Perception versus Reality: The Relationship between Subjective and Objective Measures of Sleep When On-call under Simulated Laboratory Conditions.

BACKGROUND: On-call working arrangements have been shown to negatively impact sleep. However, workers may perceive their sleep to be worse than it actually is. The aim of this study was to compare participants' pre- and post-sleep estimates of sleep duration and sleep quality with objectively measured sleep when on-call under laboratory conditions. PARTICIPANTS: 72 healthy, adult males. METHODS: Analyses were performed on three interrelated studies, all of which consisted of four nights in a sleep laboratory. Following adaptation and baseline nights were two on-call nights (sleep opportunity 23:00 h - 07:00 h). Before and after each sleep opportunity, participants provided subjective estimates of sleep. Sleep was objectively measured using polysomnography. RESULTS: Estimated sleep duration (6.74 ± 1.13 h) and sleep onset latency (20.55 ± 14.85 min) were significantly poorer than objectively measured sleep outcomes (sleep duration 7.21 ± 1.25 h; sleep latency 13.20 ± 10.06 min). Of the variance in post-sleep estimated sleep duration, 14% was associated with objectively measured minutes of N3 (R2Δ = 0.55) and REM (R2Δ = 0.75). Additionally, 14% of post-sleep sleep quality estimation variance was associated with minutes of N2 (R2Δ = 0.60) and N3 (R2Δ = 0.79), measured by polysomnography. CONCLUSIONS: Some objective measures of sleep were associated with subjective estimates of sleep duration and sleep quality. However, individuals may overestimate sleep onset latency and underestimate sleep duration during on-call periods. It may be beneficial for on-call workers to actively reflect on feelings of fatigue/alertness for workplace fatigue management, rather than relying solely on estimates of sleep.

Waking qEEG to assess psychophysiological stress and alertness during simulated on-call conditions.

INTRODUCTION: On-call schedules are associated with stress and disrupted sleep. In a recent study, under non-sleep deprived conditions, low and high-stress on-call conditions did not significantly impact sleep quality but did impact next day performance. Our aim was to determine whether quantitative electroencephalography (qEEG) would reflect changes in cortical activity in on-call conditions, predicting that the high-stress condition would display faster qEEG frequencies compared with the control and low-stress condition. METHODS: Twenty-four healthy male participants (age: 26.5 ±â€¯4.0 yrs) spent four nights in a time-isolated sleep laboratory. The within-subjects, repeated measures experimental design assessed waking EEG, via the Karolinska Drowsiness Test (KDT) during four time-points across a control day and two experimental (on-call) days. Experimental days comprised a low-stress (LS - reading task) and high-stress (HS - speech task) condition and were counterbalanced. Mixed-models analysis was used to assess condition and time by EEG biomarkers: Alpha Attenuation Coefficient (AAC), Slowing Ratio (SR) and Scaling Exponent (SE). RESULTS: Main effects were found for all three biomarkers by condition, with pairwise analysis reported. There was a significant difference in AAC between the LS condition (M = 1.26 ±â€¯=1.24) and HS condition (M = 1.01 ±â€¯0.76 p = .02) indicating decreased alertness between LS and HS. A significant increase in SR between control (M = 7.1 ±â€¯4.3) and LS (M = 10.1 ±â€¯8.5 p = .0001), and a significant increase between the LS and HS (M = 7.8 ±â€¯6.8 p = .018) showing greatest EEG slowing in the LS condition, reflecting of a passive, sleepier brain state. The SE was significantly higher in the LS (M = 1.09, ±0.17) condition compared with control (M = 1.0, ±0.11 p = .001) indicating decreased alertness in the LS task. DISCUSSION: Using qEEG biomarkers, in contrast with our initial hypothesis, the current study found that compared with control, the LS condition resulted in greater EEG slowing. These findings have implications for on-call workers who engage in periods of passive attention and highlight a protective role task stress may play in maintaining alertness levels during on-call conditions.

The usefulness of routine histopathology of bilateral nasal polyps - a systematic review, meta-analysis, and cost evaluation.

BACKGROUND: Controversy regarding the usefulness of routine histopathological examination of bilateral nasal polyps removed during endoscopic sinus surgery to identify occult diagnoses still exists. There is a paucity of high-level evidence in the literature. METHODS: A systematic review and meta-analysis was conducted. Two independent reviewers were used. Pooled proportions and numbers needed to screen were calculated. A cost per life year model was generated based on varying survival benefits and compared to other Canadian screening programs to provide financial context. RESULTS: Six studies (n = 3772 patients) were included. Of the 3772 patients, 3751 had a pre-operative clinical and post-operative pathological diagnosis of inflammatory nasal polyps. Agreement proportion was 99.44 %. There were 18 unexpected benign and three unexpected malignant diagnoses identified. This translated to a proportion of 0.48 and 0.08 % respectively. Number needed to screen was 210 and 1258 respectively. Pooled proportion for expected findings using a random effect model was 0.99 (95 % CI = 0.99-1). Pooled proportion for unexpected benign findings using a random effect model was 0.00522 (95 % CI = 0.00133-0.01). Pooled proportion for unexpected malignant findings using a random effect model was 0.00107 (95 % CI = 0.000147-0.00283). The cost to pick up one unexpected benign diagnosis was $14557.2. The cost to pick up 1 unexpected malignant diagnosis was $87204.56. Cost per quality life year calculated ranged from 3211.83 to $64677.58 based on varying assumptions on the survival benefits of identifying an unexpected malignancy. CONCLUSIONS: Routine pathological examination in screening for neoplasia may be low yield, however, no compelling evidence was found to cease such practice. Surgeons should exercise individual judgment in requesting routine examination.

Comparative outcomes of ulnar nerve transposition versus neurolysis in patients with entrapment neuropathy at the cubital tunnel: a 20-year analysis.

BACKGROUND: Entrapment neuropathy of the ulnar nerve at the level of the elbow is the shared domain of multiple surgical specialties. A wide variety of operative methods for its surgical management have been reported. Our hospital utilizes neurolysis (NL) and subcutaneous transposition (AST). The aim of this paper was to compare the clinical outcomes in patients treated by ulnar nerve transposition versus neurolysis over a 20-year period. METHODS: We included patients who underwent either neurolysis or an ulnar nerve transposition. A retrospective analysis was performed which included 480 patients at our institution between January 1992 and December 2012. In total, physical and electronic records for 480 patients were reviewed. Three-hundred and one underwent ulnar nerve transposition and 179 underwent ulnar nerve neurolysis . RESULTS: In the AST group 201/301 patients suffered from parasthesiae pre-operatively and 156/301 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 99/301 patients. At the 3-month follow-up appointment, 187/201 patients with parasthesiae and 113/156 patients with local pain had resolution of their symptoms. In the NL group 151/179 patients had parasthesiae pre-operatively and 126/179 had pain at and around the cubital tunnel. Paresis of the ulnar nerve innervated muscles was present in 56/179 patients. At the 3-month follow-up appointment, 141/151 patients with parasthesiae and 117/126 patients with local pain had resolution of their symptoms. CONCLUSIONS: In cases of ulnar nerve compression at the cubital tunnel, both neurolysis and transposition are effective in improving clinical outcome. The only statistically significant advantage of neurolysis over transposition seems to be relief of localized elbow pain. We recommend neurolysis as the preferred procedure.

Gamma knife stereotactic radiosurgery for thalamic & brainstem cavernous angiomas.

OBJECTIVE: To determine the safety and efficacy of Gamma Knife stereotactic radiosurgery (GKS) in the treatment of patients with symptomatic cavernous angiomas (CA) of the brainstem or thalamus, by comparing overall outcome to the natural history of the disease. METHODS: Over 10 years a series of 16 consecutively presenting patients (M = 9, F = 7) with thalamic or brainstem CA were treated with GKS to a single lesion, specifically excluding the haemosiderin ring from the target. Within the year prior to treatment eight patients had suffered one symptomatic haemorrhage and eight had suffered more than one symptomatic haemorrhage. Mean age at treatment was 38.9 (15-55) years. Mean prescription dose 13.31 Gray (11.0 Gy-16.0 Gy). Patients were followed up radiologically and, more importantly, clinically for a mean period of 43.8 (11-101) months, median 36 months. RESULTS: One patient suffered recurrent haemorrhage at 23 months post-GKS, but has not re-bled in the following 61 months. One patient died of thalamic haemorrhage from the treated lesion at 90 months. One patient was lost to follow up. There have been no other clinical episodes or radiological findings to suggest post-GKS haemorrhage in the remaining 13 patients, and no other complications were observed in the treated population. The annual haemorrhage rate within the first two years post GKS was 3.72% and the annual haemorrhage rate 2 years post GKS was 3.59% per annum. CONCLUSION: With the dose regimens described, GKS is safe and effective in the treatment of thalamic and brainstem CA, as assessed by significant reduction in observed rate of re-haemorrhage over that expected from the known natural history of those CAs which have already demonstrated a tendency to haemorrhage in highly eloquent areas.

Changes in structural aspects of mood during 39-66 h of sleep loss using matched controls.

A number of studies have described mood change during sleep loss in the laboratory, however, an understanding of fluctuations in structural aspects of mood under such conditions is lacking. Sixty-two healthy young adults completed one of three possible conditions: one (n = 20) or two (n = 23) nights of sleep loss or the control condition which consisted of one (n = 9) or two (n = 10) nights of 9 h time in bed. The Mood Scale II was completed every two waking hours and data were analysed in terms of the frequency and intensity of mood reports. Overall, sleep loss conditions were associated with significantly less frequent happiness and activation and more frequent fatigue reports (p < 0.001). Intensity was also significantly reduced for activation and happiness, and increased for depression, anger and fatigue (p < 0.05). Interestingly, there were no significant differences in anger following two nights in the laboratory with or without sleep. Further, two nights in the lab with normal sleep was associated with significant increases in depression intensity (p < 0.05). Findings support the hypothesis of a mood regulatory function of sleep and highlight the relative independence of frequency and intensity and of positive and negative mood dimensions. Findings also suggest that the laboratory environment, in the absence of sleep loss, may have a significant negative impact on mood.

Autistic barriers in the psychoanalysis of borderline adults.

The authors discuss Frances Tustin's work on childhood autism in order to clarify the nature and protective function of autistic barriers in adult patients who present challenging resistances in treatment. Tustin's thesis is that childhood autism constitutes a massive formation of avoidance reactions that develop in infancy to ward off traumatic awareness of bodily separateness. She describes two forms of childhood pathology that may develop: the encapsulated child who defends against all 'not me' experience by means of self-generated bodily sensations that augment the illusion of complete bodily continuity with the mother; and the entangled child who generates a protective illusion of being enfolded inside the body of the mother to minimise the experience of separateness. The transference resistances of borderline adults can be categorised according to Tustin's typology of encapsulation and entanglement. Clinical material is presented from the analyses of two borderline patients, one encapsulated and the other entangled. Despite seemingly different transference manifestations, both belong to the category of autistic barriers inasmuch as they ward off awareness of separation-induced injury to the primal self. The countertransference difficulties that the analyst encounters with patients who employ autistic barriers are discussed and treatment issues are reviewed.

An investigation of cognitive-behavior therapy combined with oral valium for children undergoing painful medical procedures.

In previous research, a cognitive-behavioral therapy (CBT) package was found to be effective in reducing children's distress associated with the painful medical procedures of bone marrow aspirations (BMAs) and lumbar punctures (LPs). Orally administered Valium demonstrated less effectiveness but was helpful in reducing behavioral distress before the medical procedure. In the present study, we investigated whether the combination of oral Valium and CBT would result in increased efficacy of the CBT. Eighty-three subjects were randomly assigned to receive either CBT or CBT plus Valium while undergoing either a BMA or an LP. Dependent variables included observed behavioral distress, self-reported fear and pain, and pulse rate. Results failed to support the value of such a combination but did provide additional evidence in regard to the effectiveness of the CBT. The need for more potent medical interventions for some children is discussed.

A stress inoculation program for parents whose children are undergoing painful medical procedures.

The efficacy of a stress inoculation intervention program was compared with that of a child focused intervention program in helping parents cope with their children's painful medical procedures. Ss included 72 parents (79% mothers) of pediatric leukemia patients (aged 3-12 years) who were undergoing either bone marrow aspirations (n = 28) or lumbar punctures (n = 44). Parents were assessed during a baseline procedure and then were randomly assigned to either a stress inoculation group or a child-focused intervention group. In the child focused intervention, parents merely observed their child's participation in a cognitive behavior therapy program. Assessment of parents included an observation measure of parent behavior, self-reported measures of anxiety and coping, and physiological measures. Results indicate that parents in the stress inoculation program reported lower anxiety scores and higher positive self-statement scores than did parents in the child-focused intervention.

The management of pain associated with pediatric procedures.

This article provides guidelines for the psychological and pharmacologic management of pain and anxiety for children undergoing medical procedures. The goals of intervention are presented, as well as issues warranting consideration in planning intervention to reduce procedure-related distress.

Psychological and social adjustment of obese children and their families.

The psychological and social adjustment of 30 obese children and their families was examined. Mothers completed the Child Behaviour Checklist and the Family Environment Scale; children completed the Self-Perception Profile for Children. The results consistently indicate that the obese children were less socially competent, had more behaviour problems, and had poorer self-perceptions than the non-obese normative samples. Families of obese children differed significantly from families in the non-distressed normative sample in that they interacted in a more negative way. The findings are discussed in terms of an 'at risk profile' and the implications for the behavioural treatment of obese children.

Social class differences in children's comprehension of adult language.

Twenty-five mothers of all social class levels were asked to tell, as if to a 6-year-old child, the stories suggested by several cartoon picture sequences. These stories, tape-recorded, were played to a hundred 6-year-old white male children of high and low social class levels, who were then asked standard comprehension questions about their content. Analysis of the comprehension scores revealed significant main effects of social class of adult speaker and of social class of child listener but no interaction of these two variables. Further analysis of transcriptions of the stories revealed two characteristics, namely the factual information included in the stories and the use of nonstandard grammar, which seemed to mediate the effects of both social class and speaker IQ on comprehension.