Smart Phone/Ecological Momentary Assessment of Sleep and Daytime Symptoms Among Older Adults With Insomnia.

OBJECTIVES: To employ smart phone/ecological momentary assessment (EMA) methods to evaluate the impact of insomnia on daytime symptoms among older adults. DESIGN: Prospective cohort study SETTING: Academic medical center PARTICIPANTS: Twenty-nine older adults with insomnia (M age = 67.5 ± 6.6 years, 69% women) and 34 healthy sleepers (M age = 70.4 ± 5.6 years, 65% women). MEASUREMENTS: Participants wore an actigraph, completed daily sleep diaries, and completed the Daytime Insomnia Symptoms Scale (DISS) via smart phone 4x/day for 2 weeks (i.e., 56 survey administrations across 14 days). RESULTS: Relative to healthy sleepers, older adults with insomnia demonstrated more severe insomnia symptoms in all DISS domains (alert cognition, positive mood, negative mood, and fatigue/sleepiness). A series of mixed model analyses were performed using the Benjamini-Hochberg procedure for correcting false discovery rate (BH-FDR) and an adjusted p-value <0.05. Among older adults with insomnia, all five prior-night sleep diary variables (sleep onset latency, wake after sleep onset, sleep efficiency, total sleep time, and sleep quality) were significantly associated with next-day insomnia symptoms (i.e., all four DISS domains). The median, first and third quintiles of the effect sizes (R2) of the association analyses were 0.031 (95% confidence interval (CI: [0.011,0.432]), 0.042(CI: [0.014,0.270]), 0.091 (CI:[0.014,0.324]). CONCLUSION: Results support the utility of smart phone/EMA assessment among older adults with insomnia. Clinical trials incorporating smart phone/EMA methods, including EMA as an outcome measure, are warranted.

A Morning Bright Light Therapy Intervention to Improve Circadian Health in Adolescent Cancer Survivors: Methods and Preliminary Feasibility.

Circadian rhythm disturbances are common among children with cancer, and are associated with poor health outcomes. Social zeitgeber theory suggests that intervening in the cascade of events that disrupt circadian rhythms may improve health outcomes. Light, most potently sunlight, is a "zeitgeber," or environmental cue instrumental in maintaining entrainment of circadian rhythms. Bright white light (BWL) therapy, a proxy for sunlight, has been used successfully to prevent deterioration of circadian rhythms in adult cancer patients, and to reentrain these rhythms in adolescents with circadian rhythm disorders. This study aimed to develop and assess preliminary feasibility of a BWL therapy intervention for supporting circadian health of adolescent cancer survivors. We hypothesized that adolescents could independently manage BWL in their home, coordinated by nurses using a mail-, phone- and internet-based format, with minimal side effects. Adolescents were instructed to use BWL for 30 minutes daily on awakening, for 28 days. Actigraphs, measuring the circadian activity rhythms of sleep and wake, were worn for 7 days at baseline and Week 4. Adverse events were screened serially. Analyses were descriptive and nonparametric. Eight adolescents participated. On average, BWL was used on 61% of days, for 15 minutes per day. Adverse events were generally mild, although one participant discontinued BWL due to persistent BWL-related nausea. This nurse-guided remote BWL therapy intervention in adolescent cancer survivors demonstrated preliminary feasibility. Future studies with larger samples are required to verify the feasibility of this study, and to determine its safety and effectiveness in supporting circadian activity rhythms.

Development and Usability Evaluation of a Facebook-Based Intervention Program for Childhood Cancer Patients: Mixed Methods Study.

BACKGROUND: Childhood cancers previously considered to be incurable now have 5-year survival rates up to 84%. Nevertheless, these patients remain at risk of morbidity and mortality from therapy-related complications. Thus, patient education and self-management strategies for promoting a healthy lifestyle are of tantamount importance for improving short- and long-term health outcomes. A Facebook-based "Healthy Teens for Soaam" (a Korean term for childhood cancers) program was developed to help improve knowledge and self-management practices of teens with cancer related to their disease and treatment. OBJECTIVE: The two-fold purpose of this usability study was (1) to describe the process of developing an 8-week Facebook-based intervention program for teens with cancer, and (2) to evaluate its usability to refine the program. METHODS: Multiple phases and methods were employed to develop and evaluate the usability of the program. Study phases included: (1) needs assessment through focus group interviews and qualitative content analysis, (2) development of module content, (3) expert review and feedback on module content, (4) Facebook-based program development, (5) usability evaluation by heuristic evaluation, (6) usability evaluation by targeted end-user testing, and (7) modification and final version of the program. Usability of the final version was confirmed through feedback loops of these phases. RESULTS: Based on 6 focus group discussion sessions, it was determined that teens with cancer were interested in seeing stories of successful childhood cancer cases and self-management after discharge, and preferred multimedia content over text. Therefore, each Facebook module was redesigned to include multimedia materials such as relevant video clips tailored for teens. Usability assessed by heuristic evaluation and user testing revealed several critical usability issues, which were then revised. Potential end users tested the final program and perceived it to be usable and useful for teens with cancer. CONCLUSIONS: To our knowledge, "Healthy Teens for Soaam" is the first Facebook-based intervention program for teens with cancer. We actively worked with current childhood cancer patients and survivors to develop and improve this program, achieved good usability, and met the expressed needs and preferences of target end users. This 8-week Facebook-based educational program for teens with cancer, developed as the first step of an upcoming intervention study, will be useful for improving knowledge and self-management strategies of teens.

Circadian activity rhythms and fatigue of adolescent cancer survivors and healthy controls: a pilot study.

STUDY OBJECTIVES: The primary objective of this study was to compare circadian activity rhythms (CARs) of adolescents within 5 years of completing cancer treatment (survivors) with that of healthy adolescent controls. Secondary objectives were to explore differences in the relationship of CARs and fatigue between survivors and controls and between early survivors (<12 months posttreatment) and late survivors (≥12 months posttreatment). METHODS: Twenty-nine survivors and 30 controls, aged 13-18 years, participated in this prospective, descriptive pilot study. Adolescents and their parents completed a baseline measure of adolescents' fatigue. Adolescents wore a wrist actigraph continuously for 7 days and concurrently kept a sleep diary. Activity data recorded by actigraphy were fitted to an extended cosine model to calculate six CAR variables: acrophase, amplitude, midline estimating statistic of rhythm (MESOR), up-MESOR, down-MESOR, and F-statistic. Linear mixed models explored the relationship between CARs and fatigue. RESULTS: There were no group differences on CAR or fatigue measures. Among survivors, earlier down-MESOR was associated with greater parent-reported fatigue (P = .020), and earlier acrophase (P = .023) and up-MESOR (P = .025) were associated with greater adolescent-reported fatigue. Significant CAR-by-time posttreatment interaction effects were found on fatigue between early and late survivors. Among controls, greater parent-reported fatigue was associated with greater MESOR (P = .0495). CONCLUSIONS: Survivors within the first 5 years posttreatment were similar to controls in CARs and fatigue, suggesting robust recovery of circadian rhythms posttreatment. Different CAR characteristics were associated with fatigue in survivors and controls. Time posttreatment influenced the relationship between CARs and fatigue for survivors, with significant effects only for early survivors.

Relationship between circadian activity rhythms and fatigue in hospitalized children with CNS cancers receiving high-dose chemotherapy.

PURPOSE: Robust circadian rhythms are increasingly recognized as essential to good health. Adult cancer patients with dysregulated circadian activity rhythms (CAR) experience greater fatigue, lower responsiveness to chemotherapy, and shorter time to relapse. There is scant research describing circadian rhythms and associated outcomes in children with cancer. As part of a larger study examining whether a cognitive-behavioral intervention could preserve sleep in children and adolescents with central nervous system cancers hospitalized for high-dose chemotherapy (HDCT), this study aimed to compare CAR of these children to published values and to investigate the relationship between CAR and fatigue. METHODS: Participants aged 4-19 years wore an actigraph throughout their hospitalization (5 days). From activity counts recorded by actigraphy, six CAR variables were calculated: amplitude, 24-h autocorrelation (r24), dichotomy index (I < O), interdaily stability (IS), intradaily variability (IV), and acrophase. Parent-reported child fatigue and child/adolescent self-reported fatigue measures were collected daily. RESULTS: Thirty-three participants were included. Three CAR variables (amplitude, r24, and I < O) showed dysregulation compared to published values. Older age was significantly associated with later acrophase and greater dysregulation of all other CAR variables. Controlling for age, more dysregulated amplitude (p = 0.001), r24 (p = 0.003), IS (p = 0.017), and IV (p = 0.001) were associated with higher parent-reported fatigue; more dysregulated IV (p = 0.003) was associated with higher child-reported fatigue. CONCLUSIONS: Participants demonstrated dysregulated CAR during hospitalization for HDCT. Greater dysregulation was associated with greater fatigue. Research on circadian dysregulation and its relationship to health-related outcomes in children with cancer, and interventions to support circadian rhythmicity, is urgently needed.

A call to action for expanded sleep research in pediatric oncology: A position paper on behalf of the International Psycho-Oncology Society Pediatrics Special Interest Group.

Sleep and circadian rhythms are closely related to physical and psychosocial well-being. However, sleep and circadian rhythm disruptions are often overlooked in children with cancer, as they are frequently considered temporary side effects of therapy that resolve when treatment ends. Yet, evidence from adult oncology suggests a bidirectional relationship wherein cancer and its treatment disrupt sleep and circadian rhythms, which are associated with negative health outcomes such as poor immune functioning and lower survival rates. A growing body of research demonstrates that sleep problems are prevalent among children with cancer and can persist into survivorship. However, medical and psychosocial outcomes of poor sleep and circadian rhythmicity have not been explored in this context. It is essential to increase our understanding because sleep and circadian rhythms are vital components of health and quality of life. In children without cancer, sleep and circadian disturbances respond well to intervention, suggesting that they may also be modifiable in children with cancer. We present this paper as a call to (a) incorporate sleep or circadian rhythm assessment into pediatric cancer clinical trials, (b) address gaps in understanding the bidirectional relationship between sleep or circadian rhythms and health throughout the cancer trajectory, and (c) integrate sleep and circadian science into oncologic treatment.

Toddler Bedtime Routines and Associations With Nighttime Sleep Duration and Maternal and Household Factors.

STUDY OBJECTIVES: The aims of this study were to examine (1) relationships among implementing a bedtime routine, nighttime awakenings, and nighttime sleep duration in toddlers from low-income, minority families and (2) differences in maternal and household characteristics between mothers who did versus those who did not implement a nightly bedtime routine for their toddler. METHODS: Data were collected from mothers of toddlers on maternal and household characteristics and toddler sleep, measured using the Children's HealthWatch Survey and the Extended Brief Infant Sleep Questionnaire (BISQ). A path analysis model was tested to investigate whether nighttime awakenings mediated the relation between implementing a bedtime routine and toddlers' nighttime sleep duration. Chi-square tests were conducted to examine differences in maternal and household characteristics (ie, maternal depressive symptoms, food, housing and energy insecurity) between mothers who did versus those who did not implement nightly bedtime routines over the past 2 weeks. RESULTS: Implementing a bedtime routine was associated with longer toddler sleep duration through a decrease in nighttime awakenings (ß = 5.04, 95% confidence interval = 0.61 to 11.35). More consistent sleep routine implementation was associated with fewer nighttime awakenings and longer sleep duration. Maternal depressive symptoms, housing insecurity, and food insecurity were associated with decreased likelihood of implementing a nightly bedtime routine. CONCLUSIONS: Maternal depressive symptoms, food insecurity, and household insecurity (factors associated with low socioeconomic status) may be associated with a negative sleep environment and poor toddler sleep quality, potentially because of decreased implementation of bedtime routines. COMMENTARY: A commentary on this article appears in this issue on page 821.

A pilot randomized controlled trial to improve sleep and fatigue in children with central nervous system tumors hospitalized for high-dose chemotherapy.

OBJECTIVES: To determine whether a sleep intervention compared with standard of care (SOC) was successful in preserving nighttime sleep in children with central nervous system cancers hospitalized for high-dose chemotherapy (HDCT) and autologous stem cell rescue, and to explore associations between sleep and fatigue during treatment. METHODS: An unblinded, randomized, controlled, multicomponent intervention (NCT00666614) including evidence-based cognitive and behavioral strategies to improve sleep was implemented in 33 children (age 4-12 years) and adolescents (age 13-19 years) during hospitalization. Children wore an actigraph to measure sleep and wake, and reported fatigue scores daily. Parents concurrently kept a sleep diary and reported fatigue scores for their children. RESULTS: The mean age was 9.5 ± 3.9 years, 81.8% were white, and 60.6% were male. Sleep in all children was seriously disturbed throughout the study. Children in the intervention group maintained their longest nighttime sleep across the study, while it declined in children receiving SOC (P = 0.009 for interaction). There were few other differences in sleep between groups. Controlling for age and baseline fatigue, higher nighttime activity score, and lower percent sleep were significantly associated with higher next-day adolescent-reported fatigue (P < 0.05); longest sleep was significantly positively associated with next-day child-reported fatigue (P = 0.018). CONCLUSION: In this sample of children undergoing HDCT, a multicomponent sleep intervention modestly preserved nighttime sleep duration, although overall sleep was poor in both groups. Sleep is an integral component of health, and may influence outcomes of children receiving HDCT. Further investigation into methods of preserving sleep in children undergoing intensive cancer therapy is warranted.

Fatigue and risk of sickness absence in the working population: A systematic review and meta-analysis of longitudinal studies.

Objectives Fatigue, a common complaint in workers, has been related to sickness absence (SA). The purpose of this systematic review and meta-analysis was to determine the prospective association between fatigue and SA in the working population. Methods An electronic literature search was conducted in five databases: PubMed, Embase, CINAHL, Psyc-INFO and Cochrane CENTRAL. Longitudinal studies were selected that focused on fatigue and future SA in workers. Random-effects meta-analyses were conducted and pooled estimates [95% confidence intervals (CI)] were obtained for the association between fatigue and risk of long-term SA in total and by sex. Heterogeneity was assessed by I 2statistics. Results Of the 16 included studies in the review, 14 provided supportive evidence for an association between fatigue and SA. The meta-analysis of 9 studies (provided 15 estimates) that were mostly of high quality showed that baseline fatigue increased the risk of long-term SA by 35% (95%CI 1.23-1.47) in workers. Heterogeneity was low-moderate (I 2=40%). The pooled estimates for an increased risk for long-term SA were 35% (95% CI 1.18-1.54) in fatigued men and 22% (95% CI 0.93-1.60) in fatigued women however this relationship was not statistically significant. Conclusion There is conclusive evidence for the prospective association between worker fatigue and long-term SA. Whereas most studies in the review measured chronic fatigue and long-term SA, there was insufficient data for the meta-analysis to draw conclusions on fatigue type. Future research is needed in this area as well as greater exploration of fatigue and long-term SA in women.

Sleep Measurement in Toddlers From Low-income Families.

OBJECTIVES: (1) To examine toddler sleep in a low-income sample by comparing sleep diaries and actigraphy and (2) to assess whether toddlers are meeting the National Sleep Foundation recommendations (11-14 hours of sleep/24 hours and bedtime before 9 PM). METHODS: A convenience sample of mother-toddler dyads was recruited from 2 health care sites serving low-income communities. An actigraph was placed on the toddler's ankle and was worn for 3 days and nights. Mothers concurrently completed a sleep diary. Bedtime, nighttime sleep duration, nap duration, and 24-hour sleep duration were collected by both measures. Actigraphy data were analyzed using a combination of manufacturer's scoring algorithm and manual editing. Descriptive statistics and paired samples t-tests were conducted to examine the differences between sleep estimates by a sleep diary and actigraphy. RESULTS: Twenty toddlers (aged 13-42 months) were included in the analyses. Based on actigraphy, 1 toddler went to bed by 9 PM on all 3 nights. Six toddlers achieved 11 to 14 hours of sleep measured in a 24-hour period for 1 of the 3 days, but when sleep was averaged across the study, none achieved this goal. Compared with actigraphy, sleep diaries underestimated bedtime by 1 hour, overestimated nighttime sleep duration by 2.5 hours, and overestimated 24-hour sleep duration by 2.3 hours, on average for all 3 nights. CONCLUSION: Mothers reported significantly earlier bedtimes and longer sleep durations for their toddlers compared with actigraphy, suggesting that objective measures differ from sleep diaries in assessing sleep in toddlers from low-income families. Findings should not be generalized to populations of low-income families without replication.

Use of Noninvasive Ventilation with Volume-Assured Pressure Support to Avoid Tracheostomy in Severe Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a common disorder in children but can occasionally present with life-threatening hypoxemia. Obesity is a significant risk factor for poor outcomes of OSA treatment. Continuous positive airway pressure (CPAP) is indicated in children who are not candidates for or have an unsatisfactory response to adenotonsillectomy. Children acutely at risk for significant morbidity with other therapies are candidates for a tracheostomy. An eight-year-old patient with morbid obesity and severe OSA refractory to CPAP therapy was treated successfully with a novel noninvasive ventilation (NIV) mode with volume-assured pressure support (VAPS) and avoided tracheostomy.

Inflammation and asthma control in children with comorbid obstructive sleep apnea.

OBJECTIVES: A bi-directional relationship exists between asthma and obstructive sleep apnea (OSA) in which presence of one is associated with increased prevalence and severity of the other. Our objective was to determine whether OSA accounted for differences in airway and systemic inflammation in asthmatic children and whether inflammation was associated with asthma control. We hypothesized that greater severity of SDB would correlate with increased upper airway and systemic inflammation and result in reduced asthma control. METHODS: Non-obese children aged 4-12 years with persistent asthma, with or without OSA were recruited. Asthma control was measured with the Childhood Asthma Control Test. Children underwent polysomnography and blood sampling, and children with OSA underwent clinically indicated adenotonsillectomy. Tonsils and sera were analyzed for 11 cytokines. RESULTS: Twenty-seven children (20 with OSA, seven without OSA) participated, mean age 7.9 years, 55.6% female, 92.6% African American. Levels did not differ for any cytokine between children with and without OSA. Lower nadir oxygen saturation was associated with higher levels of tonsil TNF-α (P < 0.001) and IL-10 (P < 0.05). Higher REM-related apnea-hypopnea index was associated with higher levels of tonsil TNF-α (P < 0.05). Children with uncontrolled asthma had significantly higher levels of serum IL-10, IL-13, and TNF-α, and tonsil TNF-α (all P < 0.05) than well-controlled asthmatic children. There was no association between OSA, or any polysomnography variable, and asthma control. CONCLUSIONS: Despite the presence of OSA-associated airway inflammation, and asthma control-associated airway and systemic inflammation, OSA was not related to level of asthma control in this non-obese, largely minority, low income sample.

A Facebook-Based Obesity Prevention Program for Korean American Adolescents: Usability Evaluation.

INTRODUCTION: Adolescent obesity is one of the most serious global public health challenges. Social networking sites are currently popular among adolescents. Therefore, the obesity prevention program for Korean American adolescents was developed on the most popular social networking site, Facebook. The purpose of this study was to evaluate the usability of a culturally tailored Facebook-based obesity prevention program for Korean American adolescents (Healthy Teens). METHOD: An explorative descriptive design of usability testing was used. Usability testing employing one-on-one observation, the think-aloud method, audio taping, screen activity capture, and surveys was performed. Twenty participants were recruited from two Korean language schools (mean age, 15.40 ± 1.50 years). Recruitment and user testing was performed between February and April 2014. Content analysis, using the inductive coding approach, was performed by three coders to analyze transcriptions. Descriptive statistics were used to analyze quantitative data including demographic characteristics, perceived usability, eHealth literacy, and health behaviors. RESULTS: Testing revealed several usability issues in content, appearance, and navigation. Participants' comments regarding content were positive. Although the Facebook platform provided limited flexibility with respect to building the site, participants described the program's appearance as appropriate. Most participants did not experience difficulty in navigating the program. DISCUSSION: Our preliminary findings indicated that participants perceived the Healthy Teens program as usable and useful. This program could be used as a robust platform for the delivery of health education to adolescents. Further research is required to assess the effects of Facebook-based programs on adolescent obesity prevention.

Development of a Teen-Friendly Health Education Program on Facebook: Lessons Learned.

INTRODUCTION: Facebook is the most popular online platform among adolescents and can be an effective medium to deliver health education. Although Korean American (KA) adolescents are at risk of obesity, a culturally tailored health education program is not available for them. Thus, our research team developed a health education program for KA adolescents on Facebook called "Healthy Teens." The aim of this study was to discuss important lessons learned through the program development process. METHOD: This program includes culturally tailored learning modules about healthy eating and physical activity. The program was developed on the basis of the social cognitive theory, and the online program was developed by applying Web usability principles for adolescents. Upon completion, the usability of the program was assessed using heuristic evaluation. RESULTS: The findings from the heuristic evaluation showed that the Healthy Teens program was usable for KA adolescents. DISCUSSION: The findings from this study will assist researchers who are planning to build similar Facebook-based health education programs.

Cognitive behavioral therapy in persons with comorbid insomnia: A meta-analysis.

Cognitive behavioral therapy for insomnia (CBT-I) is effective for treatment of primary insomnia. There has been no synthesis of studies quantifying this effect on insomnia comorbid with medical and psychiatric disorders using rigorous selection criteria. The objective of this study was to quantify the effect of CBT-I in studies including patients with medical or psychiatric disorders. Studies were identified from 1985 through February 2014 using multiple databases and bibliography searches. Inclusion was limited to randomized controlled trials of CBT-I in adult patients with insomnia diagnosed using standardized criteria, who additionally had a comorbid medical or psychiatric condition. Twenty-three studies including 1379 patients met inclusion criteria. Based on weighted mean differences, CBT-I improved subjective sleep quality post-treatment, with large treatment effects for the insomnia severity index and Pittsburgh sleep quality index. Sleep diaries showed a 20 min reduction in sleep onset latency and wake after sleep onset, 17 min improvement in total sleep time, and 9% improvement in sleep efficiency post-treatment, similar to findings of meta-analyses of CBT-I in older adults. Treatment effects were durable up to 18 mo. Results of actigraphy were similar to but of smaller magnitude than subjective measures. CBT-I is an effective, durable treatment for comorbid insomnia.

Diagnostic accuracy of behavioral, activity, ferritin, and clinical indicators of restless legs syndrome.

STUDY OBJECTIVES: Lack of a valid diagnostic measure of restless legs syndrome (RLS) for persons with dementia, who do not have the cognitive ability to report complex symptoms, impedes RLS treatment and research in this population. The aim of this study was to determine the sensitivity and specificity of a combination of indicators for identifying RLS that could eventually be used to diagnose RLS in persons with dementia. DESIGN: 3-day, prospective instrument validation. SETTING: Sleep laboratory. PARTICIPANTS: Cognitively intact, 107 with RLS, 105 without RLS. INTERVENTIONS: N/A. MEASUREMENTS: Serial 20-min observations with a new measure, the Behavioral Indicators Test-Restless Legs (BIT-RL); leg movements with 3 nights of the Periodic Activity Monitor-Restless Legs (PAM-RL); ferritin; sleep history; clinical data; polysomnography; Hopkins Telephone Diagnostic Interview of RLS Symptoms. RESULTS: The best-fitting diagnostic model for identifying RLS included previous history of iron deficiency (odds ratio [OR] 7.30), leg discomfort (OR 6.47), daytime fatigue (OR 6.15), difficulty falling asleep (OR 3.25), RLS family history (OR 2.60), BIT-RL (OR 1.49), and absence of diabetes (OR 0.27), with sensitivity 78%, specificity 79%, and 77% correctly classified. This model retained its predictive accuracy even with co-morbid sleep apnea. CONCLUSIONS: When compared to those without RLS, persons with RLS have observable behaviors, such as rubbing the legs, that differentiate them, but the behaviors have no circadian and activity-related variability. The final model of clinical and sleep historical data and observation for RLS behaviors using the BIT-RL had good diagnostic accuracy.

Experience of insomnia, symptom attribution and treatment preferences in individuals with moderate to severe COPD: a qualitative study.

Persons with chronic obstructive pulmonary disease (COPD) are known to have poor sleep quality. Acceptance of and adherence to therapies for sleep problems may depend on how the person with COPD regards the source of his sleep problem, yet little is known about their attribution as to the cause of these sleep symptoms. The objective of this study was to describe the subjective sleep complaints of individuals with COPD along with their attributions as to the cause of these symptoms, and their treatment preferences for insomnia. Three focus groups were conducted (N=18) with participants who have moderate to severe COPD. Focus group data were transcribed, compared and contrasted to identify themes of attribution. Participants reported difficulty falling asleep, staying asleep, and daytime sleepiness. They attributed their sleep problems primarily to their pulmonary symptoms, but also poor air quality (thick humid air) and death anxiety when awake during the night. There was no clear preference for type of treatment to remedy this problem (medication, cognitive therapy), although they indicated that traveling to the clinic was difficult and should be avoided as much as possible. These data suggest that environmental manipulation to improve air quality (eg, air conditioning) and modifications to reduce death anxiety could be beneficial to persons with COPD. In-person multi-session therapy may not be acceptable to persons with moderate to severe COPD, however internet-based therapy might make treatment more accessible.

Impairment in circadian activity rhythms occurs during dexamethasone therapy in children with leukemia.

BACKGROUND: Circadian rhythm disturbances in adults with cancer are associated with fatigue, time to relapse, and death. This study of circadian activity rhythms (CAR) of children with acute lymphoblastic leukemia (ALL) on continuation chemotherapy aimed to describe CAR before and after starting dexamethasone, and to determine whether fatigue was associated with less robust CAR. PROCEDURE: This was a secondary analysis of data from a multi-institutional study in which children with ALL aged 5-18 years wore an actigraph for 10 consecutive 24-hour periods, five before and five during dexamethasone therapy. CAR parameters measured by actigraphy were calculated for each 5-day period, including peak activity, MESOR, amplitude, acrophase, and circadian quotient. Fatigue was measured on study days 2, 5, 7, and 10 by parent-report and self-report for children ≥ 7 years. RESULTS: Eighty-two children qualified for CAR analysis, and 87 for analysis of daily peak activity patterns and fatigue. Mean age was 8.8 ± 3.3 years. Peak activity, MESOR, and amplitude significantly decreased during dexamethasone therapy. Children on high-dose dexamethasone (8 or 12 mg/m(2)/d) had significantly higher (better, or more robust) values of several CAR parameters than those on low-dose (6 mg/m(2)/d). There was a significant trend of decreasing daily pattern of peak activity during dexamethasone therapy only. Fatigue increased across the study and was associated with decreasing CAR peak activity, MESOR, and amplitude. CONCLUSIONS: Dexamethasone initiation was associated with a decrease in several CAR parameters, and a significant decrease in the trend of daily peak activity. Fatigue was associated with less robust CAR.

Occupational screening for sleep disorders in 12-h shift nurses using the Berlin Questionnaire.

BACKGROUND: The Berlin Questionnaire has been validated as a screening tool for sleep apnea in clinical samples, but no occupational studies have reported screening validity parameters for this instrument. The objectives of this pilot study were to describe the prevalence of sleep-disordered breathing symptoms in registered nurses and examine the validity of the Berlin Questionnaire to screen for sleep apnea in this chronically partially sleep-deprived group. Validity parameters for the Berlin Questionnaire are tabulated for published studies to 2012. METHODS: Twenty-one female nurses working full time 12-h shifts underwent overnight, in-laboratory polysomnography to identify sleep disorders and completed a Berlin Questionnaire. RESULTS: By polysomnogram, the prevalence of sleep-disordered breathing [Respiratory Disturbance Index (RDI) ≥ 5] was 43 %, although by the Berlin Questionnaire only 24 % were deemed high risk. The sensitivity of the Berlin Questionnaire to detect high-risk subjects (RDI > 5) was 0.33, with a specificity of 0.83, a positive predictive value of 0.60, and negative predictive value of 0.63. Berlin criterion 3 (obesity or hypertension) performed the best for predicting sleep apnea in 12-h shift nurses. CONCLUSIONS: Although the Berlin Questionnaire produced valuable data about symptoms of sleep apnea in this population, it had a high proportion of false negatives. To improve its sensitivity for screening health care workers for sleep apnea, it must better capture symptoms specific to this population. Increasing the weighting of Berlin criterion 3 items should be considered to improve its psychometric properties.

Capturing PLMS and their variability in children with sickle cell disease: does ankle activity monitoring measure up to polysomnography?

OBJECTIVES: To test agreement and define differences in periodic limb movements in sleep (PLMS) measured by polysomnography and an ankle activity monitor, and to describe PLMS variability across nights, feasibility of home monitoring, and correlates of PLMS in children with sickle cell disease (SCD). METHODS: Twenty children with SCD and restless legs syndrome (RLS) symptoms or polysomnography-documented PLMS underwent concurrent attended polysomnography and ankle activity monitoring over one to two nights and home activity monitoring for three nights. Serum iron and ferritin were measured pre- and post-polysomnography. RESULTS: Adequate sensitivity (1.00), specificity (0.69), and mean bias (5.0±7.4 PLMS/h) for identifying elevated PLMS by activity monitor were obtained when scoring the period from sleep onset to offset rather than time in bed per manufacturer recommendation, and using a cut-point of 10 PLMS/h. Compared to activity monitor, only polysomnographic PLMS demonstrated periodicity, at inter-movement intervals (IMI) 20-35 s; the activity monitor overscored PLMS at the beginning and end of sleep and at shorter IMI (5-15s; p≤0.003), suggesting misclassification of nonperiodic leg movements as PLMS by activity monitor. PLMS varied across four nights by 16.1±13.4 PLMS/h. Post-polysomnography ferritin was associated (positively) with PLMS (p=0.034); RLS symptoms were not. CONCLUSIONS: Ankle activity monitoring is a valid screening measure for PLMS in children with SCD and can readily be performed at home. Interpretation should incorporate a threshold for elevated PLMS of 10/h and scoring from sleep onset to offset, which could be identified with concurrent wrist actigraphy, to better account for true PLMS.