A Practice Pathway for the Treatment of Night Wakings in Children with Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) report high rates of sleep problems. In 2012, the Autism Treatment Network/ Autism Intervention Research Network on Physical Health (ATN/AIR-P) Sleep Committee developed a pathway to address these concerns. Since its publication, ATN/AIR-P clinicians and parents have identified night wakings as a refractory problem unaddressed by the pathway. We reviewed the existing literature and identified 76 scholarly articles that provided data on night waking in children with ASD. Based on the available literature, we propose an updated practice pathway to identify and treat night wakings in children with ASD.

Pilot study: can machine learning analyses of movement discriminate between leg movements in sleep (LMS) with vs. without cortical arousals?

PURPOSE: Clinical and animal studies indicate frequent small micro-arousals (McA) fragment sleep leading to health complications. McA in humans is defined by changes in EEG and EMG during sleep. Complex EEG recordings during the night are usually required to detect McA-limiting large-scale, prospective studies on McA and their impact on health. Even with the use of EEG, reliably measuring McA can be difficult because of low inter-scorer reliability. Surrogate measures in place of EEG could provide easier and possibly more reliable measures of McA. These have usually involved measuring heart rate and arm movements. They have not provided a reliable measurement of McA in part because they cannot adequately detect short wake periods and periods of wake after sleep onset. Leg movements in sleep (LMS) offer an attractive alternative. LMS and cortical arousal, including McA, commonly occur together. Not all McA occur with LMS, but the most clinically significant ones may be those with LMS [1]. Conversely, most LMS do not occur with McA, but LMS vary considerably in their characteristics. Evaluating LMS characteristics may serve to identify the LMS associated with McA. The use of standard machine learning approaches seems appropriate for this particular task. This proof-of-concept pilot project aims to determine the feasibility of detecting McA from machine learning methods analyzing movement characteristics of the LMS. METHODS: This study uses a small but diverse group of subjects to provide a large variety of LMS and McA adequate for supervised machine learning. LMS measurements were obtained from a new advanced technology in the RestEaZe™ leg band that integrates gyroscope, accelerometer, and capacitance measurements. Eleven RestEaZe™ LMS features were selected for logistic regression analyses. RESULTS: With the optimum logit probability threshold selected, the system accurately detected 76% of the McA matching the accuracy of trained visual inter-scorer reliability (71-76%). The classifier provided a sensitivity of 76% and a specificity of 86% for the identification of the LMS with McA. The classifier identified regions in sleep with high versus low rates of LMS with McA, indicating possible areas of fragmented versus undisturbed restful sleep. CONCLUSION: These pilot data are encouraging as a preliminary proof-of-concept for using advanced machine learning analyses of LMS to identify sleep fragmented by McA.

Are quality-adjusted medical prices declining for chronic disease? Evidence from diabetes care in four health systems.

Improvements in medical treatment have contributed to rising health spending. Yet there is relatively little evidence on whether the spending increase is "worth it" in the sense of producing better health outcomes of commensurate value-a critical question for understanding productivity in the health sector and, as that sector grows, for deriving an accurate quality-adjusted price index for an entire economy. We analyze individual-level panel data on medical spending and health outcomes for 123,548 patients with type 2 diabetes in four health systems: Japan, The Netherlands, Hong Kong and Taiwan. Using a "cost-of-living" method that measures value based on improved survival, we find a positive net value of diabetes care: the value of improved survival outweighs the added costs of care in each of the four health systems. This finding is robust to accounting for selective survival, end-of-life spending, and a range of values for a life-year or fraction of benefits attributable to medical care. Since the estimates do not include the value from improved quality of life, they are conservative. We, therefore, conclude that the increase in medical spending for management of diabetes is offset by an increase in quality.

Does Increased Consolidated Nighttime Sleep Facilitate Attentional Control? A Pilot Study of Nap Restriction in Preschoolers.

OBJECTIVE: The aim of this study is to understand the impact of a 5-day period of nap restriction on sleep patterns and cognitive function in typically developing preschoolers, aged 3 to 4 years. METHOD: Following 1 week of baseline assessment, 28 children were randomly assigned to either a "napping as usual" group ( n = 15) or a 5-day period of nap restriction ( n = 13). Sleep was assessed with sleep logs and actigraphy; cognition was assessed at baseline and at the end of the intervention week. RESULTS: No group differences in sleep or cognitive function were observed at baseline. For the no-nap group, the 5-day period of daytime nap restriction resulted in increased nighttime sleep. Children in the no-nap group also showed a significant improvement in attentional control compared with baseline, whereas no such changes were observed among children in the napping-as-usual group. CONCLUSION: In preschool children who typically take naps, short-term nap restriction is associated with increased nighttime sleep and may contribute to improved attentional function.

The role of polysomnography in decannulation of children with brain and spinal cord injuries.

OBJECTIVE: The objective of this retrospective review was to determine the utility of polysomnography (PSG) in influencing the decision to decannulate pediatric patients with brain and spinal cord injuries in an inpatient rehabilitation hospital setting. METHODS: Between 2010 and 2016, data were collected on pediatric patients with brain and/or spinal cord injuries who had PSG performed with the goal of decannulation. Patients underwent a decannulation protocol involving toleration of continuous tracheostomy capping and bedside tracheoscopy by otolaryngology. Decision to decannulate was determined with input from multiple disciplines. Associations were examined between decannulation success and findings on PSG as well as demographic factors, injury characteristics, otolaryngology findings, and timeline from initial injury to selected events. RESULTS: A total of 46 patients underwent PSG, after which 38 (83%) were deemed appropriate and eight (17%) were deemed inappropriate for decannulation. Individuals who were deemed ready for decannulation had significantly lower obstructive apnea hypopnea indexes (AHI) (1.7 vs 5.4 events/h, P = 0.03), respiratory disturbance indexes (RDI) (2.4 vs 7.6 events/h, P = 0.006), and peak end tidal carbon dioxide (CO2 ) levels (50.0 vs 58.7 torr, P = 0.009) on PSG compared to those who were not decannulated. There were no complications following decannulation prior to discharge. CONCLUSION: PSG provided important additional information as part of a multidisciplinary team assessment of clinical readiness for decannulation in pediatric patients with brain and spinal cord injuries who underwent a decannulation protocol. Obstructive AHI, RDI, and peak end tidal CO2 level were associated with successful decannulation prior to discharge from inpatient rehabilitation.

Cognitive Performance in Subjects With Multiple Sclerosis Is Robustly Influenced by Gender in Canonical-Correlation Analysis.

The authors explored the relations between clinical/demographic characteristics and performance on a neuropsychological battery (eight tests) in a cohort (N=46) of multiple sclerosis (MS) subjects. Findings resulted from a secondary analysis of a study examining the relationships between imaging biomarkers in MS and cognitive tasks of executive functioning. The objective was to determine whether the overlapping test results could be judiciously combined and associated with clinical/demographic variables. Canonical-correlation analysis (CCA) was utilized, and it was found that differences between performance on untimed tests, and the sum of performance on timed Trail-Making Tests, Parts A and B, best matched clinical/demographic variables, and gender was the most important feature.

Sleep disturbance and neuropsychological function in young children with ADHD.

Sleep disturbance, common among children with ADHD, can contribute to cognitive and behavioral dysfunction. It is therefore challenging to determine whether neurobehavioral dysfunction should be attributed to ADHD symptoms, sleep disturbance, or both. The present study examined parent-reported sleep problems (Children's Sleep Habits Questionnaire) and their relationship to neuropsychological function in 64 children, aged 4-7 years, with and without ADHD. Compared to typically developing controls, children with ADHD were reported by parents to have significantly greater sleep disturbance--including sleep onset delay, sleep anxiety, night awakenings, and daytime sleepiness--(all p ≤ .01), and significantly poorer performance on tasks of attention, executive control, processing speed, and working memory (all p < .01). Within the ADHD group, total parent-reported sleep disturbance was significantly associated with deficits in attention and executive control skills (all p ≤ .01); however, significant group differences (relative to controls) on these measures remained (p < .01) even after controlling for total sleep disturbance. While sleep problems are common among young children with ADHD, these findings suggest that inattention and executive dysfunction appear to be attributable to symptoms of ADHD rather than to sleep disturbance. The relationships among sleep, ADHD symptoms, and neurobehavioral function in older children may show different patterns as a function of the chronicity of disordered sleep.

Defining the roles of actigraphy and parent logs for assessing sleep variables in preschool children.

Actigraphy provides a non-invasive objective means to assess sleep-wake cycles. In young children, parent logs can also be useful for obtaining sleep-wake information. The authors hypothesized that actigraphy and parent logs were both equally valid instruments in healthy preschool-aged children. The authors studied 59 children aged 3 to 5 years in full-time day care. Each child was screened for medical problems and developmental delays before being fitted with an actigraphy watch, which was worn for 1 week. Parents maintained logs of sleep and wakefulness during the same period, with input from day care workers. In general, parents overestimated the amount of nighttime sleep measured by actigraphy by 13% to 22% (all significant). Although there was no difference in sleep onset times, parents reported later rise times on the weekend and fewer nighttime awakenings. There was no significant difference between parent logs and actigraphy with regard to daytime napping. The authors conclude that parent logs are best utilized in assessing daytime sleep and sleep onset, whereas actigraphy should be used to assess nighttime sleep and sleep offset time.

The effects of napping on cognitive function in preschoolers.

OBJECTIVE: To determine the relationship between napping and cognitive function in preschool-aged children. METHODS: Daytime napping, nighttime sleep, and cognitive function were assessed in 59 typically developing children aged 3 to 5 years, who were enrolled in full-time childcare. Participants wore an actigraphy watch for 7 days to measure sleep and napping patterns and completed neuropsychological testing emphasizing attention, response control, and vocabulary. Parents of participants completed behavior ratings and sleep logs during the study. Sleep/wake cycles were scored with the Sadeh algorithm. RESULTS: Children who napped more on weekdays were also more likely to nap during weekends. Weekday napping and nighttime sleep were inversely correlated, such that those who napped more slept less at night, although total weekday sleep remained relatively constant. Weekday napping was significantly (negatively) correlated with vocabulary and auditory attention span, and weekday nighttime sleep was positively correlated with vocabulary. Nighttime sleep was also significantly negatively correlated with performance, such that those who slept less at night made more impulsive errors on a computerized go/no-go test. CONCLUSIONS: Daytime napping is actually negatively correlated with neurocognitive function in preschoolers. Nighttime sleep seems to be more critical for development of cognitive performance. Cessation of napping may serve as a developmental milestone of brain maturation. Children who nap less do not appear to be sleep deprived, especially if they compensate with increased nighttime sleep. An alternative explanation is that children who sleep less at night are sleep deprived and require a nap. A randomized trial of nap restriction would be the next step in understanding the relationship between napping and neurocognitive performance.

Circulating 20S proteasome levels in patients with mixed connective tissue disease and systemic lupus erythematosus.

The associations of circulating 20S proteasomes (c20S) with clinical and serologic disease indices in patients with systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD) are unknown. We present the initial report that c20S levels are elevated in MCTD and correlate with clinically relevant changes in disease activity in SLE and MCTD.

Treatment of sleep disorders in children.

Sleep disorders can have a significant impact on the growth and development of children. Behavioral intervention is the first step in the management of many sleep disorders. Limit-setting is particularly challenging in younger children but must be consistent. Good sleep hygiene practices must be emphasized to adolescents as well. Indeed, good sleep hygiene is an important intervention for the entire family. There is an emerging development of pharmacologic treatments for sleep disorders. However, as with most medications used for children, there is a paucity of drugs approved by the US Food and Drug Administration for sleep in children due to the limited number of pediatric clinical trials. As a result, most of what is prescribed has been extrapolated from adult studies and is based on clinical experience.

Xylose fermentation by genetically modified Saccharomyces cerevisiae 259ST in spent sulfite liquor.

Spent sulfite pulping liquor (SSL) is a high-organic content byproduct of acid bisulfite pulp manufacture which is fermented to make industrial ethanol. SSL is typically concentrated to 240 g/l (22% w/w) total solids prior to fermentation, and contains up to 24 g/l xylose and 30 g/l hexose sugars, depending upon the wood species used. The xylose present in SSL is difficult to ferment using natural xylose-fermenting yeast strains due to the presence of inhibitory compounds, such as organic acids. Using sequential batch shake flask experiments, Saccharomyces cerevisiae 259ST, which had been genetically modified to ferment xylose, was compared with the parent strain, 259A, and an SSL adapted strain, T2, for ethanol production during SSL fermentation. With an initial SSL pH of 6, without nutrient addition or SSL pretreatment, the ethanol yield ranged from 0.32 to 0.42 g ethanol/g total sugar for 259ST, compared to 0.15-0.32 g ethanol/g total sugar for non-xylose fermenting strains. For most fermentations, minimal amounts of xylitol (<1 g/l) were produced, and glycerol yields were approximately 0.12 g glycerol/g sugar consumed. By using 259ST for SSL fermentation up to 130% more ethanol can be produced compared to fermentations using non-xylose fermenting yeast.