The impact of change of renal replacement therapy modality on sleep quality in patients with end-stage renal disease: a systematic review and meta-analysis.

BACKGROUND: Sleep disorders are common and multi-factorial in patients with advanced chronic kidney disease and end-stage renal disease (ESRD). Sleep disorders and disturbance have a negative impact on wellbeing and quality of life. OBJECTIVE: To assess the impact of a change in renal replacement therapy (RRT) modality on sleep quality and sleep disturbance in patients with ESRD. DATA SOURCES: Multiple electronic databases were searched without publication type/period restrictions. The reference lists of all included articles were manually searched for additional citations. Non-published data was identified by hand searching key conference abstracts. STUDY ELIGIBILITY CRITERIA: Participants of interest were adult patients with ESRD requiring RRT [conventional haemodialysis (HD), short daily HD, nocturnal HD, continuous ambulatory peritoneal dialysis (CAPD), continuous cycler-assisted peritoneal dialysis (CCPD) or transplantation]. The exposure or intervention of interest was switch of RRT modality. STUDY APPRAISAL: Two reviewers independently assessed all studies for inclusion and extracted relevant data. RESULTS: Sixteen studies with a combined total of 670 patients and 191 controls were included for review and described in detail. Looking specifically at restless leg syndrome, symptoms resolved in over 60% of affected patients with a switch to increased intensity RRT (either intensive HD, CCPD or transplant). Meta-analysis of the nine studies that looked specifically at sleep apnoea parameters again favoured intensive RRT over standard/conventional RRT (conventional HD or CAPD) with statistical significance [Risk ratio 0.66 (95% CI 0.51-0.84)]. Meta-analysis of all studies favoured a switch to increased intensity RRT in terms of overall sleep quality, with statistical significance [Risk ratio 0.58 (95% CI 0.40-8.83)]. LIMITATIONS: Restriction to the English language may have introduced selection bias. Funnel plot analysis suggested there was also an element of publication bias. Studies were heterogeneous in terms of patient selection, means of sleep quality assessment and modality switch. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Sleep disturbance, sleep apnoea and restless legs syndrome all tend to improve when a switch is made to intensive dialysis or transplant. This is important information for patients struggling with disturbed sleep and marked fatigue. This hypothesis-generating review highlights the need for more high quality prospective research in the area.

Steroid-responsive encephalopathy associated with autoimmune thyroiditis presenting as confusion, dysphasia, and myoclonus.

Steroid response encephalopathy associated with autoimmune thyroiditis (SREAT), or Hashimoto's encephalopathy, is a rare disorder believed to be immune-mediated. It is most often characterized by a subacute onset of confusion with altered level of consciousness, seizures, and myoclonus. We describe the case of a 48-year-old gentleman who presented with confusion and dysphasia. Specific clinical features and laboratory results led to a diagnosis of Hashimoto's encephalopathy. This case highlights the core features of this condition and the potential for complete response to steroid therapy.

Reversible posterior leukoencephalopathy induced by carboplatin and etoposide.

Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare neurologic condition characterised by specific clinical and radiologic findings. It usually manifests subacutely as insidious onset of headache, visual disturbance, altered consciousness and seizures in association with MRI findings of posterior white matter vasogenic oedema. RPLS has been reported in a wide variety of clinical settings. Hypertension, eclampsia, pre-eclampsia, renal impairment, autoimmune conditions and cytotoxic drugs are all cited as aetiologic variables. RPLS, albeit rare, is an important entity for physicians to be aware of as early recognition, and prompt intervention is critical to ensure resolution of the neurological deficit. We describe the case of a 69-year-old lady who collapsed with seizure activity after receiving carboplatin and etoposide chemotherapy for small cell lung cancer. In our opinion, the clinical and radiological courses are typical of RPLS. RPLS has rarely been reported secondary to this chemotherapy regimen, and the purpose of this report is to add to the literature and highlight the association between RPLS and cytotoxic chemotherapy.

Effect of smoke-free policies on the behaviour of social smokers.

OBJECTIVE: To test the hypothesis that proposed amendments to the Occupational Safety and Health Act making all enclosed workplaces in Western Australia smoke free would result in a decrease in cigarette consumption by patrons at nightclubs, pubs, and restaurants without adversely affecting attendance. DESIGN: Cross sectional structured interview survey. PARTICIPANTS AND SETTING: Patrons of several inner city pubs and nightclubs in Perth were interviewed while queuing for admission to these venues. OUTCOME MEASURES: Current social habits, smoking habits; and how these might be affected by the proposed regulations. Persons who did not smoke daily were classified as "social smokers." RESULTS: Half (50%) of the 374 patrons interviewed were male, 51% currently did not smoke at all, 34.3% smoked every day, and the remaining 15.7% smoked, but not every day. A clear majority (62.5%) of all 374 respondents anticipated no change to the frequency of their patronage of hospitality venues if smoke-free policies became mandatory. One in five (19.3%) indicated that they would go out more often, and 18.2% said they would go out less often. Half (52%) of daily smokers anticipated no change to their cigarette consumption, while 44.5% of daily smokers anticipated a reduction in consumption. A majority of social smokers (54%) predicted a reduction in their cigarette consumption, with 42% of these anticipating quitting. CONCLUSIONS: One in nine (11.5%) of smokers say that adoption of smoke-free policies would prompt them to quit smoking entirely without a significant decrease in attendance at pubs and nightclubs. There can be few other initiatives as simple, cheap, and popular that would achieve so much for public health.

Adolescents' knowledge of their health insurance coverage.

PURPOSE: To determine the accuracy of adolescents' self-report of health insurance coverage, using parents' report as a comparison standard. METHODS: Two separate samples of urban, school-based adolescents and their parents completed self-administered questionnaires about type of health insurance coverage. Sample 1 included 123 and Sample 2 included 93 adolescent-parent pairs. Percent agreement and the kappa statistic were determined for each of the sample groups, and for males versus females and older (> 14 years) versus younger (< or = 14 years) adolescents. RESULTS: In Sample 1, 33% of adolescent respondents responded "don't know" to the question about type of insurance coverage, and 4% left the question blank; in Sample 2, 3% answered "don't know," with none leaving the question blank. For Sample 1, we found a 57% rate of agreement of adolescents with their parents, and a corresponding kappa of .21. Females and older subjects demonstrated greater accuracy, with kappa's all in the range .13-.29. In Sample 2, 73% of subjects agreed with parents' report, with a kappa of .48. Females and older subjects also demonstrated greater accuracy, with the highest kappa of .59 demonstrated by older females. Excluding those responding with "don't know," we found overall percent agreement with parents of 87% in Sample 1 and 73% in Sample 2; the corresponding kappas were .47 and .51. Females demonstrated higher agreement with parents in both samples. The results stratifying by age were inconsistent. In Sample 1, privately insured subjects were more accurate reporters than those either on medical assistance or uninsured. In Sample 2, no differences were seen by type of insurance. CONCLUSIONS: Many adolescents do not know their health insurance coverage status. However, for those who did claim to know, acceptable rates of accuracy using both percent agreement and the kappa statistic were demonstrated. Further research is needed to determine how information about insurance is communicated to adolescents and how this knowledge affects access to and use of health services.

A faculty on the move into the community.

Faculty at the University of Rochester School of Nursing initiated a curricular redesign to prepare students for the evolving demands of the health care job market and the changing nature of the nursing profession. The concept of the "Learning Community" serves as the metaphor for the new vision of clinical education: a set of collaborative and dynamic relationships of students, faculty, clinicians, health care consumers and institutional and community sites with the mutual responsibility for the education of students and the health of all partners. Students experience firsthand the new capabilities required of professionals in the new context of health care as more than illness care.

Health status of well vs ill adolescents.

BACKGROUND: Accountability of health services in meeting needs and assessing outcomes is hampered by the absence of tools to assess health, especially in children and youth. Because it is no longer adequate to assess health by a narrow focus on biological and physiological measures, instruments that assess functional status, person-focused general health status, and overall well-being in a more comprehensive way are needed. OBJECTIVE: To examine whether a health status instrument we have developed discriminates between teenagers in schools and teenagers attending clinics for acute or chronic conditions. METHODS: Teenagers (aged 11-17 years) in schools and in general medical and specialty clinics completed a questionnaire The Child Health and Illness Profile-Adolescent Edition (CHIP-AE), comprehensively covering aspects of health in 6 domains: discomfort, satisfaction with health, disorders, achievement of social expectations, risks, and resilience. RESULTS: Acutely ill teenagers reported more physical discomfort, minor illnesses, and lower physical fitness; chronically ill teenagers reported more limitations of activity, long-term medical disorders, dissatisfaction with their health, and less physical fitness than teenagers in the school samples. Age, sex, and social class did not explain the differences. Teenagers within the acutely and chronically ill clinic populations differed substantially in their health status. IMPLICATIONS: Availability of a comprehensive instrument (CHIP-AE) to assess adolescent health provides a means of documenting health needs and outcomes in populations of teenagers with acute or chronic illness. The heterogeneity within these groups provides support for a person-focused (rather than a disease-focused) approach to assessing both needs for care and the influence of care on promoting health.

The superhighway to nursing science and practice.

Nursing is evolving within a societal context of shifting paradigms and pervasive technology. Information technology offers untold possibilities to enhance the mechanisms of health care delivery. The capacity for comprehensive access to and integration of information and knowledge suggests a holistic approach that transcends time, settings, and providers. Moreover, the interface between nursing practice and nursing informatics provides an opportunity to create new science and to expand the boundaries of nursing knowledge.

A cost estimation model for measuring professional practice.

A cost estimation model was developed to monitor the effect of an enhanced professional practice model on cost to the institution. The model detected differences across units and changes in unit activities. One unit's cost savings were greater than the others and this difference was believed to be related to stable leadership over the course of the study.

Puberty questions asked by early adolescents: what do they want to know?

OBJECTIVE: We undertook the following study to document questions asked by early adolescents regarding pubertal development. METHODS: As part of a health education program, 159 sixth-grade students (mean = 12.1 years) were surveyed to obtain their questions about puberty and their self-assessed pubertal stage. Questions were coded for content and gender specificity. RESULTS: Of 159 initial subjects, 111 generated a total of 200 questions. A majority of the questions reflected biological topics (88%), such as genital physiology (26%) and sexuality and reproduction (26%). Only 6% addressed psychosocial questions. Both females and Asians (compared with other ethnic or racial groups) expressed greater interest in the differences between male and female development (P < .05). Prepubertal males were more concerned about general puberty than were boys in later Tanner stages (P < .05). Earlier maturing males focused on genital anatomy (P < .05). CONCLUSIONS: We found that biological questions concerning puberty predominated over psychosocial topics, and that the gender, race or ethnicity, and stage of development determined the kinds of questions that early adolescents have about pubertal development. Health educators and clinicians may need to focus on physiologic areas to provide more meaningful information about development to early adolescents.

The effect of a professional practice model on staff nurse perception of work groups and nurse leaders.

OBJECTIVE: The objective of the study was to measure the effect of an enhanced professional practice model on perception of work groups and nurse leaders. BACKGROUND: Previous studies of staff nurse perception of work environment and nurse leaders were used to guide development of the professional practice model and the selection of variables. Implementation of the model was expected to result in more favorable perceptions of the work group and a desire for facilitative leadership style. METHODS: A quasi-experimental design was used to compare change over time in five-hospitals--an urban medical center, two community hospitals, and two rural hospitals. FINDINGS: Introduction of the model resulted in more favorable perceptions about the work group and a desire for a more facilitative nurse leader. CONCLUSION: Change in perception of work group and leader rather than job satisfaction may be an early indication of favorable outcome of planned change. Changes in nurse satisfaction may be a late outcome, which may be the reason findings from previous studies are mixed.

Utilization of ambulatory health services by urban adolescents.

PURPOSE: To describe adolescents' utilization of ambulatory health services and its association with sociodemographic and health status characteristics. METHODS: Adolescents (N = 199) were selected from a larger group of urban middle and high school students who had previously participated in a health risk survey. Subjects were surveyed about their health status and use of ambulatory medical services. Subjects' parents/guardians were also surveyed about sociodemographic information. Bivariate and multivariate analyses using Chisquare statistics and logistic regression techniques assessed the contribution of hypothesized variables to use of routine medical, illness-related medical, and dental services. RESULTS: Most adolescents reported having seen a physician (70%) or a dentist (79%) within the past year. Subjects reported using a wide variety of practitioners and settings, with family/general practitioners (29%), and the private office setting (23%) most commonly reported. Subjects having a regular source of care and those perceiving their health as "excellent" or "very good" were 2.4 and 3.4 times more likely to have used routine medical services than those without a regular source of care and those reporting their health as "fair" or "poor." In contrast, the strongest predictors of having received illness-related care in the past year were the presence of a current medical problem and an age by gender interaction factor. Those reporting a current medical problem were twice as likely as those not reporting a problem and older females were 6.6 times as likely as younger males to have received illness-related care within the past year. The only significant predictor of recent dental care was having private insurance. CONCLUSION: For adolescents enabling variables, such as having a regular source of care and health insurance, are stronger predictors of routine use of medical and dental care, whereas medical need and sociodemographic factors, such as age and gender, are more important in predicting use of illness-related care. These results support, in part, models that have been previously developed to explain use of ambulatory health services.

The adolescent child health and illness profile. A population-based measure of health.

This study was designed to test the reliability and validity of an instrument to assess adolescent health status. Reliability and validity were examined by administration to adolescents (ages 11-17 years) in eight schools in two urban areas, one area in Appalachia, and one area in the rural South. Integrity of the domains and subdomains and construct validity were tested in all areas. Test/retest stability, criterion validity, and convergent and discriminant validity were tested in the two urban areas. Iterative testing has resulted in the final form of the CHIP-AE (Child Health and Illness Profile-Adolescent Edition) having 6 domains with 20 subdomains. The domains are Discomfort, Disorders, Satisfaction with Health, Achievement (of age-appropriate social roles), Risks, and Resilience. Tested aspects of reliability and validity have achieved acceptable levels for all retained subdomains. The CHIP-AE in its current form is suitable for assessing the health status of populations and subpopulations of adolescents. Evidence from test-retest stability analyses suggests that the CHIP-AE also can be used to assess changes occurring over time or in response to health services interventions targeted at groups of adolescents.

The association between interdisciplinary collaboration and patient outcomes in a medical intensive care unit.

We prospectively studied the relationship between interdisciplinary collaboration and patient outcomes in the medical intensive care unit (MICU) using nurses' and residents' reports of amount of collaboration involved in making decisions about transferring patients from the MICU to a unit with a less intense level of care. Either readmission to the MICU or death was considered a negative patient outcome. Nurses' reports of collaboration were significantly (p = 0.02) and positively associated with patient outcome, controlling for severity of illness. Patient predicted risk of negative outcome decreased from 16%, when the nurse reported no collaboration in decision making, to 5% when the process was fully collaborative. There was an interaction of collaboration with availability of alternative choices in the transfer decision-making situation. When alternatives were available, collaboration was more strongly associated with patient outcome. There was no significant relationship between residents' reports of collaboration and patient outcomes. The correlation between amount of collaboration reported by nurses and residents about the same decisions was quite low (r = 0.10).

Expertise: the basis for expert system development.

Expert systems in nursing are developed with traditional knowledge engineering techniques. These techniques focus on the behavior and logic of the expert, not qualities of expertise. Expertise has been described but not explained. This article proposes a theoretical framework for the study of expertise that can be used to facilitate the development of expert systems.

ICU nurse-physician collaboration & nursing satisfaction.

ICU nurses who are satisfied with their work are more likely to be retained, leading to institutional cost savings. In this study, higher levels of nurse-physician collaboration in making decisions about patient care were found to be very important to nurses' satisfaction.