Sleep spindle evolution from infancy to adolescence.

OBJECTIVE: To investigate the development of frontally recorded sleep spindles from infancy to adolescence to provide normative data for pediatric sleep medicine. METHODS: Sleep spindle activity was investigated in 120 healthy subjects aged 3 months to 16 years in 12 age groups. At 2 a.m. (min 1:17 a.m., max 3:18 a.m.) 10 min of NREM 2 was checked. Spindles were visually scored in the electroencephalogram from F4/A1. RESULTS: The age dependency of interspindle interval, length of spindle, and spindle density, was statistically significant (Kruskal-Wallis p<0.0001). There were U-shaped curves for spindle length, spindle density, and an inverted U-shaped curve for the interspindle interval. Results of the post hoc U-test p<0.05 (Bonferroni corrected, m=66): Spindle length was minimal at 1.7 up to 3.0 years. Spindle density (number of spindles) was minimal between the ages of 1.7 and 2.3 years, thereafter there was a high increase that reached a plateau at age 5 years and remained up to 16 years. Interspindle interval was maximal at 1.7 and 2.3 years. CONCLUSIONS: Sleep spindle activity changes with maturation in terms of length and density. SIGNIFICANCE: The establishment of age-related normative data of sleep spindle activity can improve identification of NREM 2 in infancy, childhood, and adolescence, and enable detection of delayed neural maturation and/or sleep instability.

Methods to develop arthritis and osteoporosis measures: a view from the National Committee for Quality Assurance (NCQA).

OBJECTIVE: Performance measurement at various levels of the health care system promotes improved processes that can result in the provision of more consistent and effective care. This chapter articulates the methodology and criteria utilized in measures development to ensure accountability and serve the information needs of physicians, health care systems, health plans and consumers, using arthritis and osteoporosis as example conditions. METHODS: Observational studies conducted to assess the validity and feasibility of performance measures focused on arthritis and osteoporosis. Clinical expert panels were convened to develop measure specifications based on guidelines and evidence supporting critical aspects of care. The aspects of care that were assessed included: DMARD utilization for patients with rheumatoid arthritis; appropriate gastrointestinal prophylaxis for patients utilizing NSAIDS; comprehensive osteoarthritis care; comprehensive symptom assessment and medical management of woman over 65 years who experienced a bone fracture. RESULTS: The implementation of performance measures for key aspects of arthritis and osteoporosis care is challenged by the availability of administrative data. However, potential for improvement is evident in each of the areas studied. CONCLUSION: The key challenge to the feasibility of arthritis performance measures is the lack of administrative data to identify the eligible population. Administrative data capture suffers as a result of under-coding and under-recognition of arthritis. Consensus around a single set of measures creates a powerful tool for focusing on key components of care as a basis for quality improvement and allows for a valid comparison of care within and across health care settings.

Health status of preterm low-birth-weight infants. Comparison of maternal reports.

BACKGROUND: Developers of measures of child health status have documented acceptable reliability and some validity, but less attention has been paid to the concurrent and predictive validity of these measures. METHODS: We examined the concurrent and predictive validity of the RAND General Health Rating Index, the Stein-Jessop Functional Status II-R, and the mother's global assessment of her child's health on a 5-point scale, in a sample of preterm low-birth-weight children (n = 608) who were followed up as controls in the Infant Health and Development Program. We compared maternal-reported measures assessed at 24 months with other measures of growth, morbidity, functioning, and health care utilization assessed concurrently and at 36 months in bivariate and multivariate analyses. RESULTS: After controlling for other factors, the RAND General Health Rating Index and the Stein-Jessop Functional Status II-R were unrelated to the growth, utilization, or functioning measures. The RAND General Health Rating Index was significantly, but weakly, related to future morbidity. The mother's global perception of health was significantly related to outpatient utilization and behavior problems. CONCLUSIONS: Clinicians may find that maternal assessment of overall child health is a sensitive but nonspecific indicator of the mother's concern. For researchers, none of these measures seems likely to serve as a proxy for health care utilization or morbidity in studies of other phenomena, or as an indicator of detailed health outcomes.

Plasma levels of DSIP in infants in the first year of life and SIDS risk.

In searching for abnormalities related to the sudden infant death syndrome (SIDS), delta sleep-inducing peptide (DSIP), a regulatory peptide with sleep promoting actions, was investigated in the first year of life in four groups of children: (1) preterm infants (n = 28), (2) infants with a high mean apnea duration evaluated polysomnographically (n = 26), (3) healthy full-term infants (n = 37) and (4) siblings of SIDS-victims (n = 26). DSIP was radioimmunoassayed in plasma. Half of the infants were also investigated polygraphically during sleep. The ratio between quiet sleep and active sleep was determined. There was no age dependence of the plasma level of DSIP in the first year of life but there was an increase in the ratio of quiet/active sleep depending of maturity. The level of DSIP in healthy full-term infants was significantly higher (P less than 0.05) (median: 1885 pmol/l, interquartile range: 757 pmol/l) than in preterms (1595; 385) and in infants with a high mean apnea duration (1542; 373). There was no significant difference in DSIP concentrations between healthy full-term infants and SIDS-siblings (1605; 271).

Arousals and obstructive sleep apnea syndrome in children.

OBJECTIVE: Observations of children with obstructive sleep apnea syndrome (OSAS) show a restless sleep. But there is no significant disturbance of sleep macrostructure as in adult OSAS patients. It will be proved, whether the analysis of arousals permits a comprehensive characterization of this respiratory related sleep disturbance. Considering the problems in EEG-arousals detection in dependence of age and maturation we will compare the results of analysis of EEG- and movement arousals to find out a more practicable way for arousal analysis in childhood. METHODS: Twenty OSAS pediatric patients (aged 3.1-14.3 years, median 7.5 years) and 20 age matched children with no OSAS (aged 3.3-13.9 years, median 7.9 years) were examined polysomnographically. Clinically confirmed OSAS patients with an apnea/hypopnea index (AHI) > or = 5/h TST (total sleep time) were examined during 1 whole night before treatment (diagnostic night - baseline) and after/under receiving therapy. Various polygraphic parameters to describe the macrostructure of sleep (sleep efficiency, NREM 1-4, REM) and the microstructure of sleep (EEG- and movement arousals) were analyzed. Furthermore the AHI, heart rate and oxygen saturation were evaluated. RESULTS: Patients with clinically and polysomnographically confirmed OSAS had significantly more EEG (median 21.0/interquartile range 9.31 /h TST) and movement arousals (20.4/13.1 /h TST) before therapy than after/under therapy (EEG: 9.9/6.3 /h TST; movement: 9.2/3.8/h TST). The frequency of arousals was comparable in OSAS children after/under treatment and controls (EEG: 9.0/4.2/h TST; movement 9.3/3.4/h TST). In the 3 groups there was no significant correlation between AHI and number of EEG-arousals and movement arousals. AHI was significantly higher in OSAS children in comparison to controls and treated OSAS. In contrast to adults, sleep efficiency and macrostructure of sleep were not different in controls and OSAS children with or without treatment. Also, oxygen saturation and heart rate, had the same values in controls, OSAS children and OSAS children after/under treatment. CONCLUSIONS: OSAS in children is characterized by a restless sleep, i.e. by an enhanced number of movement and EEG-arousals. The microstructure of sleep but not the macrostructure is changed. There is a high coincidence between EEG arousals and movement arousals. The evaluation of arousals especially the analysis of movement arousals is helpful to estimate treatment effect in OSAS patients.

First night effect in children and adolescents undergoing polysomnography for sleep-disordered breathing.

OBJECTIVE: To establish whether there is a first night effect (FNE) in children and adolescents with suspected obstructive sleep apnoea undergoing polysomnography (PSG) and whether this affects sleep and breathing, furthermore, to determine the extent to which age may influence the sleep and cardiorespiratory parameters. METHODS: One hundred and thirty-one children and adolescents (age classes-A: 2-6 years n=37; B: 7-12 years n=60; C: 13-17 years n=34) underwent PSG on 2 consecutive nights (I and II) under identical conditions for suspected sleep-related respiratory disorders. One hundred and five patients including 3 patients with obstructive sleep apnoea syndrome (OSAS) treated by adenotonsillectomy and 18 OSAS patients receiving nCPAP-therapy had no PSG-abnormalities (Group 1-A: n=28; B: n=53; C: n=24). A further 26 patients (Group 2) had clinically and polysomnographically confirmed untreated OSAS (A: n=9; B: n=12; C: n=5). RESULTS: There were no statistically significant differences between children with no PSG-abnormalities (Group 1) and those with OSAS (Group 2) in terms of sleep parameters (arousal indices excluded), oxygen saturation (SaO(2)) and heart rate (HR), and these parameters have, therefore, been pooled for the entire group (n=131) in the 3 age classes A, B and C. In the second and third age classes, sleep efficiency on the first night was reduced. In all age classes, there was significantly more wakefulness during the first night. In the second and third age ranges, the proportion of NREM 1 in the first night was significantly higher, with a correspondingly reduced proportion of NREM 4 in the third age group. In all age classes, REM sleep was significantly less during the first night, but REM latency was comparable on both nights. On the first night, the mean HR was higher. There were significant differences in apnoea/hypopnoea-index (AHI), electroencephalogram (EEG)-arousal-index (AI) and motoric arousal index (jerk index, JI) between Groups 1 and 2. In neither group, were there any significant differences in AHI, mean SaO(2) or number of EEG-arousals between nights 1 and 2. Only in the age class A, in Group 2 (n=9) was the number of motoric arousals significantly higher on the first night. Comparison of the age classes A, B, and C revealed that most polysomnographic parameters were age-dependent. Increasing age was found to correlate with a higher proportion of NREM 1, especially on the first night. Also, there was an age-dependent increase in NREM 2 on both nights, a decrease in NREM 3 on the first night, and a decrease in NREM 4 on both nights. In older children, we also found a lower proportion of REM sleep on the first night and a lower HR on both nights. In Group 1, we found a lowered AHI, AI and JI (for JI significant only on the first night) in older patients. No such age dependence of AHI, AI and JI was seen in OSAS patients (Group 2). CONCLUSIONS: In children and adolescents, there is an FNE comparable with that described in adults. In OSAS children and also in children with no PSG-abnormalities, there is night-to-night-variability in sleep parameters, but not in respiratory parameters. An adaptation night is, therefore, necessary when sleep architecture is to be studied, but not when only the nocturnal respiratory pattern is investigated. Sleep parameters, HR and arousal indices are all age-dependent.

Women's satisfaction with primary care: a new measurement effort from the PHS National Centers of Excellence in Women's Health.

This paper describes efforts by the National Centers of Excellence in Women's Health to develop a woman-specific primary care satisfaction instrument suitable for quality improvement and research.

Barriers to screening sexually active adolescent women for chlamydia: a survey of primary care physicians.

PURPOSE: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening. METHODS: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses. RESULTS: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%). CONCLUSIONS: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.

A fork in the road: decision time for behavioral pediatrics.

The rapid growth of managed care, and especially that of managed behavioral healthcare organizations (MBHOs), is likely to diminish the role of developmental-behavioral pediatrics and separate care for medical and behavioral problems. Thus, a rethinking of the practice of developmental-behavioral pediatrics is required. This study reviews the structure of MBHOs, identifies barriers to the provision of services by developmental-behavioral pediatricians, describes alternative practice models for consideration, and makes recommendations. The aims of the recommendations are to stimulate an active discussion about these issues, spark an advocacy effort, and ensure the continued participation of developmental-behavioral pediatricians in the care of children with special needs. The study concludes that managed care will push developmental-behavioral pediatricians into integration with primary care group practices or into specialty mental health networks. Immediate discussion, action, and advocacy will be required to ensure a presence in these decisions for developmental-behavioral pediatricians.

The effects of mental health factors on ambulatory care visits by rural teens.

This study sought to determine the effects of mental health variables on rural adolescents' use of ambulatory health care services and whether these effects varied across common outpatient settings. Using a cross-sectional survey design, 2,297 adolescents who attended public schools in grades 7 through 12 in one isolated rural Mississippi River Delta county were assessed via a standardized health behavior survey. This self-report measure inquired about relevant health behaviors such as alcohol use, depressive symptoms, and health service use. The students' mean age was 15 years and 58 percent of the sample were black. Approximately 11 percent of the sample reported symptoms of depression, 16.5 percent reported problem drinking, and slightly fewer than 6 percent reported both. After controlling for predisposing, enabling, and need factors, the reporting of depressive symptoms, problem drinking, or both was related to an increased number of outpatient visits in three of four sites examined. However, differences among sites were observed. These data suggest that mental health problems are associated with increased visits to ambulatory settings, and these problems affect service use differentially. Thus, effective interventions and better linkages between ambulatory settings and mental health providers may reduce unnecessary use.

A comparison of ambulatory Medicaid claims to medical records: a reliability assessment.

This study compares the documentation of ambulatory care visits and diagnoses in Medicaid paid claims and in medical records. Data were obtained from Maryland Medicaid's 1988 paid claims files for 2407 individuals who were continuously enrolled for the fiscal year, had at least one billed visit for one of six indicator conditions, and had received the majority of their care from one provider. The patients sampled were also stratified on the basis of the case-mix adjusted cost of their usual source of care. The medical records for these individuals as maintained by their usual source of care were abstracted by trained nurse reviewers to compare claims and record information. Linked claim and medical record data for sampled patients were used to calculate: (i) the percent of billed visits documented in the record, (ii) the percent of medical record visits where both the date and the diagnosis agreed with the claims data, and (iii) the ratio of medical record visits to visits from billed claims. Included in the analysis were independent variables specifying place of residence, type and costliness of usual care source, level of patient utilization, and indicator condition on which patient was sampled. Ninety percent of the visits chronicled in the paid claims were documented in the medical record with 82% agreeing on both date and diagnosis. Compared to the medical records kept by private physicians and community health centers, a significantly lower percent of hospital medical records agreed with the claims data. Total volume of visits was 2.6% higher in the medical records than in the claims. Claims data substantially understated visits in the medical record by 25% for low cost providers and by 41% for patients with low use rates (based on claims information). Conversely, medical records substantially understated billed visits by 19% for rural patients and by 10% for persons with high visit rates. Although Medicaid claims are relatively accurate and useful for examining average ambulatory use patterns, they are subject to significant biases when comparing subgroups of providers classified by case-mix adjusted cost and patients classified by utilization rates. Medicaid programs are using claims data for profiling and performance assessment need to understand the limitations of administrative data.

[Theophylline in the treatment of sleep-related breathing disorders]. / Theophyllin in der Therapie schlafbezogener Atmungsstörungen.

The methylxanthine derivates are known to have respiratory stimulant properties. Therefore theophylline is used in sleep related disturbances of breathing. Theophylline reduces central apneas and periodic breathing in infants. The efficiency of theophyllin is confirmed in reducing central apneas in patients with neurologic diseases or Cheyne Stokes breathing in patients with congestive heart failure. In patients with obstructive sleep apnoea the effect of theophylline is doubtful. An effect of therapy exists in some mild forms of sleep apnoea (apnoea index < 20/h total sleep time). Further studies are necessary to investigate the precise mechanism of of theophylline in obstructive sleep apnoea.

A controlled study of sensation awareness and verbal disclosure for regulation of arousal and anxiety.

Interactions of attention and verbalization were investigated for effects of self-reported arousal and state-anxiety. Levels of verbalization from silence through talking-without-a-listener to disclosure were compared while self-directed attention was manipulated for sensation versus general thoughts and feelings. Following a stimulus, disclosure of sensations was expected to reduce state anxiety and increase energetic arousal significantly more than disclosure of thoughts. Based on a randomly assigned sample of 120 men, a 3 x 2 x 2 multivariate analysis of variance indicated a significant interaction in the predicted directions. A significant interaction was also found for the 3 x 2 interaction for energetic arousal. For state anxiety means were in the predicted direction. Results indicate that verbalization of sensations is more energizing and calming than silence, while for general thought, silence is more energizing and calming than verbalization. The results suggest efficacy in reframing self-talk to quiet awareness and in communicating sensed distinctions as they emerge.

[Sleep evaluation in infancy, early childhood and childhood]. / Schlafbewertung im Säuglings-, Kleinkindes- und Kindesalter.

There is no common strategy for the determination of sleep stages in the childhood. In the first year of life, the differentiation in active and quiet sleep has been established. But there are several opinions about necessary parameters for the characterization of sleep states in this period of life. Therefore, the results of these evaluations are quite different. Our presented concept of sleep staging reflects neurophysiological, vegetative as well as behavioral parameters. The concept divides the sleep into light sleep, deep sleep and REM-periods. The determination of sleep states is possible by this concept both in infants and in children of different age, because it considers developmental changes of used physiological criteria.

Effects of prenatally administered thyroid hormones or glucocorticoids on maturation of kidney function in newborn rats.

Influences of treatment with thyroid hormones or dexamethasone during pregnancy on development of kidney function were studied in newborn rats. Treatment of dams for 3 days is followed by a higher rate of urine production in newborn rats. A statistically significant raise of sodium/potassium ratio in tetraiodothyronine- or dexamethasone-treated rats indicates a higher degree of maturation of kidney function. Treatment of dams with dexamethasone is followed by an increase of absolute excreted quantities of sodium and potassium in newborn rats. Treatment of dams with triiodothyronine can increase renal excretion of p-aminohippurate in newborn rats.