Concordance between self-reported sleep and actigraphy-assessed sleep in adult survivors of childhood cancer: the impact of psychological and neurocognitive late effects.

PURPOSE: To examine self-reported (30-day) sleep versus nightly actigraphy-assessed sleep concordance in long-term survivors of childhood cancer. METHODS: Four hundred seventy-seven participants enrolled in the St. Jude Lifetime Cohort (53.5% female, median (range) age 34.3 (19.3-61.6) years, 25.4 (10.9-49.3) years from diagnosis) completed the Pittsburgh Sleep Quality Index and ≥ 3 nights of actigraphy. Participants had neurocognitive impairment and/or a self-reported prolonged sleep onset latency (SOL). Self-reported 30-day sleep and nightly actigraphic sleep measures for sleep duration, SOL, and sleep efficiency (SE) were converted into ordinal categories for calculation of weighted kappa coefficients. General linear models estimated associations between measurement concordance and late effects. RESULTS: Agreements between self-reported and actigraphic measures were slight to fair for sleep duration and SOL measures (kw = 0.20 and kw = 0.22, respectively; p < 0.0001) and poor for SE measures (kw = 0.00, p = 0.79). In multivariable models, severe fatigue and poor sleep quality were significantly associated with greater absolute differences between self-reported and actigraphy-assessed sleep durations (B = 26.6 [p < 0.001] and B = 26.8 [p = 0.01], respectively). Survivors with (versus without) memory impairment had a 44-min higher absolute difference in sleep duration (B = 44.4, p < 0.001). Survivors with, versus without, depression and poor sleep quality had higher absolute discrepancies of SOL (B = 24.5 [p = 0.01] and B = 16.4 [p < 0.0001], respectively). Poor sleep quality was associated with a 12% higher absolute difference in SE (B = 12.32, p < 0.0001). CONCLUSIONS: Self-reported sleep and actigraphic sleep demonstrated discordance in our sample. Several prevalent late effects were statistically significantly associated with increased measurement discrepancy. Future studies should consider the impacts of late effects on sleep assessment in adult survivors of childhood cancer.

Hospital Security Programs and Policies Related to Guns and Other Weapons.

EXECUTIVE SUMMARY: Workplace violence in healthcare is a health and safety problem that can have a significant impact on the mission and effectiveness of organizations. To ascertain hospital approaches to address violence and experiences with guns and other weapons, we conducted a survey of International Association for Healthcare Security & Safety members. Although many hospitals have enhanced their security programs, many challenges persist. We found that armed security appears to be increasingly prevalent in hospitals, and the use of Tasers appears to be increasing the most in comparison to other weapons. Most of our survey respondents did not perceive officers losing control of their weapons during altercations in their healthcare facility as a real risk. In addition, roughly half of the respondents reported that portable metal detectors (including wands) were not used in their facilities. The disposition of weapons confiscated by security also raised concerns about how legally owned firearms can be safely returned to their owners while they are still on hospital property.

Sleepless in Fairfax: the difference one more hour of sleep can make for teen hopelessness, suicidal ideation, and substance use.

Insufficient sleep is a risk factor for depression, suicidality, and substance use, yet little is known about gender, ethnic, and community-level differences in sleep and its associated outcomes, especially during adolescence. Further, much of the prior work has compared groups of teens getting plenty as opposed to insufficient amounts of sleep rather than examine sleep hours continuously. The present study examined adolescent weekday self-reported sleep duration and its links with hopelessness, suicidality, and substance use in a suburban community with very early high school start times. We utilized a large (N = 27,939, 51.2% female) and ethnically diverse sample of adolescents from the 2009 Fairfax County (Virginia) Youth Survey, an anonymous, self-report, population-level survey administered to all 8th, 10th and 12th grade students in public schools in the county. High-school students reported an average 6.5 h of sleep per school night, with 20% obtaining ≤5 h, and only 3% reporting the recommended 9 h/night. Females and minority youth obtained even less sleep on average, and the reduction in sleep in the transition from middle school to high school was more pronounced for females and for Asian students. Hierarchical, multivariate, logistic regression analyses, controlling for background variables, indicated that just 1 h less of weekday sleep was associated with significantly greater odds of feeling hopeless, seriously considering suicide, suicide attempts, and substance use. Relationships between sleep duration and suicidality were stronger for male teens, and sleep duration was more associated with hopelessness for white students compared to most ethnic minority groups. Implications for intervention at multiple levels are discussed.

Observations of Delayed Changes in Respiratory Function among Allergy Clinic Patients Exposed to Wildfire Smoke.

Wildfires have increased in frequency and magnitude and pose a significant public health challenge. The principal objective of this study was to assess the impact of wildfire smoke on respiratory peak flow performance of patients exposed to two different wildfire events. This longitudinal study utilized an observational approach and a cohort study design with a patient-level clinical dataset from a local outpatient allergy clinic (n = 842). Meteorological data from a local weather station served as a proxy for smoke exposure because air quality measurements were not available. This study found that there were decreases in respiratory peak flow among allergy clinic patients one year after each wildfire event. For every one percent increase in wind blowing from the fire towards the community, there was, on average, a 2.21 L per minute decrease in respiratory peak flow. This study observed an effect on respiratory peak flow performance among patients at a local allergy clinic one year after suspected exposure to wildfire smoke. There are likely multiple reasons for the observation of this relationship, including the possibility that wildfire smoke may enhance allergic sensitization to other allergens or that wildfire smoke itself may elicit a delayed immune response.

Risk factors for workplace encounters with weapons by hospital employees.

Objective: The specific aim of this study was to determine which risk factors were associated with frequent weapons confiscation in a healthcare facility. This study investigated the hypothesis that hospital-related factors impact the frequency of weapons confiscation. Study design: Cross-sectional. Methods: A cross-sectional survey was administered on-line to hospital security directors and assessed the associations of organizational factors with the frequency of weapons confiscation. Results: It was found that hospitals with metal detectors were more than 5 times as likely to frequently confiscate weapons, suggesting this intervention is effective. It was also found that hospitals with psychiatric units were more likely to have frequent confiscation of weapons, likely due to the standard procedure of searching patients before admission to the psychiatric unit. Conclusion: This data suggests that searching patients and using metal detectors are important tools in the prevention of weapons entering a healthcare setting.

Prospective associations of insomnia markers and symptoms with depression.

Whether insomnia, a known correlate of depression, predicts depression longitudinally warrants elucidation. The authors examined 555 Wisconsin Sleep Cohort Study participants aged 33-71 years without baseline depression or antidepressant use who completed baseline and follow-up overnight polysomnography and had complete questionnaire-based data on insomnia and depression for 1998-2006. Using Poisson regression, they estimated relative risks for depression (Zung scale score > or =50) at 4-year (average) follow-up according to baseline insomnia symptoms and polysomnographic markers. Twenty-six participants (4.7%) developed depression by follow-up. Having 3-4 insomnia symptoms versus none predicted depression risk (age-, sex-, and comorbidity-adjusted relative risk (RR) = 3.2, 95% confidence interval: 1.1, 9.6). After multiple adjustments, frequent difficulty falling asleep (RR = 5.3, 95% confidence interval: 1.1, 27.9) and polysomnographically assessed (upper or lower quartiles) sleep latency, continuity, and duration (RRs = 2.2-4.7; P's < or = 0.05) predicted depression. Graded trends (P-trend < or = 0.05) were observed with increasing number of symptoms, difficulty falling asleep, and difficulty returning to sleep. Given the small number of events using Zung > or =50 (depression cutpoint), a limitation that may bias multivariable estimates, continuous depression scores were analyzed; mean values were largely consistent with dichotomous findings. Insomnia symptoms or markers increased depression risk 2.2- to 5.3-fold. These results support prior findings based on self-reported insomnia and may extend similar conclusions to objective markers. Heightened recognition and treatment of insomnia may prevent subsequent depression.

Sleep apnea and kidney transplant outcomes: findings from a 20-year (1997-2017) historical cohort study.

OBJECTIVE/BACKGROUND: A historic cohort single-center study of kidney transplant recipients with graft loss examined the associations between sleep apnea and two transplant outcomes, death with a functioning graft (DWFG), and graft survival time. PATIENT/METHODS: Adult patients who received transplants and experienced graft failure or DWFG from January 1, 1997 to January 1, 2017 constituted the cohort (n = 322). Data for the study were obtained by merging two secondary data sources: the Organ Procurement and Transplantation Network (OPTN) database and the transplant center's medical records. A Cox regression modeled the association of diagnosed sleep apnea, stratified by year-of transplant surgery, with graft survival time. Using backward elimination, this model was adjusted for recipient age, race/ethnicity, gender, functional status, donor age, and antigen mismatch. RESULTS: No statistically significant differences were found for proportions of DWFG in those with, versus without, sleep apnea, informing our censoring approach. When examining graft survival time, the Cox regression model was stratified given a sleep apnea and year-of-transplant interaction (p < 0.01, adjusted model). For patients transplanted between 1997 and 2008, sleep apnea was statistically significantly associated with a decreased risk of graft failure or cardiovascular-related DWFG [adjusted Hazard Ratio (aHR) = 0.63, 95%CI, 0.42-0.94]. For patients transplanted between 2009 and 2017, sleep apnea statistically significantly increased the risk of graft failure or cardiovascular-related DWFG (aHR = 2.61, 95%CI, 1.13-6.00). CONCLUSIONS: In a cohort of transplant recipients with graft loss, sleep apnea increased the risk of graft loss nearly three-fold among patients transplanted between 2009 and 2017. Similar DWFG proportions by sleep apnea presence indicate this risk is likely driven by renal failure, not mortality. Further research on whether treatment of sleep apnea can improve graft survival is warranted.

An exploratory study examining the associations between sunlight exposure, sleep behaviours and sleep outcomes during an Arctic summer.

Few evidence-based recommendations exist for maintaining healthy sleep during Arctic summers. Our study aimed to examine associations between sleep hygiene, sunlight exposure and sleep outcomes in workers living in and/or near the Arctic Circle during a 24-h light period. A survey was administered July 2017 to 19 workers at 3 Arctic base camps in Northeastern Alaska. Participants with poorer sleep hygiene reported increased sleepiness (r=.62, p=0.01); this correlation remained moderately strong, albeit not statistically significant (NS), after controlling for shift work (r=.46, p=0.06). No other statistically significant correlations between sleep hygiene and sleep outcomes were found. Weekly daytime (<8pm) and evening (>8pm) sunlight exposures, estimated from daily self-reported sunlight exposures for a typical workday and day off, were dichotomised, based on means, into: longer (>45 h/week) versus shorter (<45 h/week) daytime exposures, and longer (>16 h/week) versus shorter (<16 h/week) evening exposures. Participants reporting longer, versus shorter, weekly daytime sunlight exposure had statistically significantly (Mann-Whitney U=18.00, Z=-1.98, p≤0.05) decreased median sleep duration (6 h, 18 min versus 8 h, respectively) during the past month. Correlations of r≥.3 for longer, vis-à-vis shorter, daylight sunlight exposure suggest it could be related to poorer sleep outcomes, such as insufficient sleep and sleep quality, yet, as these correlations were NS, future work is needed to determine this. Weak or no correlations (and NS differences) were found for longer, versus shorter, weekly evening sunlight exposure and sleep outcomes. Findings support previous research suggesting self-regulation behaviours alone are not protective against poor sleep in Arctic environments. Sleep outcomes did not differ statistically significantly by evening sunlight exposure length. Longer weekly daytime sunlight exposure, versus shorter, was significantly associated with decreased sleep duration. Results from this exploratory study should be confirmed in studies using larger sample sizes.

Longitudinal association of sleep-disordered breathing and nondipping of nocturnal blood pressure in the Wisconsin Sleep Cohort Study.

STUDY OBJECTIVES: The association of sleep-disordered breathing (SDB) and blunting of normal nocturnal lowering of blood pressure (BP) (nondipping) has only been examined cross-sectionally. The purpose of this study is to investigate whether SDB is prospectively associated with nondipping. METHODS: The longitudinal association between SDB and incident nondipping was examined in a subsample of 328 adults enrolled in the Wisconsin Sleep Cohort Study who completed 2 or more 24-hour ambulatory BP studies over an average of 7.2 years of follow-up. SDB identified by baseline in-laboratory polysomnography was defined by apnea-hypopnea index (AHI) categories. Systolic and diastolic nondipping was defined by systolic and diastolic sleep-wake BP ratios > 0.9. All models were adjusted for age, sex, body mass index at baseline and follow-up, smoking, alcohol consumption, hypertension, sleep time, length of follow-up time, and antihypertensive medication use. RESULTS: There was a dose-response increased odds of developing systolic nondipping in participants with SDB. The adjusted odds ratios (95% confidence interval) of incident systolic nondipping for baseline AHI 5 to < 15 and AHI > or = 15, versus AHI < 5, were 3.1 (1.3-7.7) and 4.4 (1.2-16.3), respectively (P trend = 0.006). The adjusted odds ratios (95% confidence interval) of incident diastolic nondipping for corresponding SDB categories were not statistically significant: 2.0 (0.8-5.6) and 1.3 (0.2-7.1). CONCLUSIONS: Our longitudinal findings of a dose-response increase in development of systolic nondipping of BP with severity of SDB at baseline in a population-based sample provide evidence consistent with a causal link. Nocturnal systolic nondipping may be a mechanism by which SDB contributes to increased cardiovascular disease.

Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.

BACKGROUND: Sleep-disordered breathing (SDB) is a treatable but markedly under-diagnosed condition of frequent breathing pauses during sleep. SDB is linked to incident cardiovascular disease, stroke, and other morbidity. However, the risk of mortality with untreated SDB, determined by polysomnography screening, in the general population has not been established. METHODS: An 18-year mortality follow-up was conducted on the population-based Wisconsin Sleep Cohort sample (n = 1522), assessed at baseline for SDB with polysomnography, the clinical diagnostic standard. SDB was described by the number of apnea and hypopnea episodes/hour of sleep; cutpoints at 5, 15 and 30 identified mild, moderate, and severe SDB, respectively. Cox proportional hazards regression was used to estimate all-cause and cardiovascular mortality risks, adjusted for potential confounding factors, associated with SDB severity levels. RESULTS: All-cause mortality risk, adjusted for age, sex, BMI, and other factors was significantly increased with SDB severity. The adjusted hazard ratio (HR, 95% CI) for all-cause mortality with severe versus no SDB was 3.0 (1.4,6.3). After excluding persons who had used CPAP treatment (n = 126), the adjusted HR (95% CI) for all-cause mortality with severe versus no SDB was 3.8 (1.6,9.0); the adjusted HR (95% CI) for cardiovascular mortality was 5.2 (1.4,19.2). Results were unchanged after accounting for daytime sleepiness. CONCLUSIONS: Our findings of a significant, high mortality risk with untreated SDB, independent of age, sex, and BMI underscore the need for heightened clinical recognition and treatment of SDB, indicated by frequent episodes of apnea and hypopnea, irrespective of symptoms of sleepiness.

Longitudinal association of sleep-related breathing disorder and depression.

BACKGROUND: Sleep-related breathing disorder (SRBD) and depression have each been independently associated with substantial morbidity, impairment, and disability. The development of clinical strategies for screening and managing depression in patients with SRBD requires elucidation of the association between the 2 conditions. This population-based epidemiological study assesses SRBD as a longitudinal predictor of depression. METHODS: Men (n = 788) and women (n = 620) randomly selected from a working population were evaluated for SRBD by in-laboratory polysomnography and for depression by the Zung depression scale. Results of multiple studies, performed at 4-year intervals, were available for most participants. Sleep-related breathing disorder was characterized by the apnea-hypopnea index (AHI; events per hour) categories: AHI = 0, no SRBD; 0 < AHI < 5, minimal SRBD; 5 < or = AHI < 15, mild SRBD; and AHI > or = 15, moderate or worse SRBD. Depression was defined as a score of 50 or higher on the Zung scale or use of antidepressants. Potential confounding, interacting, and mediating factors were assessed by clinical measurements and questionnaires. RESULTS: In purely longitudinal models, an increase of 1 SRBD category (eg, from minimal to mild SRBD) was associated with a 1.8-fold (95% confidence interval, 1.3-2.6) increased adjusted odds for development of depression. In adjusted models combining longitudinal and cross-sectional associations, compared with participants with no SRBD, the odds for development of depression were increased by 1.6-fold (95% confidence interval, 1.2-2.1) in participants with minimal SRBD, by 2.0-fold (95% confidence interval, 1.4-2.9) in participants with mild SRBD, and by 2.6-fold (95% confidence interval, 1.7-3.9) in those with moderate or worse SRBD. CONCLUSION: Our longitudinal findings of a dose-response association between SRBD and depression provide evidence consistent with a causal link between these conditions and should heighten clinical suspicion of depression in patients with SRBD.

Hypnotic hiccups.

Our patient presented with repetitive, self-limited bouts of forceful hiccups in sleep. Eszopiclone, a commonly prescribed hypnotic, appeared to cause these intermittent hiccups. This case is a reminder that eszopiclone may cause this adverse effect, and that it may be the bed partner and not the patient who furnishes critical sleep medicine history.

Adolescent crash rates and school start times in two central Virginia counties, 2009-2011: a follow-up study to a southeastern Virginia study, 2007-2008.

BACKGROUND AND OBJECTIVE: Early high school start times (EHSST) may lead to sleep loss in adolescents ("teens"), thus resulting in higher crash rates. (Vorona et al., 2011). In this study, we examined two other adjacent Virginia counties for the two years subsequent to the above-mentioned study. We again hypothesized that teens from jurisdictions with EHSST (versus later) experience higher crash rates. METHODS: Virginia Department of Motor Vehicles supplied de-identified aggregate data on weekday crashes and time-of-day for 16-18 year old (teen) and adult drivers for school years 2009-2010 and 2010-2011 in Henrico and Chesterfield Counties. Teen crash rates for counties with early versus later school start-times were compared using two-sample Z-tests and these compared to adult crash rates using pair-wise tests. RESULTS: Henrico teens manifested a statistically higher crash rate of 48.8/1000 licensed drivers versus Chesterfield's 37.9/1000 (p = 0.04) for 2009-2010. For 2010-2011, HC 16-17 year old teens demonstrated a statistically significant higher crash rate (53.2/1000 versus 42.0/1000), while for 16-18 teens a similar trend was found, albeit nonsignificant (p = 0.09). Crash peaks occurred 1 hour earlier in the morning and 2 hours earlier in the afternoon in Chesterfield, consistent with commute times. Post hoc analyses found significantly more run-off road crashes to the right (potentially sleep-related) in Chesterfield teens. Adult crash rates and traffic congestion did not differ between counties. CONCLUSIONS: Higher teen crash rates occurred in jurisdictions with EHSST, as in our prior study. This study contributes to and extends existing data on preventable teen crashes and high school start times.

Nocturnal diaphoresis secondary to mild obstructive sleep apnea in a patient with a history of two malignancies.

Numerous medical disorders, including obstructive sleep apnea, may cause nocturnal diaphoresis. Previous work has associated severe obstructive sleep apnea with nocturnal diaphoresis. This case report is of import as our patient with severe nocturnal diaphoresis manifested only mild sleep apnea, and, for years, his nocturnal diaphoresis was ascribed to other causes, i.e., first prostate cancer and then follicular B-cell lymphoma. Additionally, it was the nocturnal diaphoresis and not more common symptoms of obstructive sleep apnea, such as snoring, that led to the definitive diagnosis of his sleep apnea and then to treatment with a gratifying resolution of his onerous symptom.

Dissimilar teen crash rates in two neighboring southeastern Virginia cities with different high school start times.

STUDY OBJECTIVES: Early high school start times may contribute to insufficient sleep leading to increased teen crash rate. Virginia Beach (VB) and Chesapeake are adjacent, demographically similar cities. VB high schools start 75-80 minutes earlier than Chesapeake's. We hypothesized that VB teens would manifest a higher crash rate than Chesapeake teens. METHODS: The Virginia Department of Motor Vehicles (DMV) provided de-identified, aggregate 2008 and 2007 data for weekday crashes and crash times in VB and Chesapeake for drivers aged 16-18 years ("teens"), and provided 2008 and 2007 crash data for all drivers. Data allowed comparisons of VB versus Chesapeake crash rates for teens (overall and hour-by-hour), and teens versus all other ages. We compared AM and PM traffic congestion (peak hours) in the two cities. RESULTS: In 2008, there were 12,916 and 8,459 Virginia Beach and Chesapeake 16- to 18-year-old drivers, respectively. For VB and Chesapeake, teen drivers' crash rates in 2008 were 65.8/1000 and 46.6/1000 (p < 0.001), respectively, and in 2007 were 71.2/1000 and 55.6/1000. Teen drivers' crash peaks in the morning occurred one hour earlier in VB than Chesapeake, consistent with school commute time. Congestion data for VB and Chesapeake did not explain the different crash rates. CONCLUSIONS: A significantly increased teen crash rate for both 2008 and 2007 occurred in VB, the city with earlier high school start times. Future studies using individual level data may clarify if sleep restriction, circadian dyssynchrony, and sleep inertia might contribute to this increased crash rate.

Symptom presentation in patients hospitalized with acute heart failure.

OBJECTIVES: The objectives of this study were to examine the type and frequency of symptoms in patients hospitalized with acute heart failure (HF) as well as the relationship between symptom patterns and patient characteristics, treatment practices, and hospital outcomes in patients hospitalized with decompensated HF. METHODS: The study sample consisted of 4537 residents of the Worcester, MA metropolitan area hospitalized for decompensated HF at 11 greater Worcester medical centers in 1995 and 2000. RESULTS: The average age of the study sample was 76 years; the majority (57%) were women, and three-quarters of our patient population had been previously diagnosed with HF. Dyspnea (93%) was the most frequent complaint reported by patients followed by the presence of peripheral edema (70%), cough (51%), orthopnea (37%), and chest pain/discomfort (30%). Patients reporting few cardiac symptoms were less likely to be treated with effective cardiac therapies during hospitalization than patients with multiple cardiac signs and symptoms and experienced higher hospital (9.7% vs. 7.7%) as well as 30-day (17.1% vs. 10.2%) death rates (P < 0.05). CONCLUSIONS: The results of this study in residents of a large New England community suggest that patients with fewer reported symptoms of decompensated HF were less likely to receive effective cardiac treatments and had worse short-term outcomes. Reasons for these differences in treatment practices and short-term outcomes need to be elucidated and attention directed to these high-risk patients.

Depression: relationships to sleep paralysis and other sleep disturbances in a community sample.

Sleep disturbances are important correlates of depression, with epidemiologic research heretofore focused on insomnia and sleepiness. This epidemiologic study's aim was to investigate, in a community sample, depression's relationships to other sleep disturbances: sleep paralysis (SP), hypnagogic/hypnopompic hallucinations (HH), cataplexy - considered rapid eye movement-related disturbances - and automatic behavior (AB). Although typical of narcolepsy, these disturbances are prevalent, albeit under-studied, in the population. Cross-sectional analyses (1998-2002), based on Wisconsin Sleep Cohort Study population-based data from 866 participants (mean age 54, 53% male), examined: depression (Zung Self-Rating Depression Scale), trait anxiety (Spielberger State-Trait Anxiety Inventory, STAI-T >or= 75th percentile), and self-reported sleep disturbances. Descriptive sleep data were obtained by overnight polysomnography. Adjusted logistic regression models estimated depression's associations with each (>few times ever) outcome - SP, HH, AB, and cataplexy. Depression's associations with self-reported SP and cataplexy were not explained by anxiety. After anxiety adjustment, severe depression (Zung >or=55), vis-à-vis Zung <50, increased SP odds approximately 500% (P = 0.0008). Depression (Zung >or=50), after stratification by anxiety given an interaction (P = 0.02), increased self-reported cataplexy odds in non-anxious (OR 8.9, P = 0.0008) but not anxious (OR 1.1, P = 0.82) participants. Insomnia and sleepiness seemed only partial mediators or confounders for depression's associations with self-reported cataplexy and SP. Anxiety (OR 1.9, P = 0.04) partially explained depression's (Zung >or=55) association with HH (OR 2.2, P = 0.08). Anxiety (OR 1.6, P = 0.02) was also more related than depression to AB. Recognizing depression's relationships to oft-neglected sleep disturbances, most notably SP, might assist in better characterizing depression and the full range of its associated sleep problems in the population. Longitudinal studies are warranted to elucidate mediators and causality.