSIONS: Consistent with findings in the general population, a curvilinear relationship between sleep duration and mortality was observed in advanced cancer patients. The high prevalence of sleep problems and link with mortality warrants routine screening and development of evidence-based treatments for sleep problems in the oncology setting.

Racial and ethnic disparities in parent-reported diagnosis of ADHD: National Survey of Children's Health (2003, 2007, and 2011).

BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is the most commonly diagnosed mental disorder among children in the United States. While overall ADHD prevalence continues to rise, few have examined difference by race/ethnicity. OBJECTIVE: To examine trends in parent-reported ADHD prevalence between 2003 and 2011 across racial/ethnic groups and the role of sociodemographic factors in observed differences in ADHD. METHOD: Data were from 3 waves of the National Survey of Children's Health (2003, 2007, and 2011), including 190,408 children aged 5-17 years. Independent variables included race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, other non-Hispanic), gender, age, poverty level, primary language, insurance status, parental marital status, and neighborhood safety. Sociodemographic factors and year were compared among those diagnosed with ADHD and between racial/ethnic groups using χ(2) tests. Adjusted logistic regression models, stratified by race/ethnicity, were fit to examine the association between identified risk factors and ADHD across racial/ethnic groups. Parental report of an ADD or ADHD diagnosis for a child aged 5-17 years was the dependent variable. If the household included more than 1 child aged 5-17 years, 1 was selected at random. RESULTS: Increasing trends were observed over the past decade in the prevalence of parent-reported ADHD overall (43%, P < .001), among children aged 10-14 years (47%, P < .001), and adolescents aged 15-17 years (52%, P < .001). Although the ADHD prevalence was still highest among whites, increasing trends were observed for all racial/ethnic groups, most notably among Hispanics, increasing 83% from 2003 to 2011 (P < .001). A greater increase in ADHD was also observed among females (55%, P < .001) than among males (40%). CONCLUSIONS: Economics, family status, non-English language in the home, and neighborhood safety factors differentially impacted diagnosed ADHD across racial/ethnic groups. Although new insights into the role of economic, family, and neighborhood factors on parent-reported ADHD diagnoses were noted, more research is needed to understand causes of the observed racial/ethnic disparities.

Teaching Health Care Students the Radial Arterial Puncture Procedure.

The radial artery puncture is a frequently ordered medical procedure for patients requiring blood gas analysis. Deviating from the proper procedure increases the likelihood of error and jeopardizes patient safety. The teaching methodology for the radial artery puncture is rarely addressed in the medical literature. First-year respiratory care students enrolled in a clinical practice course participated in an expanded curriculum on arterial puncture technique. The new five-step curriculum included: 1) a face-to-face lecture, 2) radial artery localization, 3) blunt-tipped needle simulation, 4) manikin arm puncture, and 5) a peer assessment video. Students participated in an inter-rater reliability exercise for step five. The multi-step process for teaching the arterial puncture stressed process over outcome. Students were required to master each step with a satisfactory evaluation to successfully pass the unit. Students also demonstrated high inter-rater evaluation scores of a peer video of the arterial puncture. Additional research is needed to determine if widespread application of the curriculum across other respiratory care programs and other healthcare disciplines is possible. The detailed report of our new curriculum offers other academic researchers the ability to formally study its usefulness.

Managing Asthma on the College Campus: Findings of a Texas Pilot Study.

BACKGROUND: Students attending institutions of higher education have the option of utilizing their student health center (SHC) for asthma management. However, a review of the available literature revealed no previous research as to how SHCs on college campuses in Texas manage students with asthma. This led to the following research questions; how are SHCs in Texas managing asthma for college students, and what are the SHC directors' attitudes and perceptions of the impact of asthma on their college campuses? METHODS: This descriptive pilot study randomly selected 20 colleges in Texas; 17 institutions agreed to participate. The inclusion criteria consisted of 4-y colleges accredited by the Southern Association of Colleges and Schools with an undergraduate student population of greater than 1,000 full-time students, excluding online colleges. Once identified, the director of each institution's SHC was contacted by telephone and invited to complete the Managing Asthma on College Campuses Survey instrument via telephone interview (n = 14) or e-mail (n = 3). Descriptive statistics were used to analyze quantitative data and common themes were noted for the qualitative data. RESULTS: Quantitative data obtained through the survey revealed 23.5% of SHCs provide individualized asthma action plans to students and 35% of SHCs stated they have an emergency action plan for asthma exacerbations. Respondents noted 2 major barriers for effective asthma management on campus: lack of understanding of chronic disease management and underuse of the SHC due to a lack of awareness of its existence. Perceived barriers to visiting the SHC included access issues, money, and students self-medicating with short-acting ß2 agonist inhalers and/or over-the-counter medications. CONCLUSIONS: The majority of directors were satisfied with asthma services provided to students; however, they felt more face-to-face asthma education was needed.

Comparing the effects of rise time and inspiratory cycling criteria on 6 different mechanical ventilators.

BACKGROUND: Inspiratory rise time and cycling criteria are important settings in pressure support ventilation. The purpose of this study was to investigate the impact of minimum and maximum rise time and inspiratory cycling criteria settings on 6 new generation ventilators. Our hypothesis was there would be a difference in the exhaled tidal volume, inspiratory time, and peak flow among 6 different ventilators, based, on change in rise time and cycling criteria. METHODS: The research utilized a breathing simulator and 4 different ventilator models. All mechanical ventilators were set to a spontaneous mode of ventilation with settings of pressure support 8 cm H2O and PEEP of 5 cm H2O. A minimum and maximum setting for rise time and cycling criteria were examined. Exhaled tidal volume, inspiratory time, and peak flow measurements were recorded for each simulation. RESULTS: Significant (P < .001) differences were found when comparing minimum and maximum rise time and minimum and maximum cycling criteria for each ventilator. CONCLUSIONS: Significant differences in exhaled tidal volume, inspiratory time, and peak flow were observed by adjusting rise time and cycling criteria. This research demonstrates that during pressure support ventilation strategy, adjustments in rise time and/or cycling criteria can produce changes in inspiratory parameters. Obviously, this finding has important implications for practitioners who utilize a similar pressure support strategy when conducting a ventilator wean. Additionally, this study outlines major differences among ventilator manufacturers when considering inspiratory rise time and cycling criteria.