Sleep disturbance and cognitive functioning among firefighters.

Firefighters are at risk for chronic sleep disruption due to their rotating 24-hour on and 48-hour off work schedule and hazardous work conditions. Forty-five firefighters were assessed to determine the impact of their shift schedule on sleep duration, sleep quality, processing speed, sustained attention, vigilance, and mental health. Assessments were conducted at the start and end of shift. Firefighters endorsed sleeping 5 hours 21 minutes at work, and the results suggest that even minimal sleep disruption affected cognitive functioning (e.g. processing speed, visual-motor coordination, and reaction time), increasing the likelihood of poor work performance or injury.

Potential uses of naltrexone in emergency department patients with opioid use disorder.

Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.

Quality of Life Enhancement Research Program: Lessons Learned.

The attempted Quality of Life Enhancement program appeared to be a novel method for creating a symbiotic and sustainable relationship between a large Southeastern university and local nursing home and assisted living facilities (ALF), through which ALF residents would attend university arts and sporting events. During implementation, it was discovered that this project was unsustainable, undesired, unneeded by many care centers, difficult to implement, and required a dedicated and specialized staff. After attempting to enroll 14 local care facilities, only 2 were interested in becoming involved and produced 5 eligible participants. During the program itself, coordination with facilities and residents was difficult to maintain and unique transportation and accommodation needs were challenging to overcome. Finally, data collection was time consuming and generally unfruitful. Ultimately the project was discontinued after a year of attempted recruitment and implementation of inclusive changes to protocol. While creating an ongoing relationship with local care facilities and local universities may enhance opportunities for residents and research into important areas, such relationships take time, effort, and specialized staff to maintain.

Socioeconomic status and hippocampal volume in children and young adults.

An individual's socioeconomic status (SES) is often viewed as a proxy for a host of environmental influences. SES disparities have been linked to variance in brain structures particularly the hippocampus, a neural substrate of learning and memory. However, it is unclear whether the association between SES and hippocampal volume is similar in children and adults. We investigated the relationship between hippocampal volume and SES in a group of children (n = 31, age 8-12 years) and a group of young adults (n = 32, age 18-25 years). SES was assessed with four indicators that loaded on a single factor, therefore a composite SES scores was used in the main analyses. Hippocampal volume was measured using manual demarcation on high resolution structural images. SES was associated with hippocampal volume in the children, but not in adults, suggesting that in childhood, but not adulthood, SES-related environmental factors influence hippocampal volume. In addition, hippocampal volume, but not SES, was associated with scores on a memory task, suggesting that net effects of postnatal environmental factors, captured by SES, are more distal determinants of memory performance than hippocampal volume. Longitudinal investigation of the association between SES, hippocampal volume and cognitive functioning may further our understanding of the putative neural mechanisms underlying SES-related environmental effects on cognitive development.

The relationship between moderate alcohol consumption, depressive symptomatology, and C-reactive protein: the Health and Retirement Study.

OBJECTIVE: Moderate alcohol use has been broadly associated with health benefits among older adults, including improved mood. Aims of this study were to evaluate the relationship of moderate alcohol use and depressive symptomatology over a period of eight years, and to examine inflammation, indicated by C-reactive protein (CRP), as one mechanism by which this relationship functions. METHODS: The study included 3177 community-dwelling participants over the age of 65 in 2008 drawn from the Health and Retirement Study. Data from the 2006, 2008, 2012, and 2014 waves were used. Alcohol use was measured via self-report and was dichotomized as abstinent (0 drinks per week) and moderate (1-14 drinks per week). Inflammation was measured using CRP, which was collected using an enzyme-linked immunosorbent assay and provided in units of µg/mL. Control variables included gender, age, body mass index (BMI), and medical burden. RESULTS: A latent growth curve model with full information maximum likelihood was used, with results revealing that moderate drinkers endorsed fewer depressive symptoms at baseline and a steeper rate of change over time. Abstinent respondents' depressive symptomatology was characterized by a more linear change rate. Further, moderate drinkers had lower CRP levels suggesting that inflammation partially mediates the relationship between moderate alcohol use and depressive symptomatology. CONCLUSIONS: Moderate alcohol use predicts fewer depressive symptoms among older adults. This relationship is partially moderated by CRP and is eroded by the passage of time. Future research should identify additional mechanisms relating alcohol to positive health outcomes and less depressive symptomatology. Copyright © 2017 John Wiley & Sons, Ltd.

Code-based Diagnostic Algorithms for Idiopathic Pulmonary Fibrosis. Case Validation and Improvement.

RATIONALE: Population-based studies of idiopathic pulmonary fibrosis (IPF) in the United States have been limited by reliance on diagnostic code-based algorithms that lack clinical validation. OBJECTIVES: To validate a well-accepted International Classification of Diseases, Ninth Revision, code-based algorithm for IPF using patient-level information and to develop a modified algorithm for IPF with enhanced predictive value. METHODS: The traditional IPF algorithm was used to identify potential cases of IPF in the Kaiser Permanente Northern California adult population from 2000 to 2014. Incidence and prevalence were determined overall and by age, sex, and race/ethnicity. A validation subset of cases (n = 150) underwent expert medical record and chest computed tomography review. A modified IPF algorithm was then derived and validated to optimize positive predictive value. RESULTS: From 2000 to 2014, the traditional IPF algorithm identified 2,608 cases among 5,389,627 at-risk adults in the Kaiser Permanente Northern California population. Annual incidence was 6.8/100,000 person-years (95% confidence interval [CI], 6.1-7.7) and was higher in patients with older age, male sex, and white race. The positive predictive value of the IPF algorithm was only 42.2% (95% CI, 30.6 to 54.6%); sensitivity was 55.6% (95% CI, 21.2 to 86.3%). The corrected incidence was estimated at 5.6/100,000 person-years (95% CI, 2.6-10.3). A modified IPF algorithm had improved positive predictive value but reduced sensitivity compared with the traditional algorithm. CONCLUSIONS: A well-accepted International Classification of Diseases, Ninth Revision, code-based IPF algorithm performs poorly, falsely classifying many non-IPF cases as IPF and missing a substantial proportion of IPF cases. A modification of the IPF algorithm may be useful for future population-based studies of IPF.

Recommendations to limit life support: a national survey of critical care physicians.

RATIONALE: There is debate about whether physicians should routinely provide patient surrogates with recommendations about limiting life support. OBJECTIVES: To explore physicians' self-reported practices and attitudes. METHODS: A cross-sectional, stratified survey of 1,000 randomly selected US critical care physicians was mailed. We included a vignette to experimentally examine how surrogate desire for a recommendation and physician agreement with the surrogate modified whether physicians would provide a recommendation. MEASUREMENTS AND MAIN RESULTS: Proportion of respondents reporting they routinely provide surrogates with a recommendation and how responses varied based on vignette characteristics. A total of 608 (66%) of 922 eligible physicians participated. Approximately one (22%) in five reported always providing surrogates with a recommendation, whereas 1 (11%) in 10 reported rarely or never doing so. Almost all respondents reported comfort making recommendations (92%) and viewed them as appropriate (93%). Most also viewed recommendations as a critical care physician's duty (87%) and did not view them as unduly influential (80%). Approximately two-fifths (41%) believed recommendations were only appropriate if sought by surrogates. In response to the vignettes, nearly all respondents (91%) provided a recommendation when the surrogate requested a recommendation and the physician agreed with the surrogate's likely decision. Physicians were less likely to provide an unwanted recommendation, both when physicians agreed (29%) and disagreed with the surrogate's likely decision (44%). CONCLUSIONS: There is substantial variation among physicians' self-reported use of recommendations to surrogates of critically ill adults. Surrogates' desires for recommendations and physicians' agreement with surrogates' likely decisions may have important influence on whether recommendations are provided.

Critical care physicians' approaches to negotiating with surrogate decision makers: a qualitative study.

OBJECTIVE: To describe how critical care physicians manage conflicts with surrogates about withdrawing or withholding patients' life support. DESIGN: Qualitative analysis of key informant interviews with critical care physicians during 2010. We transcribed interviews verbatim and used grounded theory to code and revise a taxonomy of themes and to identify illustrative quotes. SETTING: Three academic medical centers, one academic-affiliated medical center, and four private practice groups or private hospitals in a large Midwestern city SUBJECTS: Fourteen critical care physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Physicians reported tailoring their approach to address specific reasons for disagreement with surrogates. Five common approaches were identified: 1) building trust; 2) educating and informing; 3) providing surrogates more time; 4) adjusting surrogate and physician roles; and 5) highlighting specific values. When mistrust was an issue, physicians endeavored to build a more trusting relationship with the surrogate before readdressing decision making. Physicians also reported correcting misunderstandings by providing targeted education, and some reported highlighting specific patient, surrogate, or physician values that they hoped would guide surrogates to agree with them. When surrogates struggled with decisionmaking roles, physicians attempted to reinforce the concept of substituted judgment. Physicians noted that some surrogates needed time to "come to terms" with the patent's illness before agreeing with physicians. Many physicians had witnessed colleagues negotiate in ways they found objectionable such as providing misleading information, injecting their own values into the negotiation or behaving unprofessionally toward surrogates. Although some physicians viewed their efforts to encourage surrogates' agreement as persuasive, others strongly denied persuading surrogates and described their actions as "guiding" or "negotiating." CONCLUSIONS: Physicians reported using a tailored approach to resolve decisional conflicts about life support and attempted to change surrogates' decisions in accordance with what the physician thought was in the patients' best interests. Although physicians acknowledged their efforts to change surrogates' decisions, many physicians did not perceive these efforts as persuasive.

Sedation and analgesia for the mechanically ventilated patient.

Mechanically ventilated patients in the intensive care unit routinely require sedative and analgesic medications to manage pain and anxiety. These medications may have unpredictable effects with long-term use. Strategies that may help to improve patient outcomes include thoughtful selection of medications, use of objective sedation and pain scales, and implementation of protocolized sedation.

The relationship between service learning and medical student academic and professional outcomes.

BACKGROUND: Little is known about the relationship between medical student participation in service and performance outcomes. PURPOSE: To examine relationships between involvement in required service learning and measures of academic and professional achievement and specialty choice. METHODS: Using preexisting, self-reported data for Tulane University School of Medicine's class of 2004, we categorized students as low, moderate, or high on commitment and involvement in service learning (CISL) and compared to multiple outcomes: class rank; election to the Alpha Omega Alpha (AOA) Honor Society; election to the Gold Humanism in Medicine Honor Society; total percent scores on 2 multistation, structured, clinical examinations; and specialty choice per 2004 residency match results. RESULTS: Service learning involvement was related to class rank. There was a marginal relationship between CISL and election to AOA but no association with election to the Gold Humanism in Medicine Honor Society, Year 2 or 3 clinical skills examination results, or specialty choice. CONCLUSIONS: High participation in service learning and service learning leadership identify a group of students less likely to be in the top quartile of their class yet who are making important contributions to the community and profession.