A systematic review of the effectiveness of sleep hygiene in children with ADHD.

Attention deficit/hyperactivity disorder (ADHD) is often accompanied by sleep problems in children. Sleep hygiene is defined as a set of behavioural, environmental, or cognitive modifications to improve sleep, and is routinely clinically utilised as first-line treatment for insomnia in ADHD. The objective of this systematic review of the literature is to evaluate the effectiveness of sleep hygiene interventions for sleep difficulties in children with ADHD. Sixteen relevant articles met the inclusion criteria, involving 1,469 participants, with a mean age of 9.6 years, across 6 countries. Fifteen studies found that sleep hygiene interventions were effective in improving sleep, while one did not show any significant improvement. Definite conclusions on the effectiveness of the interventions are difficult to draw due to the limited number of studies and a high risk of bias. There is growing evidence to support the use of sleep hygiene interventions to improve sleep quality in children with ADHD and sleep disturbance. However, well-conducted clinical trials are required to strengthen the evidence.

Evaluation of a pilot of nurse practitioner led, GP supported rural palliative care provision.

BACKGROUND: Providing end of life care in rural areas is challenging. We evaluated in a pilot whether nurse practitioner (NP)-led care, including clinical care plans negotiated with involved health professionals including the general practitioner(GP), ± patient and/or carer, through a single multidisciplinary case conference (SMCC), could influence patient and health system outcomes. METHODS: Setting - Australian rural district 50 kilometers from the nearest specialist palliative care service. PARTICIPANTS: Adults nearing the end of life from any cause, life expectancy several months. Intervention- NP led assessment, then SMCC as soon as possible after referral. A clinical care plan recorded management plans for current and anticipated problems and who was responsible for each action. Eligible patients had baseline, 1 and 3 month patient-reported assessment of function, quality of life, depression and carer stress, and a clinical record audit. Interviews with key service providers assessed the utility and feasibility of the service. RESULTS: Sixty-two patients were referred to the service, forty from the specialist service. Many patients required immediate treatment, prior to both the planned baseline assessment and the planned SMCC (therefore ineligible for enrollment). Only six patients were assessed per protocol, so we amended the protocol. There were 23 case conferences. Reasons for not conducting the case conference included the patient approaching death, or assessed as not having immediate problems. Pain (25 %) and depression (23 %) were the most common symptoms discussed in the case conferences. Ten new advance care plans were initiated, with most patients already having one. The NP or RN made 101 follow-up visits, 169 phone calls, and made 17 referrals to other health professionals. The NP prescribed 24 new medications and altered the dose in nine. There were 14 hospitalisations in the time frame of the project. Participants were satisfied with the service, but the service cost exceeded income from national health insurance alone. CONCLUSIONS: NP-coordinated, GP supported care resulted in prompt initiation of treatment, good follow up, and a care plan where all professionals had named responsibilities. NP coordinated palliative care appears to enable more integrated care and may be effective in reducing hospitalisations.

Palliative care in australia.

Australia is a very large country with a relatively small, diverse population. Palliative care is delivered by a range of professionals, from general (family) practitioners and community care nurses to large tertiary referral palliative care services. A national strategy provides a service development framework that informs the provision of these services. The National Palliative Care Program has provided extensive service improvement in the past decade. Challenges to improving the delivery of palliative care center around meeting the requirements of people with nonmalignant life-limiting illnesses; growing the specialist workforce; maintaining the skills of the primary care workforce; and providing palliative care to special populations such as the aged, indigenous Australians, non-English-speaking Australians, and children.

Pilot study to determine the optimal dose of methylphenidate for an n-of-1 trial for fatigue in patients with cancer.

PURPOSE: In advanced cancer, the prevalence of fatigue is high and can be related to treatment or disease. Methylphenidate hydrochloride (MPH) is a central nervous system stimulant that has been used to palliate fatigue. There is no standard dose for MPH when used for this indication; recommended doses range from 5­20 + mg/d. METHOD: To identify a dose to test formally in a subsequent n-of-1 trial of fatigue, we recruited patients with advanced cancer and a fatigue score of 4 or more on a 10-point scale. Following a 3-day baseline assessment, each patient titrated MPH at doses ranging from 5 mg/d to 15 mg twice daily at 3-day intervals. In a daily diary, patients recorded measures of fatigue, depression, toxicity, and symptom control. RESULTS: Ten patients provided consent, 9 completed 8 days and 5 received maximum dose at day 15. Three patients were unwilling to increase the dose to maximum levels as they were satisfied with the response at a lower dose. Across all patients, there was a pattern of rapidly improving fatigue and depression scores to day 9 (5 mg twice daily), with minimal improvement thereafter. CONCLUSION: The results indicate a dose of 5 mg twice daily for the definitive study. There was little correlation between performance status and maximum tolerated dose. No patient withdrew because of toxicity.