Seasonal and weather variation of sleep and physical activity in 12-14-year-old children.

Background: Understanding variation in physical activity (PA) and sleep is necessary to develop novel intervention strategies targeting adolescents' health behaviors. We examined the extent to which PA and sleep vary by aspects of the physical environment. Participants: We performed a cross-sectional analysis of 669 adolescents in the Project Viva cohort. Methods: We estimated total PA, sleep duration, sleep efficiency, and sleep midpoint timing from wrist accelerometers. We used multivariable linear regression models and generalized estimated equations to assess associations of PA and sleep with season and daily weather conditions obtained from the National Oceanic and Atmospheric Administration archive. Results: Mean age was 12.9 (SD 0.6) years; 51% were female and 68% were white. Mean sleep duration was 466 (SD 42) min per night and total PA was 1,652 (SD 431) counts per min per day. Sleep midpoint time was 41 (95% CI: 27 to 54) min later in summer, 28 (95% CI: -41 to -14) min earlier in spring, and 29 (95% CI: -43 to -15) min earlier in autumn compared to winter. Higher temperature and longer day length both were associated with small reductions of nightly sleep duration. Adolescents were less physically active during winter and on rainy and short sunlight days. There was an inverse U-shaped relationship between PA and mean temperature. Conclusions: Season was associated with large changes in sleep timing, and smaller changes in other sleep and PA measurements. Given the importance of sleep and circadian alignment, future health behavioral interventions may benefit by targeting "season-specific" interventions.

Demographic, Socioeconomic, and Clinical Factors Associated with Severe Vision Loss in Patients with Neovascular Glaucoma.

Purpose: To investigate the association between demographic, socioeconomic, and clinical factors and severe vision loss in patients with neovascular glaucoma (NVG). Patients and Methods: A retrospective chart review of patients referred to the University of Virginia (UVA), diagnosed with NVG, and treated for NVG between January 2010 and December 2020 was performed. Patients were grouped according to vision outcomes after 1 year of treatment: mild - moderate vision loss (best corrected visual acuity [BCVA] > light perception [LP]) and severe vision loss (BCVA ≤ LP). The associations between patient characteristics and BCVA were also examined. Results: Of the 89 patients (99 eyes), those with progression to severe vision loss presented with higher intraocular pressure (IOP) (p < 0.001) and lower visual acuity (p = 0.003) on average. However, there was no difference in IOP between the vision loss groups after one year of treatment. Univariate analysis showed a moderate association between a history of type 2 diabetes mellitus (T2DM) and severe vision loss (p = 0.033). Increasing age was associated with an increased likelihood of progression to severe vision loss (odds ratio [OR] 1.074, p = 0.008). Females were more likely to exhibit severe vision loss (OR 3.281, p = 0.036). Patients with Medicare (OR 0.098, p = 0.005) or private insurance (OR 0.110, p = 0.006) were less likely to progress to severe vision loss than those without insurance. Conclusion: Progression of vision loss in patients with NVG may be influenced by the stage of disease at diagnosis, age, sex, T2DM, and insurance status.

Association of Cannabis with Apneic Episodes in a Breastfed Infant: A Case Study.

Background: The use of cannabis and its perceived safety among pregnant and breastfeeding women has increased in the context of expanding legalization. Current guidelines recommend abstaining from the use of cannabis while pregnant or breastfeeding due to the potential for harm, although there is still much that is unknown in this field. Case Presentation: A 5-week-old infant presented with recurrent apneic episodes and a positive urine delta-9-tetrahydrocannabinol (THC) screening test. The infant's mother reported regular cannabis use for treatment of depression and anxiety while pregnant and breastfeeding. The infant was subsequently transitioned to formula feedings, and the infant's condition improved. Conclusion: Cannabis and its active metabolites can be transferred into breast milk and may have deleterious neurologic effects on infants. However, a causal relationship between cannabis exposure and short- or long-term neurologic sequelae has not yet been definitively established. Further studies are warranted to assess the safety of maternal cannabis use for breastfed infants.

Extracorporeal Life Support Organization Center of Excellence recognition is associated with improved failure to rescue after cardiac arrest.

OBJECTIVE: The influence of Extracorporeal Life Support Organization (ELSO) center of excellence (CoE) recognition on failure to rescue after cardiac surgery is unknown. We hypothesized that ELSO CoE would be associated with improved failure to rescue. METHODS: Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. Patients were stratified by whether or not their operation was performed at an ELSO CoE. Hierarchical logistic regression analyzed the association between ELSO CoE recognition and failure to rescue. RESULTS: A total of 43,641 patients were included across 17 centers. In total, 807 developed cardiac arrest with 444 (55%) experiencing failure to rescue after cardiac arrest. Three centers received ELSO CoE recognition, and accounted for 4238 patients (9.71%). Before adjustment, operative mortality was equivalent between ELSO CoE and non-ELSO CoE centers (2.08% vs 2.36%; P = .25), as was the rate of any complication (34.5% vs 33.8%; P = .35) and cardiac arrest (1.49% vs 1.89%; P = .07). After adjustment, patients undergoing surgery at an ELSO CoE facility were observed to have 44% decreased odds of failure to rescue after cardiac arrest, relative to patients at non-ELSO CoE facility (odds ratio, 0.56; 95% CI, 0.316-0.993; P = .047). CONCLUSIONS: ELSO CoE status is associated with improved failure to rescue following cardiac arrest for patients undergoing cardiac surgery. These findings highlight the important role that comprehensive quality programs serve in improving perioperative outcomes in cardiac surgery.

Renal recovery in cardiac surgery patients requiring postoperative renal-replacement therapy.

OBJECTIVE: Renal failure after cardiac surgery is associated with increased morbidity and mortality. There is a lack of data examining the rate of renal recovery after patients have started dialysis following cardiac surgery. We aimed to determine the frequency of and time to renal recovery of patients requiring dialysis after cardiac surgery. METHODS: All patients who developed new-onset renal failure requiring dialysis following cardiac surgery at our institution from 2011 to 2022 were included. Renal recovery, time to renal recovery, and mortality at 1 year were merged with patients' Society of Thoracic Surgeons Adult Cardiac Surgery Database files. Kaplan-Meier analysis was used to predict time to renal recovery; we censored patients who died or were lost to follow up. Cox regression was used for risk-adjustment. RESULTS: A total of 312 patients were included in the final analysis. Mortality during index hospital admission was 33% (n = 105), and mortality at 1 year was 45% (n = 141). Of those surviving at 1 year, 69% (n = 118) remained renally recovered. Median renal recovery time was 56 (37-74) days. Accounting for mortality as a competing risk, 51% of patients were predicted to achieve renal recovery. Increasing age (hazard ratio, 0.98; 0.514-0.94, P < .026) and increasing total packed red blood cells (hazard ratio, 0.0958; 0.937-0.987, P < .001) received were found to be significant negative predictors of renal recovery in the Fine-Gray model for subhazard distribution. CONCLUSIONS: More than two-thirds of patients with renal failure who survived the perioperative period had renal recovery within 1 year after surgery. Recovery was driven primarily by postoperative complications rather than comorbidities and intraoperative factors, suggesting renal failure in the postoperative cardiac surgery patient surviving to discharge is unlikely to be permanent.

Identifying patients with cellulitis who are likely to require inpatient admission after a stay in an ED observation unit.

BACKGROUND: Emergency department observation units (EDOU) are often used for patients with cellulitis to provide intravenous antibiotics followed by a transition to an oral regimen for discharge. Because institutional regulations typically limit EDOU stays to 24 hours, patients lacking a clinical response within this period will often be subsequently admitted to the hospital for further treatment. OBJECTIVE: The aim of this study was to determine the rate of hospital admission and characteristics predictive of admission in patients with cellulitis who are initially placed in an ED observation unit. METHODS: A retrospective cohort study of patients placed into EDOU with a diagnosis of skin infection was conducted. Age, sex, history of diabetes mellitus, immunosuppression, intravenous drug use, location of cellulitis, presence of abscess, laboratory infectious markers, vital signs, and outpatient antibiotic treatment were recorded. The primary outcome was a hospital admission due to failure to respond to treatment within the 24-hour observation time window. Significant variables on univariate analysis were used to create a multivariate analysis, which identified predictive characteristics. RESULTS: Four hundred six patient charts were reviewed, with 377 meeting inclusion criteria; the inpatient admission rate from EDOU was 29.2%. Using logistic regression techniques, we created a model of independent predictors for need of admission after 24 hours: cellulitis of the hand (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.9), measured temperature higher than 100.4°F (OR, 2.5; 95% CI, 1.1-5.5), and lactate greater than 2 (OR, 3.1; 95% CI, 1.3-7.3) were predictive of failure of ED observation. CONCLUSIONS: Patients with cellulitis placed into ED observation status were more likely to fail an observation trial if they had an objective fever in the ED, an elevated lactate, or a cellulitis that involved the hand.

Delirium is associated with failure to rescue after cardiac surgery.

Objective: Postoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. Methods: We studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. Results: Any episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. Conclusions: A single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates.

Off-Hours Intensive Care Unit Transfer Is Associated With Increased Mortality and Failure to Rescue.

BACKGROUND: Cardiac postoperative intensive care unit (ICU) beds are a limited resource, and when a patient no longer requires this level of care they are quickly transferred out. We hypothesized that complications and ICU readmission increased when transfer occurred during off-hours compared with regular work hours. METHODS: From 2010 to 2021, patients who underwent a Society of Thoracic Surgeons index operation at a single center were assigned a group based on their ICU transfer time, defined as when they physically arrived on the acute care floor. Patients were stratified into off-hours vs regular hours by their transfer time. Off-hours was defined as 9 pm to 5 am. Risk-adjusted multivariable logistic regression analyzed the association of ICU readmission, postoperative complications, operative mortality, and failure to rescue by group. RESULTS: The cohort included 5951 patients (off-hours n = 292 [4.9%], regular-hours n = 5659 [95.1%]). Patients in the off-hours group had significantly greater odds of risk-adjusted ICU readmission (odds ratio 1.99, 95% CI 1.25-3.04, P < .002) and mortality (odds ratio 3.88, 95% CI 2.27-6.33, P < .001). In the major complications subgroup (Off-hours n = 55, Regular-hours n = 603), Off-hours transfer was associated with increased mortality (failure to rescue) (odds ratio 3.05, 95% CI 1.58-5.69, P = .001). CONCLUSIONS: Off-hours ICU to floor transfer was associated with increased postoperative complications, ICU readmission, and mortality, suggesting that the timing of ICU transfer may impact outcomes. This elucidates targets for quality and process improvement for our center and others facing the same resource constraints.

Cardiac Surgery Outcomes During the COVID-19 Pandemic Worsened Across All Socioeconomic Statuses.

BACKGROUND: Increasing socioeconomic distress has been associated with worse cardiac surgery outcomes. The extent to which the pandemic affected cardiac surgical access and outcomes remains unknown. We sought to examine the relationship between the COVID-19 pandemic and outcomes after cardiac surgery by socioeconomic status. METHODS: All patients undergoing a Society of Thoracic Surgeons (STS) index operation in a regional collaborative, the Virginia Cardiac Services Quality Initiative (2011-2022), were analyzed. Patients were stratified by timing of surgery before vs during the COVID-19 pandemic (March 13, 2020). Hierarchic logistic regression assessed the relationship between the pandemic and operative mortality, major morbidity, and cost, adjusting for the Distressed Communities Index (DCI), STS predicted risk of mortality, intraoperative characteristics, and hospital random effect. RESULTS: A total of 37,769 patients across 17 centers were included. Of these, 7269 patients (19.7%) underwent surgery during the pandemic. On average, patients during the pandemic were less socioeconomically distressed (DCI 37.4 vs DCI 41.9; P < .001) and had a lower STS predicted risk of mortality (2.16% vs 2.53%, P < .001). After risk adjustment, the pandemic was significantly associated with increased mortality (odds ratio 1.398; 95% CI, 1.179-1.657; P < .001), cost (+$4823, P < .001), and STS failure to rescue (odds ratio 1.37; 95% CI, 1.10-1.70; P = .005). The negative impact of the pandemic on mortality and cost was similar regardless of DCI. CONCLUSIONS: Across all socioeconomic statuses, the pandemic is associated with higher cost and greater risk-adjusted mortality, perhaps related to a resource-constrained health care system. More patients during the pandemic were from less distressed communities, raising concern for access to care in distressed communities.

The Society of Thoracic Surgeons Definition of Failure to Rescue Should Consider Including Cardiac Arrest.

BACKGROUND: Failure to rescue (FTR) is a new quality measure in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. The STS defines FTR as death after permanent stroke, renal failure, reoperation, or prolonged ventilation. Our objective was to assess whether cardiac arrest should be included in this definition. METHODS: Patients undergoing an STS index operation in a regional collaborative (2011-2021) were included. The performance of the STS definition of FTR was compared with a definition that included the STS complications plus cardiac arrest (STS+). Centers were grouped into FTR rate terciles using the STS and STS+ definitions of FTR, and changes in their relative performance rating were assessed. RESULTS: A total of 43,641 patients were included across 17 centers. Cardiac arrest was the most lethal complication: 55.0% of patients who experienced cardiac arrest died. FTR after any complication (13 total) occurred among 884 patients. The STS definition of FTR accounted for 83% (735 of 884) of all FTR. The addition of cardiac arrest to the STS definition significantly increased the proportion of overall FTR accounted for (92.2% [815 of 884]; P < .001). Choice of FTR definition led to substantial differences in center-level relative performance rating by FTR rate. CONCLUSIONS: Mortality after cardiac arrest is not completely captured by the STS definition of FTR and represents an important source of potentially preventable death after cardiac surgery. Future quality improvement efforts using the STS definition of FTR should account for this.

Center case volume is associated with Society of Thoracic Surgeons-defined failure to rescue in cardiac surgery.

OBJECTIVE: Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. METHODS: Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. RESULTS: A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001). CONCLUSIONS: Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.

Longitudinal association of actigraphy-assessed sleep with physical growth in the first 6 months of life.

STUDY OBJECTIVES: Suboptimal sleep is associated with obesity and its sequelae in children and adults. However, few studies have examined the association between sleep and physical growth in infants who experience rapid changes in sleep/wake patterns. We examined the longitudinal association of changes in objectively assessed sleep/wake patterns with changes in growth between ages 1 and 6 months. METHODS: We studied 298 full-term infants in the longitudinal Rise & SHINE cohort study. Changes from 1 and 6 months in nighttime sleep duration, wake after sleep onset (WASO), and number of waking bouts ≥5 min were assessed using ankle actigraphy. Overweight was defined as age- and sex-specific weight for length ≥95th percentile. Generalized estimating equation analyses adjusted for infants' and mothers' characteristics. RESULTS: The mean (SD) birth weight was 3.4 (0.4) kg; 48.7% were boys. In multivariable adjusted models, each 1-h increase in nighttime sleep duration between months 1 and 6 was associated with a 26% decrease in the odds of overweight from 1 to 6 months (odds ratio [OR] = 0.74; 95% confidence interval [CI, 0.56, 0.98]). Each 1-unit decrease in number of waking bouts was associated with a 16% decrease in the odds of overweight (OR = 0.84; 95% CI [0.72, 0.98]). Changes in WASO were not associated with the odds of overweight. CONCLUSIONS: Greater increases in nighttime sleep duration and more consolidation of nighttime sleep were associated with lower odds of overweight from 1 to 6 months. Adverse sleep patterns as early as infancy may contribute to excess adiposity.

Associations of sleep-related behaviors and the sleep environment at infant age one month with sleep patterns in infants five months later.

OBJECTIVE: To characterize family and environmental correlates of sleep patterns that may contribute to differences in infant sleep. METHODS: We studied 313 infants in the Rise & SHINE (Sleep Health in Infancy & Early Childhood study) cohort. Our main exposures were the parent-reported sleep environment, feeding method and sleep parenting strategies at infant age one month. The main outcomes were nighttime sleep duration, longest nighttime sleep and number of awakenings measured by actigraphy at age six months. We used multivariable linear regression models to examine associations, and secondarily also explored the role of sleep-related environmental exposures in mediating previously observed associations of racial/ethnicity and parental education with infant sleep characteristics. RESULTS: In adjusted models, a non-dark sleep environment (versus an always dark sleep location) and taking the baby to parent's bed when awake at night (versus no co-sleeping) were associated with 28 (95% CI, -45, -11) and 18 (95% CI, -33, -4) minutes less sleep at night, respectively. Bottle feeding at bedtime was associated with 62 (95% CI, 21, 103) minutes additional longest nighttime sleep period. Exploratory mediation analyses suggested a modest mediating role of a non-dark sleep environment on racial/ethnic and educational differences in sleep duration. CONCLUSIONS: Infant sleep duration was positively associated with a dark sleep environment and a focal feed at bedtime while taking the baby to the parent's bed was associated with reduced infant sleep. Modifying the sleep environment and practices may improve infant sleep and reduce sleep health disparities.

Socioeconomic distress is associated with failure to rescue in cardiac surgery.

OBJECTIVE: The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue. METHODS: Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue. RESULTS: A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044). CONCLUSIONS: Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients.

Study of placing a second intravenous line in trauma.

OBJECTIVE: We evaluated the benefit of emergency medical services providers' placing a second intravenous (IV) line in the prehospital trauma setting. Our hypothesis was that the placement of a second IV catheter in trauma does not result in an improvement in heart rate, blood pressure, rehospitalizaton rate, or 30-day mortality. METHODS: A retrospective chart review of 320 trauma patients in a one-year period was conducted at our level I trauma center. All trauma patients who had vascular access obtained prehospitally were included. RESULTS: Patients with two IV lines received an average of 348.4 mL more fluid (95% confidence interval [CI]: 235.6, 461.1; p < 0.0001). No change in heart rate, pulse oximetry, Glasgow Coma Scale score, systolic blood pressure, rehospitalization rate, or 30-day mortality was noted. These effects persisted for patients who were initially tachycardic (heart rate 3.92 bpm; 95% CI ?3.01, 10.82; p = 0.27) or hypotensive (blood pressure 22.00 mmHg; 95% CI ?4.17, 48.16; p = 0.10). CONCLUSIONS: Redundant prehospital IV lines provided no noticeable benefit in physiologic support for trauma patients. When controlling for confounding variables, no significant outcome difference was noted, even in the hypotensive patients. The traditional approach for establishment of a secondary IV line in prehospital trauma patients should not be followed in a dogmatic fashion.

Associations between parent-reported and objectively measured sleep duration and timing in infants at age 6 months.

STUDY OBJECTIVES: To compare the estimates of sleep duration and timing from survey, diary, and actigraphy in infants at age 6 months, overall and by select demographics and other factors. METHODS: In total, 314 infants participating in the Rise & SHINE (Sleep Health in Infancy & Early Childhood study) cohort in Boston, MA, USA, wore an actigraph on their left ankle for 7 days. Parents concurrently completed a sleep diary and the expanded version of the Brief Infant Sleep Questionnaire. Concordance between parent-reported and objective sleep estimates was assessed using Bland-Altman plots, Spearman's rank correlations, intraclass correlations, and linear regression models. RESULTS: Mean infant age was 6.4 (0.6 SD) months; 51% were female and 42% were Non-Hispanic white. Mean total sleep duration using actigraphy was 526 (67 SD) minutes per night, 143 (42 SD) minutes per day, and 460 (100 SD) minutes during the longest nighttime sleep period. Relative to actigraphy, parent-completed survey and diary overestimated total day (by 29 and 31 minutes, respectively) and night sleep duration (67 and 43 minutes, respectively) and underestimated the longest sleep (58 minutes), with the highest agreement for sleep onset and offset timing (differences < 30 minutes). There was a tendency toward greater bias among short- and long-sleeping infants. Self-reporting bias for diary-measured longest nighttime sleep and total night sleep duration was higher in infants of parents reporting a problem with their baby's night awakenings and in low-income families, respectively. CONCLUSIONS: Our findings underscore the need to be cautious when comparing findings across studies using different sleep assessment methods.

Emergence of racial/ethnic and socioeconomic differences in objectively measured sleep-wake patterns in early infancy: results of the Rise & SHINE study.

STUDY OBJECTIVES: To characterize objectively assessed sleep-wake patterns in infants at approximately 1 month and 6 months and examine the differences among infants with different racial/ethnic backgrounds and household socioeconomic status (SES). METHODS: Full-term healthy singletons wore an ankle-placed actigraph at approximately 1 month and 6 months and parents completed sleep diaries. Associations of racial/ethnic and socioeconomic indices with sleep outcomes were examined using multivariable analyses. Covariates included sex, birth weight for gestational age z-score, age at assessment, maternal education, household income, bed-sharing, and breastfeeding. RESULTS: The sample included 306 infants, of whom 51% were female, 42.5% non-Hispanic white, 32.7% Hispanic, 17.3% Asian, and 7.5% black. Between 1 month and 6 months, night sleep duration increased by 65.7 minutes (95% CI: 55.4, 76.0), night awakenings decreased by 2.2 episodes (2.0, 2.4), and daytime sleep duration decreased by 73.3 minutes (66.4, 80.2). Compared to change in night sleep duration over this development period for white infants (82.3 minutes [66.5, 98.0]), night sleep increased less for Hispanic (48.9 minutes [30.8, 66.9]) and black infants (31.6 minutes [-5.9, 69.1]). Night sleep duration also increased less for infants with lower maternal education and household income. Asian infants had more frequent night awakenings. Adjustment for maternal education and household income attenuated all observed day and night sleep duration differences other than in Asians, where persistently reduced nighttime sleep at 6 months was observed. CONCLUSIONS: Racial/ethnic differences in sleep emerge in early infancy. Night and 24-hour sleep durations increase less in Hispanic and black infants compared to white infants, with differences largely explained by SES.

The Mucosally-Adherent Rectal Microbiota Contains Features Unique to Alcohol-Related Cirrhosis.

Most studies examining correlations between the gut microbiota and disease states focus on fecal samples due to ease of collection, yet there are distinct differences when compared to samples collected from the colonic mucosa. Although fecal microbiota has been reported to be altered in cirrhosis, correlation with mucosal microbiota characterized via rectal swab has not been previously described in this patient population. We conducted a cross-sectional analysis using 39 stool and 39 rectal swabs from adult patients with cirrhosis of different etiologies and performed shotgun metagenomic sequencing. Bacterial growth studies were performed with Escherichia coli. Two asaccharolytic bacterial taxa, Finegoldia magna and Porphyromonas asaccharolytica, were increased in rectal swabs relative to stool (FDR < 0.01). Genomic analysis of the microbiome revealed 58 genes and 16 pathways that differed between stool and rectal swabs (FDR < 0.05), where rectal swabs were enriched for pathways associated with protein synthesis and cellular proliferation but decreased in carbohydrate metabolism. Although no features in the fecal microbiome differentiated cirrhosis etiologies, the mucosal microbiome revealed decreased abundances of E. coli and Enterobacteriaceae in alcohol-related cirrhosis relative to non-alcohol related cirrhosis (FDR < 0.05). In vitro bacterial culture studies showed that physiological concentrations of ethanol and its oxidative metabolites inhibited E. coli growth in a pH- and concentration-dependent manner. Characterization of the mucosally associated gut microbiome via rectal swab revealed findings consistent with amino acid/nitrogen abundance versus carbohydrate limitation in the mucosal microenvironment as well as unique features of alcohol-related cirrhosis possibly consistent with the influence of host-derived metabolites on the composition of mucosally adherent microbiota.

Nightly sleep duration, fragmentation, and quality and daily risk of migraine.

OBJECTIVE: To test the hypotheses that insufficient duration, high fragmentation, and poor sleep quality are temporally associated with migraine onset on the day immediately following the sleep period (day 0) and the following day (day 1). METHODS: In this prospective cohort study of 98 adults with episodic migraine, participants completed twice-daily electronic diaries on sleep, headaches, and other health habits, and wore wrist actigraphs for 6 weeks. We estimated the incidence of migraine following nights with short sleep duration, high fragmentation, or low quality compared to nights with adequate sleep with conditional logistic regression models stratified by participant and adjusted for caffeine intake, alcohol intake, physical activity, stress, and day of week. RESULTS: Participants were a mean age of 35.1 ± 12.1 years. We collected 4,406 days of data, with 870 headaches reported. Sleep duration ≤6.5 hours and poor sleep quality were not associated with migraine on day 0 or day 1. Diary-reported low efficiency was associated with 39% higher odds of headache on day 1 (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.06-1.81). Actigraphic-assessed high fragmentation was associated with lower odds of migraine on day 0 (wake after sleep onset >53 minutes, OR 0.64, 95% CI 0.48-0.86; efficiency ≤88%, OR 0.74, 95% CI 0.56-0.99). CONCLUSION: Short sleep duration and low sleep quality were not temporally associated with migraine. Sleep fragmentation, defined by low sleep efficiency, was associated with higher odds of migraine on day 1. Further research is needed to understand the clinical and neurobiologic implications of sleep fragmentation and risk of migraine.

The Use of Actigraphy Differentiates Sleep Disturbances in Active and Inactive Crohn's Disease.

BACKGROUND: Sleep disturbances (SDs) are commonly reported in patients with Crohn's disease (CD). Several survey instruments assessing subjective measures of insufficient sleep have identified SDs in subjects with CD. However, there are limited data on objective measures of SDs in these patients as they relate to disease activity. In this prospective cross-sectional study, we compared objective estimates of sleep obtained using multiday wrist actigraphy in individuals with CD with varying disease activity. METHODS: Eighty patients with a diagnosis of CD were recruited to take part in the study. Participants were stratified by disease activity into remission, mild disease, and moderate to severe disease groups using the Harvey-Bradshaw Index and C-reactive protein levels. Participants were excluded on the basis of significant comorbidity (Charlson Comorbidity Index ≥3), a known history of a sleep disorder, or the concomitant use of systemic corticosteroids. Participants completed surveys, including the PROMIS-SD Short Form 8a, the Epworth Sleepiness Scale, and the Women's Health Initiative Insomnia Rating scale, and were provided with an accelerometer that estimated sleep-wake patterns over 7 days. Comparisons of actigraphic sleep parameters were performed between disease activity groups. Multivariate logistic regression analyses were performed using covariates determined a priori to have an association with sleep disturbance in CD through a review of the literature. RESULTS: Of the 80 participants enrolled in the study, 72 completed 5 days of actigraphy data: 28 subjects in remission, 22 subjects with mild disease activity, and 22 subjects with moderate to severe disease activity. Self-reported sleep characteristics assessed by questionnaires were similar between groups. By actigraphy, individuals with moderate to severe CD spent a significantly longer time awake after falling asleep compared with subjects with remissive disease or compared with subjects with mild disease (65.8 minutes vs 44.3 minutes and 49.1 minutes, respectively; each P < 0.05). Individuals with moderate to severe CD had significantly lower sleep efficiency compared with those with remissive CD (86.6% vs 89.9%; P = 0.03). In the multivariate analyses, moderate to severe CD disease activity was significantly associated with an increased amount of fragmented sleep (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.23-11.32; P = 0.02; WASO ≥ 60 minutes). Moreover, the use of controlled substances was associated with poor sleep efficiency (OR, 3.86; 95% CI, 1.01-14.7; P = 0.04; SE ≤ 85.5%). CONCLUSIONS: This is the first study to objectively quantify disturbed sleep using wrist actigraphy in adults with CD with varying disease activity. Wrist actigraphy may serve as a useful modality for discerning SD in subjects with active vs remissive disease that is not evident with questionnaires alone. Although we determined that disease severity is a significant factor that leads to SDs in CD, larger studies using these objective measures may help determine the contribution of other factors.