Promoting a Sleep-friendly Environment by Minimizing Overnight Room Entries.

Introduction: Despite its importance in illness recovery, the sleep of hospitalized children is frequently interrupted. This quality improvement intervention aimed to reduce overnight room entries by minimizing unnecessary interventions. Methods: This study occurred at a university-affiliated children's hospital on the hospital medicine services from March 26, 2021, to April 14, 2022. The intervention included order set changes and the implementation of a rounding checklist designed to address factors most closely associated with sleep disruption and overnight room entries. The outcome measure was overnight (10 pm to 6 am) room entries, counted using room entry sensors. Process measures reflected the intervention targets (overnight vital sign orders, medication administration, and intravenous fluid use). The method of analysis was statistical process control charting. Results: After identifying special cause variation, the average number of overnight room entries decreased from 8.1 to 6.8, a 16% decrease. This decrease corresponded with the implementation of a rounding checklist. However, there continued to be variability in average room entries, suggesting a process lacking ongoing stability. During this period, avoidance of overnight medications and intravenous fluid increased by 28% and 17%, respectively. Conclusions: Implementing a rounding checklist to a broad patient population decreased overnight room entries. However, future work is needed to better understand the factors associated with sustaining such an improvement.

Behavioral and Neural Sustained Attention Deficits in Bipolar Disorder and Familial Risk of Bipolar Disorder.

BACKGROUND: Few neuroimaging studies compare individuals affected with bipolar disorder (BP), at high familial risk of BP, and at low risk to identify endophenotypes for BP. None have examined variability in attention, despite promising behavioral work in this area. We used functional magnetic resonance imaging (fMRI) methods uniquely powered to compare the neural correlates of attention variability in these three groups. METHODS: The present study examined 8- to 25-year-old individuals (n = 106) who completed an fMRI attention task: 24 with BP, 29 at risk based on a first-degree relative with BP, and 53 healthy, low-risk individuals. Group differences in intrasubject variability in reaction time were examined, and a sophisticated fMRI analytic approach was used to quantify precisely trialwise associations between reaction time and brain activity. The latter has not been examined previously in BP or risk of BP. RESULTS: Relative to healthy individuals, those with BP or at risk for BP exhibited increased reaction time variability (F2,102 = 4.26, p = .02, ηp2 = .08). Importantly, we identified blunted relationships between trialwise variation in reaction time and brain activity in the inferior and middle frontal gyri, precuneus, cingulate cortex, caudate, and postcentral gyrus (all regions: p < .001, ηp2 > .06) in both at-risk and BP individuals compared with healthy, low-risk individuals. This blunting partially mediated group differences in reaction time variability (ß = .010, 95% confidence interval 0.002 to 0.020, Sobel Z = 2.08, p = .038). CONCLUSIONS: Blunting in key frontal, cingulate, and striatal areas was evident in unaffected, at-risk individuals and in euthymic BP patients. Elucidating such novel neural endophenotypes can facilitate new approaches to BP prediction, diagnosis, and prevention.

Functional connectivity during masked and unmasked face emotion processing in bipolar disorder.

Little is known regarding the neural connectivity and correlates during automatic, unconscious face emotion processing in individuals with bipolar disorder (BD). In this study, 14 adults with BD and 14 healthy volunteers (HV) underwent fMRI scanning while completing an affective priming task with unconsciously perceived and consciously perceived faces (angry, happy, neutral, blank oval). We found that, regardless of awareness level and emotion types, BD patients exhibited diminished functional connectivity between amygdala and ventromedial prefrontal cortex (vmPFC) compared to HV. This connectivity finding is present in the absence of activation differences in amygdala. In addition, in medial frontal gyrus, BD patients displayed greater activation while HV displayed less activation to angry and neutral faces compared to blank ovals. These results suggest that aberrant amygdala-vmPFC connectivity and neural dysfunction in areas implicated in appraisal and expression of emotions (medial frontal gyrus) may be the pathophysiological correlates of emotional processing in BD regardless of awareness level.

An Open Pilot Study of Training Hostile Interpretation Bias to Treat Disruptive Mood Dysregulation Disorder.

OBJECTIVE: Irritability in disruptive mood dysregulation disorder (DMDD) may be associated with a biased tendency to judge ambiguous facial expressions as angry. We conducted three experiments to explore this bias as a treatment target. We tested: 1) whether youth with DMDD express this bias; 2) whether judgment of ambiguous faces can be altered in healthy youth by training; and 3) whether such training in youth with DMDD is associated with reduced irritability and associated changes in brain function. METHODS: Participants in all experiments made happy versus angry judgments of faces that varied along a happy to angry continuum. These judgments were used to quantify a "balance point," the facial expression at which a participant's judgment switches from predominantly happy to predominantly angry. We first compared balance points in youth with DMDD (n = 63) versus healthy youth (n = 26). We then conducted a double-blind, randomized controlled trial of active versus sham balance-point training in 19 healthy youth. Finally, we piloted open, active balance-point training in 14 youth with DMDD, with 10 completing an implicit functional MRI (fMRI) face-emotion processing task. RESULTS: Relative to healthy youth, DMDD youth manifested a shifted balance point, expressed as a tendency to classify ambiguous faces as angry rather than happy. In both healthy and DMDD youth, active training is associated with a shift in balance point toward more happy judgments. In DMDD, evidence suggests that active training may be associated with decreased irritability and changes in activation in the lateral orbitofrontal cortex. CONCLUSIONS: These results set the stage for further research on computer-based treatment targeting interpretation bias of angry faces in DMDD. Such treatment may decrease irritability and alter neural responses to subtle expressions of happiness and anger.

Neural correlates of masked and unmasked face emotion processing in youth with severe mood dysregulation.

Reproducibility of results is important in improving the robustness of conclusions drawn from research, particularly in functional magnetic resonance imaging (fMRI). In this study, we aim to replicate a previous study on the neural correlates of face emotion processing above and below awareness level using an independent sample of youth with severe mood dysregulation (SMD) and healthy volunteers (HV). We collected fMRI data in 17 SMD and 20 HV, using an affective priming paradigm with masked (17 ms) and unmasked (187 ms) faces (angry, happy, neutral, blank oval). When processing masked and unmasked angry faces, SMD patients exhibited increased activation in the parahippocampal gyrus (PHG) and superior temporal gyrus relative to HV. When processing masked and unmasked happy faces, SMD patients showed decreased activation in the insula, PHG and thalamus compared with HV. During masked face processing in general across emotions, youth with SMD showed greater ventromedial prefrontal cortex (vmPFC) activation relative to HV. Perturbed activation in emotion processing areas (e.g. insula, PHG, superior temporal gyrus and thalamus) manifests as hyper-sensitivity toward negative emotions and hypo-sensitivity toward positive emotions may be important in the etiology and maintenance of irritability, aggression and depressive symptoms in SMD. vmPFC dysfunction may mediate over-reactivity to face emotions associated with irritability.

Effects of the Young Adolescent Sleep Smart Program on sleep hygiene practices, sleep health efficacy, and behavioral well-being.

OBJECTIVES: Using a social learning model, the aim of the Sleep Smart Program was to primarily improve sleep health behaviors and secondarily improve academic performance and behavioral well-being. DESIGN: Randomized control trial for a social learning-based preventive intervention program. PARTICIPANTS: A diverse group of seventh graders from 2 urban, middle schools were randomly assigned, according to school, to an 8-session Sleep Smart Program (SS = 70) or a comparison group (comparison = 73). MEASUREMENTS: Sleep patterns, sleep hygiene, and sleep health efficacy; academic performance; and behavioral well-being were assessed at 4 times of measure (baseline, postintervention, 2 follow-up times in eighth grade). RESULTS: SS seventh graders experienced significantly greater sleep health efficacy, improved physiological and emotional sleep hygiene, more time in bed, and earlier bedtimes vs comparison group. SS (vs comparison) participants also reported a significant decrease in internalizing behavior problems and sustained academic performance. Finally, although not maintained at time 4, SS participants continued to report improved sleep health efficacy at time 3, whereas the comparison group participants' sleep health efficacy declined. CONCLUSION: The Sleep Smart preventive intervention was effective in improving sleep health efficacy, sleep hygiene, time in bed, and bedtimes; in maintaining grades; and in reducing internalizing behavior problems, yet these changes were not sustained at follow-up.

A comparison study of the utilization of National Cholesterol Education Program guidelines by cardiology and internal medicine practices: implications for the advanced practice nurse.

PURPOSE: To determine whether patients with hypercholesterolemia were being treated according to the updated 2001 National Cholesterol Education Program (NCEP) clinical guidelines and whether a difference existed between internists and cardiologists in the implementation of these guidelines. DATA SOURCES: This retrospective study used data obtained from a review of 200 patient charts that were compared with the NCEP guidelines. CONCLUSIONS: Results indicated that 67% of internal medicine patients and 71% of cardiology patients who qualified for pharmaceutical treatment received prescriptions for cholesterol-lowering medications. The difference between internal medicine and cardiology physicians was not statistically significant. IMPLICATIONS FOR PRACTICE: Like physicians, nurse practitioners should become familiar with and utilize the updated guidelines as standards of practice to promote and improve patient outcomes over the life span.