Placebo effects in randomized trials of pharmacological and neurostimulation interventions for mental disorders: An umbrella review.

There is a growing literature exploring the placebo response within specific mental disorders, but no overarching quantitative synthesis of this research has analyzed evidence across mental disorders. We carried out an umbrella review of meta-analyses of randomized controlled trials (RCTs) of biological treatments (pharmacotherapy or neurostimulation) for mental disorders. We explored whether placebo effect size differs across distinct disorders, and the correlates of increased placebo effects. Based on a pre-registered protocol, we searched Medline, PsycInfo, EMBASE, and Web of Knowledge up to 23.10.2022 for systematic reviews and/or meta-analyses reporting placebo effect sizes in psychopharmacological or neurostimulation RCTs. Twenty meta-analyses, summarising 1,691 RCTs involving 261,730 patients, were included. Placebo effect size varied, and was large in alcohol use disorder (g = 0.90, 95% CI [0.70, 1.09]), depression (g = 1.10, 95% CI [1.06, 1.15]), restless legs syndrome (g = 1.41, 95% CI [1.25, 1.56]), and generalized anxiety disorder (d = 1.85, 95% CI [1.61, 2.09]). Placebo effect size was small-to-medium in obsessive-compulsive disorder (d = 0.32, 95% CI [0.22, 0.41]), primary insomnia (g = 0.35, 95% CI [0.28, 0.42]), and schizophrenia spectrum disorders (standardized mean change = 0.33, 95% CI [0.22, 0.44]). Correlates of larger placebo response in multiple mental disorders included later publication year (opposite finding for ADHD), younger age, more trial sites, larger sample size, increased baseline severity, and larger active treatment effect size. Most (18 of 20) meta-analyses were judged 'low' quality as per AMSTAR-2. Placebo effect sizes varied substantially across mental disorders. Future research should explore the sources of this variation. We identified important gaps in the literature, with no eligible systematic reviews/meta-analyses of placebo response in stress-related disorders, eating disorders, behavioural addictions, or bipolar mania.

Obstructive Sleep Apnoea Contributes to Executive Function Impairment in Young Children with Down Syndrome.

OBJECTIVE/BACKGROUND: Children with Down syndrome (DS) commonly experience difficulties with executive function (EF). They are also vulnerable to obstructive sleep apnoea (OSA). OSA is associated with EF deficits in typically developing children. A recent study reported an association between OSA and cognitive deficits in 38 school-aged children with DS. We experimentally investigated EF behaviours in young children with DS, and their association with OSA. PARTICIPANTS AND METHODS: Children with DS were recruited to take part in a larger study of OSA (N = 202). Parents of 80 children (50 male) aged 36 to 71 months (M = 56.90, SD = 10.19 months) completed the Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P). Of these 80 children, 69 were also successfully studied overnight with domiciliary cardiorespiratory polygraphy to diagnose OSA. RESULTS: Obstructive apnoea/hypopnoea index was in the normal range (0-1.49/h) for 28 children but indicated OSA (≥1.5/h) in 41 children. Consistent with previous research, we found a large effect for children experiencing particular weaknesses in working memory, planning and organising, whilst emotional control was a relative strength. OSA was associated with poorer working memory (ß = .23, R2 = .05, p = .025), emotional control (ß = .20, R2 = .04, p = .047) and shifting (ß = .24, R2 = .06, p = .023). CONCLUSIONS: Findings suggest that known EF difficulties in DS are already evident at this young age. Children with DS already have limited cognitive reserve and can ill afford additional EF deficit associated with OSA. OSA is amenable to treatment and should be actively treated in these children to promote optimal cognitive development.

A cross-syndrome study of the differential effects of sleep on declarative memory consolidation in children with neurodevelopmental disorders.

Sleep plays an active role in memory consolidation. Because children with Down syndrome (DS) and Williams syndrome (WS) experience significant problems with sleep and also with learning, we predicted that sleep-dependent memory consolidation would be impaired in these children when compared to typically developing (TD) children. This is the first study to provide a cross-syndrome comparison of sleep-dependent learning in school-aged children. Children with DS (n = 20) and WS (n = 22) and TD children (n = 33) were trained on the novel Animal Names task where they were taught pseudo-words as the personal names of ten farm and domestic animals, e.g. Basco the cat, with the aid of animal picture flashcards. They were retested following counterbalanced retention intervals of wake and sleep. Overall, TD children remembered significantly more words than both the DS and WS groups. In addition, their performance improved following night-time sleep, whereas performance over the wake retention interval remained stable, indicating an active role of sleep for memory consolidation. Task performance of children with DS did not significantly change following wake or sleep periods. However, children with DS who were initially trained in the morning continued to improve on the task at the following retests, so that performance on the final test was greater for children who had initially trained in the morning than those who trained in the evening. Children with WS improved on the task between training and the first retest, regardless of whether sleep or wake occurred during the retention interval. This suggests time-dependent rather than sleep-dependent learning in children with WS, or tiredness at the end of the first session and better performance once refreshed at the start of the second session, irrespective of the time of day. Contrary to expectations, sleep-dependent learning was not related to baseline level of performance. The findings have significant implications for educational strategies, and suggest that children with DS should be taught more important or difficult information in the morning when they are better able to learn, whilst children with WS should be allowed a time delay between learning phases to allow for time-dependent memory consolidation, and frequent breaks from learning so that they are refreshed and able to perform at their best.

Duration of sleep at 3 years of age is associated with fat and fat-free mass at 4 years of age: the Southampton Women's Survey.

Many studies have shown that shorter sleep duration in childhood is associated with higher body mass index (BMI), and have proposed that it is due to an effect of sleep on adiposity. There is little evidence about the association of sleep with fat-free mass. This study examined the association between child's sleep duration at age 3 years and fat and fat-free mass at 4 years of age in a prospective cohort study of 302 boys and 285 girls. Study participants were taking part in the Southampton Women's Survey, a longitudinal study of mothers and children from preconception onwards. Total sleep duration at age 3 years was derived from parental report of night sleep and nap duration. Body composition was assessed by Dual-energy X-ray Absorptiometry (DXA) at 4 years. Mean total sleep duration was 11.5 hours. In linear regression analyses, adjusted for potentially confounding factors (maternal educational attainment, prepregnancy BMI, smoking during pregnancy, child's gestational age at birth, age at DXA, sex, age last breastfed, dietary quality at 3 years, TV watching and hours actively on the move and parental social class), shorter sleep in hours was associated with higher BMI (kg/m(2) ) [ß: -0.2340, 95% confidence interval (CI): -0.373 to -0.096], a greater fat mass index (kg) (ß: -0.1182, 95% CI: -0.218 to -0.018) and a greater fat-free mass index (kg) (ß: -0.100, 95% CI: -0.185 to -0.015). Previous research suggested that the association between shorter sleep and higher body mass index is due to an effect on adiposity. Our findings are novel, suggesting that the relationship between sleep and BMI is also determined by an effect on muscle.

The Importance of Sleep: Attentional Problems in School-Aged Children With Down Syndrome and Williams Syndrome.

In typically developing (TD) children, sleep problems have been associated with day-time attentional difficulties. Children with developmental disabilities often suffer with sleep and attention problems, yet their relationship is poorly understood. The present study investigated this association in school-aged children with Down syndrome (DS) and Williams syndrome (WS). Actigraphy and pulse oximetry assessed sleep and sleep-disordered breathing respectively, and attention was tested using a novel visual Continuous Performance Task (CPT).Attentional deficits were evident in both disorder groups. In the TD group, higher scores on the CPT were related to better sleep quality, higher oxyhemoglobin saturation (SpO2), and fewer desaturation events. Sleep quality, duration, and SpO2 variables were not related to CPT performance for children with DS and WS.

Estimating Population Density of the San Martin Titi Monkey (Callicebus oenanthe) in Peru Using Vocalisations.

We calculated the population density of the critically endangered Callicebus oenanthe in the Ojos de Agua Conservation Concession, a dry forest area in the department of San Martin, Peru. Results showed significant differences (p < 0.01) in group densities between forest boundaries (16.5 groups/km2, IQR = 21.1-11.0) and forest interior (4.0 groups/km2, IQR = 5.0-0.0), suggesting the 2,550-ha area harbours roughly 1,150 titi monkeys. This makes Ojos de Agua an important cornerstone in the conservation of the species, because it is one of the largest protected areas where the species occurs.

Sleep enhances memory consolidation in children.

Sleep is an active state that plays an important role in the consolidation of memory. It has been found to enhance explicit memories in both adults and children. However, in contrast to adults, children do not always show a sleep-related improvement in implicit learning. The majority of research on sleep-dependent memory consolidation focuses on adults; hence, the current study examined sleep-related effects on two tasks in children. Thirty-three typically developing children aged 6-12 years took part in the study. Actigraphy was used to monitor sleep. Sleep-dependent memory consolidation was assessed using a novel non-word learning task and the Tower of Hanoi cognitive puzzle, which involves discovering an underlying rule to aid completion. Children were trained on the two tasks and retested following approximately equal retention intervals of both wake and sleep. After sleep, children showed significant improvements in performance of 14% on the non-word learning task and 25% on the Tower of Hanoi task, but no significant change in score following the wake retention interval. Improved performance on the Tower of Hanoi may have been due to children consolidating explicit aspects of the task, for example rule-learning or memory of previous sequences; thus, we propose that sleep is necessary for consolidation of explicit memory in children. Sleep quality and duration were not related to children's task performance. If such experimental sleep-related learning enhancement is generalizable to everyday life, then it is clear that sleep plays a vital role in children's educational attainment.

Implementing a Respectful Maternity Care Guideline During Childbirth Experiences.

OBJECTIVE: To measure the impact of an evidence-based guideline on respectful maternity care on nurses' attitudes and beliefs about childbirth practices. DESIGN: A quality improvement pilot project with a pretest/posttest design examining the attitudes and beliefs of intrapartum nurses about childbirth practices of respectful care. SETTING: High-risk intrapartum unit at a tertiary care center in the southeastern United States. PARTICIPANTS: A convenience sample of 130 registered nurses were invited to participate, and nine completed the pre- and posttests. INTERVENTION/MEASUREMENTS: The intervention included a recorded webinar, access to printed and electronic copies of the guideline, discussions in daily huddles, and a virtual journal club. Data were collected using the 42-item Nurse Attitudes and Beliefs Questionnaire-Revised. Lower scores are reflective of attitudes and beliefs that support a medical model of care, whereas higher scores are reflective of a physiologic model of care. Descriptive statistics and the Wilcoxon signed rank test were used to analyze changes in attitudes and beliefs based on the aggregate scores of the nurse participants. RESULTS: Although there was no change in nurse attitude and beliefs about childbirth practices after 3 months (p = .058), the aggregate scores on a scale of 42 to 168 increased by 5.6 points. Two subscales of the Nurse Attitudes and Beliefs Questionnaire-Revised-Medical Model of Conflict and Women's Autonomy-had the greatest increase in aggregate scores. CONCLUSION: Understanding nurses' attitudes and beliefs can assist in identifying barriers to the provision of respectful care, particularly during labor and birth, when patients are most vulnerable. Measurement of nurse attitudes and beliefs regarding respectful maternity care may require a longer immersion in a respectful maternity care program to allow for changes over time.

Role of overnight oximetry in assessing the severity of obstructive sleep apnoea in typically developing children: a multicentre study.

BACKGROUND AND OBJECTIVE: Cardiorespiratory polygraphy (CRP) is the predominant technology used to diagnose obstructive sleep apnoea (OSA) in tertiary centres in the UK. Nocturnal pulse oximetry (NPO) is, however, cheaper and more accessible. This study evaluated the ability of NPO indices to predict OSA in typically developing (TD) children. METHODS: Indices from simultaneous NPO and CRP recordings were compared in TD children (aged 1-16 years) referred to evaluate OSA in three tertiary centres. OSA was defined as an obstructive apnoea-hypopnoea index (OAHI) ≥1 event/hour. Receiver operating characteristic curves assessed the diagnostic accuracy of NPO indices including ODI3 (3% Oxygen Desaturation Index, ODI4 (4% Oxygen Desaturation Index), delta 12 s index and minimum oxygen saturation. Two-by-two tables were generated to determine the sensitivities and specificities of whole number cut-off values for predicting OAHIs ≥1, 5 and 10 events/hour. RESULTS: Recordings from 322 TD children, 197 male (61.2%), median age 4.9 years (range 1.1-15.6), were reviewed. OAHI was ≥1/hour in 144 (44.7%), ≥5/hour in 61 (18.9%) and ≥10/hour in 28 (8.7%) cases. ODI3 and ODI4 had the best diagnostic accuracy. ODI3 ≥7/hour and ODI4 ≥4/hour predicted OSA in TD children with sensitivities/specificities of 57.6%/85.4% and 46.2%/91.6%, respectively. ODI3 ≥8/hour was the best predictor of OAHI ≥5/hour (sensitivity 82.0%, specificity 84.3%). CONCLUSION: Raised ODI3 and ODI4 predict OSA in TD children with high specificity but variable sensitivity. NPO may be an alternative to diagnose moderate-severe OSA if access to CRP is limited. Low sensitivities to detect mild OSA mean that confirmatory CRP is needed if NPO is normal.

Ventilatory function in children with severe motor disorders using night-time postural equipment.

AIM: Night-time postural equipment (NTPE) can prevent hip subluxation in children with severe motor disorders (SMDs). However, it is unclear how it affects ventilatory function. The aims of the study were to determine how NTPE use affects ventilatory function and to compare night-to-night variability of ventilatory function in children with SMDs and typically developing healthy children. METHOD: Fifteen NTPE users (six males, nine females), aged 1 to 19 years (mean age 8y 7mo) alternated sleep condition between NTPE and sleeping unsupported for 14 nights. In all but two participants, gross motor function was classified as Gross Motor Function Classification System (GMFCS) level V; in the other two it was level IV. Oxyhaemoglobin saturation (SpO2 ) was monitored each night and transcutaneous CO2 (PtcCO2 ) for one night in each sleep condition. In 17 healthy children of similar age, home SpO2 only was monitored for seven nights. RESULTS: In 13 of 15 NTPE users and 12 of the 17 typically developing children, SpO2 monitoring was satisfactorily completed. Of the children with SMDs, two had mean SpO2 levels below the treatment threshold for supplemental oxygen, which was uniquely associated with use of NTPE in only one participant, and three had nocturnal hypoventilation, which was uniquely associated with NTPE use in only one case. Night-to-night SpO2 variability was higher in children with SMDs than in typically developing children. INTERPRETATION: NTPE may impair or enhance ventilatory function in a minority of children. Owing to night-to-night variability in SpO2 , at least three nights of monitoring are recommended to determine optimal positioning for effective ventilation before and after NTPE introduction.

Placebo effects in mental health disorders: protocol for an umbrella review.

INTRODUCTION: Given the high prevalence of mental health disorders and their significant socioeconomic burden, there is a need to develop improved treatments, and to evaluate them through placebo-controlled trials. However, the magnitude of the placebo response in randomised controlled trials to test medications may be substantial, affecting their interpretation. Therefore, improved understanding of the patient, trial and mental disorder factors that influence placebo responses would inform clinical trial design to better detect active treatment effects. There is a growing literature exploring the placebo response within specific mental health disorders, but no overarching synthesis of this research has been produced to date. We present a protocol for an umbrella review of systematic reviews and/or meta-analyses in which we aim to understand the effect size and potential predictors of placebo response within, and across, mental health disorders. METHODS AND ANALYSIS: We will systematically search databases (Medline, PsycINFO, EMBASE+EMBASE Classic, Web of Knowledge) for systematic reviews and/or meta-analyses that report placebo effect size in clinical trials in patients with mental health disorders (initial search date 23 October 2022). Screening of abstracts and full texts will be done in pairs. We will extract data to qualitatively examine how placebo effect size varies across mental health disorders. We also plan to qualitatively summarise predictors of increased placebo response identified either quantitatively (eg, through meta-regression) or qualitatively. Risk of bias will be assessed using the AMSTAR-2 tool. We aim to not only summarise the current literature but also to identify gaps in knowledge and generate further hypotheses. ETHICS AND DISSEMINATION: We do not believe there are any specific ethical considerations relevant to this study. We will publish the results in a peer-reviewed journal.

Sleep problems in children with cerebral palsy and their relationship with maternal sleep and depression.

AIM: To compare sleep problems in children with cerebral palsy to typically developing children. To study the relationship between sleep problems in children with cerebral palsy and maternal sleep quality and depression. METHODS: Fifty-seven children with cerebral palsy aged 4-12 years were identified from a UK disability database. Maternal sleep disturbance and mood were assessed using the Pittsburgh Sleep Quality Index and the Major Depression Inventory. Child sleep problems, assessed with the Children's Sleep Habits Questionnaire, but not maternal variables, were compared to 102 typically developing children. RESULTS: Forty children (70%) were recruited with a mean age of 7.8 (SD 2.4). Sleep anxiety, night wakings, parasomnias and sleep-disordered breathing sub-scales indicated significantly more difficulties than in typically developing children. 40% of mothers of children with cerebral palsy had poor sleep quality of whom 44% had depressed mood. Child and maternal sleep disturbance were significantly correlated. Maternal sleep quality predicted 50% of the variance in maternal depression. CONCLUSIONS: Children with cerebral palsy have more sleep problems than typically developing peers. Their mothers also have disturbed sleep that correlates with maternal depression. Childhood sleep problems can be treated and should be identified in routine clinical practice.

Efficacy on sleep parameters and tolerability of melatonin in individuals with sleep or mental disorders: A systematic review and meta-analysis.

We conducted the first systematic review and series of meta-analyses to assess the efficacy and tolerability of melatonin in children/adolescents or adults with sleep or mental health disorders, using the same set of criteria across disorders and ages. Based on a pre-registered protocol (PROPSPERO: CRD42021289827), we searched a broad range of electronic databases up to 02.02.2021 for randomized control trials (RCTs) of melatonin. We assessed study quality using the Risk of Bias tool, v2. We included a total of 34 RCTs (21 in children/adolescents: N = 984; 13 in adults: N = 1014). We found evidence that melatonin significantly improved sleep onset latency and total sleep time, but not sleep awaking, in children and adolescents with a variety of neurodevelopmental disorders, and sleep onset latency (measured by diary) as well as total sleep time (measured with polysomnography) in adults with delayed sleep phase disorder. No evidence of significant differences between melatonin and placebo was found in terms of tolerability. We discuss clinical and research implications of our findings.

Segmentation of the foveal and parafoveal retinal architecture using handheld spectral-domain optical coherence tomography in children with Down syndrome.

BACKGROUND: Down syndrome is a common multigene, multisystem disorder associated with abnormalities of visual function and characteristic changes in the majority of tissues in the eye. Historic descriptions of macular structure in Down syndrome have been variable, but optical coherence tomography allows increasingly detailed characterization of retinal architecture in vivo. We demonstrate the feasibility of retinal imaging in children with Down syndrome using handheld OCT in an outpatient clinical setting, and describe the foveal and parafoveal retinal architecture in this group. METHODS: Fourteen White British children aged between 4 and 11 with Down syndrome were recruited to have handheld SD-OCT retinal imaging performed at a single centre in an outpatient clinical setting. The thickness of the retinal layers at the fovea and parafovea was analysed using segmentation software, and compared with age-matched controls from a previously published normative UK dataset. RESULTS: Sixty-seven percent of the children studied had grade 1 foveal hypoplasia. At the fovea, the ganglion cell layer (p = 0.002) and inner nuclear layer (p < 0.001) were thickened relative to the control group. At the parafovea, there was thickening of the retina attributable to numerous layers in both the inner and outer retina, which remained significant after Bonferroni correction. CONCLUSION: OCT imaging of children with Down syndrome in an outpatient setting is feasible. There is a high incidence of foveal hypoplasia in this group, associated with thickening of the ganglion cell and inner nuclear layers at the fovea.

Sleep problems in low income, urban pediatric populations living at different altitudes in Colombia.

OBJECTIVE: To determine the frequency of sleep problems in low-income, urban pediatric populations in cities at different altitudes in Colombia. METHODS: A descriptive, cross-sectional population-based observational study was conducted in children aged between 2 and 12 years in the low income, urban areas of three cities in Colombia (Santa Marta, Bucaramanga, and Bogotá) located at 15, 959, and 2640 m above sea level, respectively. Sociodemographic data were collected, and the Spanish version of the Pediatric Sleep Questionnaire was used. RESULTS: 1989 children were surveyed, distributed as follows: Santa Marta (32.0%), Bucaramanga (33.4%), and Bogotá (34.6%). The overall prevalence of sleep problems was 39.0%. Children from Santa Marta had the highest frequency of parasomnias (58.0%); those from Bucaramanga had the highest frequency of attention deficit symptoms (4.0%) and apneic pauses witnessed by parents or caregivers (5.7%). Finally, Bogotá, the only high-altitude location, had the highest frequency of sleep disordered breathing (17.2%). CONCLUSIONS: The study found a high frequency of sleep problems in the pediatric population, especially at higher altitudes when compared to lower altitude settings. Sleep disorders warrant early detection and timely therapeutic intervention.

Chimpanzees balance resources and risk in an anthropogenic landscape of fear.

Human-wildlife coexistence is possible when animals can meet their ecological requirements while managing human-induced risks. Understanding how wildlife balance these trade-offs in anthropogenic environments is crucial to develop effective strategies to reduce risks of negative interactions, including bi-directional aggression and disease transmission. For the first time, we use a landscape of fear framework with Bayesian spatiotemporal modelling to investigate anthropogenic risk-mitigation and optimal foraging trade-offs in Critically Endangered western chimpanzees (Pan troglodytes verus). Using 12 months of camera trap data (21 camera traps, 6722 camera trap days) and phenology on wild and cultivated plant species collected at Caiquene-Cadique, Cantanhez National Park (Guinea-Bissau), we show that humans and chimpanzees broadly overlapped in their use of forest and anthropogenic parts of the habitat including villages and cultivated areas. The spatiotemporal model showed that chimpanzee use of space was predicted by the availability of naturalised oil-palm fruit. Chimpanzees used areas away from villages and agriculture more intensively, but optimised their foraging strategies by increasing their use of village areas with cultivated fruits when wild fruits were scarce. Our modelling approach generates fine-resolution space-time output maps, which can be scaled-up to identify human-wildlife interaction hotspots at the landscape level, informing coexistence strategy.

Breathing Patterns and Oxygenation Saturation During Sleep in Children Habitually Living at High Altitude in the Andes: A Systematic Review.

Background: Human respiratory physiology changes significantly in high altitude settings and these changes are particularly marked during sleep. It is estimated that 170 million people live above 2,500 m in environments where normal sleep parameters differ from those established at sea level or low altitude. Methods: We conducted a systematic review of publications reporting sleep studies in healthy children living at high altitude. For this purpose, data from PubMed, EMBASE, SciELO and Epistemomikos bases were retrieved up to August 2021. Results: Six articles met specified inclusion criteria; all reporting data were from South America involving 245 children (404 sleep studies) in children aged 0.6 months to 18 years, at altitudes between 2,560 to 3,775 m. The main results were: (1) Central apnea index decreased as the age increased. (2) The obstructive apnea/hypopnea index showed a bimodal profile with an increase in young infants up to age of 4 months, decreasing to 15 months of age, and then a second peak in children aged 4 to 9 years of age, dropping in older schoolchildren and adolescents. (3) Periodic breathing in the first months of life is more marked with increasing altitude and decreases with age. Conclusions: There are few studies of sleep physiology in children living at high altitude. The international parameters defining normal apnea indices currently used at low altitude cannot be applied to high altitude settings. The interpretation of sleep studies in children living at high altitude is complex because there are important developmental changes across childhood and a wide range of altitude locations. More normative data are required to determine thresholds for respiratory pathology at a variety of high altitude settings.

Sleep-Related Rhythmic Movement Disorder in Young Children with Down Syndrome: Prevalence and Clinical Features.

Sleep-related Rhythmic Movement Disorder (RMD) affects around 1% of UK pre-school children. Little is known about RMD in Down syndrome (DS). We aimed to determine: (a) the prevalence of RMD in children with DS aged 1.5-8 years; (b) phenotypic and sleep quality differences between children with DS and RMD and sex- and age-matched DS controls; and (c) night-to-night variability in rhythmic movements (RMs). Parents who previously reported RMs from a DS research registry of 202 children were contacted. If clinical history suggested RMD, home videosomnography (3 nights) was used to confirm RMs and actigraphy (5 nights) was used to assess sleep quality. Phenotype was explored by demographic, strengths and difficulties, Q-CHAT-10/social communication and life events questionnaires. Eight children had confirmed RMD. Minimal and estimated maximal prevalence were 4.10% and 15.38%, respectively. Sleep efficiency was significantly lower in RMD-cases (69.1%) versus controls (85.2%), but there were no other phenotypic differences. There was considerable intra-individual night-to-night variability in RMs. In conclusion, RMD has a high prevalence in children with DS, varies from night to night and is associated with poor sleep quality but, in this small sample, no daytime phenotypic differences were found compared to controls. Children with DS should be screened for RMD, which is amenable to treatment.

AWHONN Members' Recommendations on What to Include in Updated Standards for Professional Registered Nurse Staffing for Perinatal Units.

OBJECTIVE: To solicit advice from members of the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) on what to include in an update of nurse staffing standards. DESIGN: Online, single-question survey with thematic analysis of responses. SETTING: Electronic survey link sent via e-mail. PARTICIPANTS: AWHONN members who shared their e-mail with the association and who responded to the survey (n = 1,813). MEASURES: Participants were asked to answer this single question: "The AWHONN (2010) Guidelines for Professional Registered Nurse Staffing for Perinatal Units are being updated. During their initial development, feedback from nearly 900 AWHONN members was extremely helpful in providing specific details for the nurse staffing guidelines. We'd really like to hear from you again. Please give the writing team your input. What should AWHONN consider when updating the AWHONN nurse staffing guidelines?" RESULTS: The e-mail was successfully delivered to 20,463 members; 8,050 opened the e-mail, and 3,050 opened the link to the survey. There were 1,892 responses. After removing duplicate and blank responses, 1,813 responses were available for analysis. They represented all hospital practice settings for maternity and newborn care and included nurses from small-volume and rural hospitals. Primary concerns of respondents centered on two aspects of patient acuity-the increasing complexity of clinical cases and the need to link nurse staffing standards to patient acuity. Other themes included maintaining current nurse-to-patient ratios, needing help with implementation in the context of economic challenges, and changing wording from "guidelines" to "standards" to promote widespread adoption. CONCLUSION: In a single-question survey, AWHONN members offered rich, detailed recommendations that were used in the updating of the AWHONN nurse staffing standards.

Chimpanzee responses to researchers in a disturbed forest-farm mosaic at Bulindi, western Uganda.

We describe the behavior of a previously unstudied community of wild chimpanzees during opportunistic encounters with researchers in an unprotected forest-farm mosaic at Bulindi, Uganda. Data were collected during 115 encounters between May 2006 and January 2008. Individual responses were recorded during the first minute of visual contact. The most common responses were "ignore" for arboreal chimpanzees and "monitor" for terrestrial individuals. Chimpanzees rarely responded with "flight". Adult males were seen disproportionately often relative to adult females, and accounted for 90% of individual responses recorded for terrestrial animals. Entire encounters were also categorized based on the predominant response of the chimpanzee party to researcher proximity. The most frequent encounter type was "ignore" (36%), followed by "monitor" (21%), "intimidation" (18%) and "stealthy retreat" (18%). "Intimidation" encounters occurred when chimpanzees were contacted in dense forest where visibility was low, provoking intense alarm and agitation. Adult males occasionally acted together to repel researchers through aggressive mobbing and pursuit. Chimpanzee behavior during encounters reflects the familiar yet frequently agonistic relationship between apes and local people at Bulindi. The chimpanzees are not hunted but experience high levels of harassment from villagers. Human-directed aggression by chimpanzees may represent a strategy to accommodate regular disruptions to foraging effort arising from competitive encounters with people both in and outside forest. Average encounter duration and proportion of encounters categorized as "ignore" increased over time, whereas "intimidation" encounters decreased, indicating some habituation occurred during the study. Ecotourism aimed at promoting tolerance of wildlife through local revenue generation is one possible strategy for conserving great apes on public or private land. However, the data imply that habituating chimpanzees for viewing-based ecotourism in heavily human-dominated landscapes, such as Bulindi, is ill-advised since a loss of fear of humans could lead to increased negative interactions with local people.