Control and Prevention of Anthrax, Texas, USA, 2019.

The zoonotic disease anthrax is endemic to most continents. It is a disease of herbivores that incidentally infects humans through contact with animals that are ill or have died from anthrax or through contact with Bacillus anthracis-contaminated byproducts. In the United States, human risk is primarily associated with handling carcasses of hoofstock that have died of anthrax; the primary risk for herbivores is ingestion of B. anthracis spores, which can persist in suitable alkaline soils in a corridor from Texas through Montana. The last known naturally occurring human case of cutaneous anthrax associated with livestock exposure in the United States was reported from South Dakota in 2002. Texas experienced an increase of animal cases in 2019 and consequently higher than usual human risk. We describe the animal outbreak that occurred in southwest Texas beginning in June 2019 and an associated human case. Primary prevention in humans is achieved through control of animal anthrax.

The validity, reliability, and utility of the iButton® for measurement of body temperature circadian rhythms in sleep/wake research.

OBJECTIVE: Changes in core body temperature due to heat transfer through the skin have a major influence on sleep regulation. Traditional measures of skin temperature are often complicated by extensive wiring and are not practical for use in normal living conditions. This review describes studies examining the reliability, validity and utility of the iButton®, a wireless peripheral thermometry device, in sleep/wake research. METHODS: A review was conducted of English language literature on the iButton as a measure of circadian body temperature rhythms associated with the sleep/wake cycle. RESULTS: Seven studies of the iButtton as a measure of human body temperature were included. The iButton was found to be a reliable and valid measure of body temperature. Its application to human skin was shown to be comfortable and tolerable with no significant adverse reactions. Distal skin temperatures were negatively correlated with sleep/wake activity, and the temperature gradient between the distal and proximal skin (DPG) was identified as an accurate physiological correlate of sleep propensity. Methodological issues included site of data logger placement, temperature masking factors, and temperature data analysis. CONCLUSIONS: The iButton is an inexpensive, wireless data logger that can be used to obtain a valid measurement of human skin temperature. It is a practical alternative to traditional measures of circadian rhythms in sleep/wake research. Further research is needed to determine the utility of the iButton in vulnerable populations, including those with neurodegenerative disorders and memory impairment and pediatric populations.

Modulation of vigilance in the primary hypersomnias by endogenous enhancement of GABAA receptors.

The biology underlying excessive daytime sleepiness (hypersomnolence) is incompletely understood. After excluding known causes of sleepiness in 32 hypersomnolent patients, we showed that, in the presence of 10 µM γ-aminobutyric acid (GABA), cerebrospinal fluid (CSF) from these subjects stimulated GABA(A) receptor function in vitro by 84.0 ± 40.7% (SD) relative to the 35.8 ± 7.5% (SD) stimulation obtained with CSF from control subjects (Student's t test, t = 6.47, P < 0.0001); CSF alone had no effect on GABA(A) signaling. The bioactive CSF component had a mass of 500 to 3000 daltons and was neutralized by trypsin. Enhancement was greater for α2 subunit- versus α1 subunit-containing GABA(A) receptors and negligible for α4 subunit-containing ones. CSF samples from hypersomnolent patients also modestly enhanced benzodiazepine (BZD)-insensitive GABA(A) receptors and did not competitively displace BZDs from human brain tissue. Flumazenil--a drug that is generally believed to antagonize the sedative-hypnotic actions of BZDs only at the classical BZD-binding domain in GABA(A) receptors and to lack intrinsic activity--nevertheless reversed enhancement of GABA(A) signaling by hypersomnolent CSF in vitro. Furthermore, flumazenil normalized vigilance in seven hypersomnolent patients. We conclude that a naturally occurring substance in CSF augments inhibitory GABA signaling, thus revealing a new pathophysiology associated with excessive daytime sleepiness.

Sleep, hunger, satiety, food cravings, and caloric intake in adolescents.

BACKGROUND AND PURPOSE: Prevalence of adolescent obesity has increased worldwide. Although diet and exercise patterns are major determinants of weight, recent studies with adults and children have shown that total amount of sleep is inversely associated with body mass index (BMI). The purpose of this study was to examine associations among total sleep time (TST), hunger, satiety, food cravings, and caloric intake in a sample of healthy adolescents. DESIGN-METHODS: Participants were recruited from the community and a local high school. Demographic data such as sleeping habits, pubertal status, food cravings, caloric intake, physical activity, height, and weight were collected between October 2006 and April 2007. Participants also completed a 7-day sleep-hunger-satiety diary. Descriptive and parametric procedures were used for data analyses (alpha=.05). FINDINGS: The sample (N=85) included 56% females (n=48), 76% African American (n=65) adolescents. Mean age was 15.6+/-1.4 years and mean BMI was 24.3+/-5.4 kg/m(2). Mean reported 7-day cumulative nocturnal sleep was 52.9 (+/-6.0) hours; mean reported cumulative daytime sleep (or napping) was 3.7 (+/-3.4) hours. Multiple regression analyses showed age, gender, and race were associated with feelings of hunger, satiety, total food cravings and caloric intake. A greater total food-cravings score was associated with increased daytime sleep. CONCLUSIONS: These findings indicate an unexpected association between increased daytime sleep and eating behaviors that potentially lead to obesity. Longitudinal studies using objective measures of sleep, appetite regulation, and caloric intake are needed to better understand relationships between appetite and sleep in adolescents from varying racial and gender groups. CLINICAL RELEVANCE: By carefully considering adolescent sleep (especially daytime sleep), race, and gender, clinicians and school health nurses in the US and other countries are in a unique position to develop novel approaches to prevent and reduce obesity.

Insomnia on dialysis nights: the beneficial effects of cool dialysate.

BACKGROUND: Hemodialysis (HD) induces physiological changes that may affect the ability to dissipate heat and adversely affect sleep on the nights following treatment. We studied the effects of altering dialysate temperature on polysomnographic measures of nocturnal sleep and the time course of proximal skin temperature. METHODS: The sample included seven stable HD patients. The three-phase randomized trial was conducted in a research facility. After one acclimatization night, subjects were readmitted in the evening on two additional occasions for 42 hours and received HD the next morning in the warm condition (dialysate--37 degrees C) and cool condition (dialysate--35 degrees C) in random order. Continuous proximal skin temperature (axillary, Tax) and polysomnographic measures of sleep were recorded the nights before and after HD was administered. RESULTS: Highly significant findings included that the course of Tax was markedly affected by the interaction of time and condition. In addition, there was a greater drop of Tax in the early morning following the warm condition than during the baseline nights or in the cool condition. Logistic regression indicated that the odds for the occurrence of sleep and its deeper stages were strongly and positively associated with Tax. Time of sleep onset was earlier in the cool condition (p = 0.032) with trends toward longer total sleep times (p = 0.090) and shorter REM latencies (p = 0.088). CONCLUSIONS: These observations suggest that the use of cool dialysate during HD may improve nocturnal sleep the night following treatment by decreasing sympathetic activation and sustaining the normally elevated nocturnal skin temperature until later into the morning hours.

Sleep/Wake patterns of individuals with advanced cancer measured by ambulatory polysomnography.

PURPOSE: Sleep/wake disturbances are prevalent in patients with advanced cancer, but 24-hour polysomnography (PSG) examinations of these patterns have not been undertaken. The purpose of this study was to describe these sleep/wake patterns using continuous PSG and to explore relationships with selected demographic and clinical variables. PATIENTS AND METHODS: The sample included patients with advanced cancer (solid tumors); those with neurologic disorders or psychosis, substance abuse, or brain metastasis were excluded. The final sample included 114 participants with a mean age of 51.1 years (+/- 9.1 years). Participants underwent continuous, ambulatory PSG for 42 hours in their home environments. Standard PSG measures were calculated. Analysis included data from 2 nights and the intervening day. Descriptive statistics were used to summarize sleep/wake parameters of the average of the 2 nights and the intervening day. Nonparametric analyses were used to detect differences and relationships among the variables. RESULTS: Compared with normative data, participants had reduced quantity and quality of nocturnal sleep and episodes of sleep scattered throughout the day. Increased daytime sleep was negatively associated with several key parameters of nocturnal sleep quantity and quality. Women, whites, and those who were married/partnered and had more education had better nocturnal sleep. Cancer type and selected medications may be risk factors for disturbed sleep and waking. CONCLUSION: Participants experienced severe difficulty with "state maintenance", or the ability to maintain both the sleep and waking states. Research designed to identify the etiology of these problems is needed to develop effective interventions.

Lowering dialysate temperature improves sleep and alters nocturnal skin temperature in patients on chronic hemodialysis.

Hemodialysis (HD) induces physiological changes that may affect the ability to dissipate heat and adversely affect sleep. We studied the effects of altering dialysate temperature on polysomnographic measures of nocturnal sleep and the time course of proximal skin temperature. The sample included seven stable HD patients. The three-phase randomized trial was conducted in a research facility. After one acclimatization night, subjects were readmitted in the evening on two additional occasions for 42 h and received HD the next morning in the warm condition (dialysate 37 degrees C) and cool condition (dialysate 35 degrees C) in random order. Continuous proximal skin temperature (axillary, T(ax)) and polysomnographic measures of sleep were recorded the nights before and after HD was administered. Highly significant findings included that the time course of T(ax) was markedly affected by dialysis temperature. There was a greater drop of T(ax) in the early morning following the warm condition than during the baseline nights or in the cool condition. Logistic regression indicated that the odds for the occurrence of sleep and its deeper stages were strongly and positively associated with T(ax). Time of sleep onset was earlier in the cool condition (P = 0.03) with trends toward longer total sleep times (P = 0.09) and shorter rapid-eye-movement latencies (P = 0.09). These observations suggest that the use of cool dialysate during HD may improve nocturnal sleep by decreasing sympathetic activation and sustaining the normally elevated nocturnal skin temperature until later into the morning hours.

A retrospective examination of the relationship between body mass index and polysomnographic measures of sleep in adolescents.

Total sleep time is inversely related to body mass index (BMI) in adults and children, an observation not well characterized in the adolescent population. We conducted a retrospective chart review that indicated certain sleep disruptions were associated with increased BMI by polysomnography in this group.

Sleep-wake disturbances and quality of life in patients with advanced lung cancer.

PURPOSE/OBJECTIVES: To examine the scope and severity of subjective sleep-wake disturbances in patients with lung cancer and compare them to a group of healthy adults who were similar in age, gender, and race, and to examine the impact of sleep-wake disturbances on measures of health-related quality of life (QOL). DESIGN: Descriptive, comparative. SETTING: University-based and private urban ambulatory care clinics. SAMPLE: 43 patients with advanced non-small cell or small cell lung cancer and 36 healthy adults. All participants were cognitively intact, and none had any known neurologic disorder, polysomnographically diagnosed sleep disorder, mood or anxiety disorders, or cerebral metastasis. METHODS: Questionnaires, interview, and medical record review. MAIN RESEARCH VARIABLES: Nocturnal sleep (quality, quantity, and disturbance), daytime sleepiness, and health-related QOL (physical, mental). FINDINGS: Patients with lung cancer had poor perceived nocturnal sleep quality and excessive daytime sleepiness that differed significantly from the comparison group. Sleep disturbances in the group with lung cancer were characterized by breathing difficulty, cough, nocturia, and frequent awakenings. Sleep-wake disturbances were significantly associated with poorer health-related QOL after controlling for group. Excessive daytime sleepiness was associated most often with decreases in mental health, whereas poor nocturnal sleep was associated most often with decreases in physical health. CONCLUSIONS: Findings suggest that sleep-wake disturbances are common in patients with lung cancer and that the disturbances are significantly associated with health-related QOL. Patients with lung cancer may be at risk for sleep-disordered breathing. IMPLICATIONS FOR NURSING: The magnitude of nocturnal sleep disturbance and daytime sleepiness identified in this study reinforces the importance of ongoing screening and effective intervention for sleep-wake disturbances in patients with lung cancer.

A secondary analysis of racial differences in periodic leg movements in sleep and ferritin in hemodialysis patients.

BACKGROUND AND OBJECTIVE: Hemodialysis (HD) is associated with restless legs syndrome (RLS) and periodic leg movements in sleep (PLMS), but the mechanisms underlying these relationships remain unclear. African-American HD patients have been reported previously to have a reduced likelihood of RLS. Alterations in iron metabolism, known to be a risk factor for idiopathic forms of RLS, could represent the basis for these racial differences. PATIENTS AND METHODS: In secondary data analyses from a previously published study, we examined raw and log-transformed values for plasma ferritin and polysomnographically recorded PLMS in Caucasian and African-American HD patients. RESULTS: African-American (n=36) HD patients had higher ferritin and lower PLMS than Caucasians (n=10). However, within the African-American population, ferritin levels were unrelated to PLMS. CONCLUSIONS: These results are compatible with previously reported racial differences in RLS to the extent that PLMS were less common in the African-American population. However, they suggest that if a differential genetic vulnerability underlies those racial differences, it may not manifest as a deficiency in iron metabolism, at least within the constraints of the marker of iron stores used here (e.g. serum ferritin) and in the specific population studied (hemodialysis). Future studies with larger, more representative samples of African-Americans and Caucasians will be required to replicate such differences.

Age changes in timing and 24-hour distribution of self-reported sleep.

OBJECTIVE: Aging has been associated with increased nocturnal awakenings, increased napping, earlier bedtimes and wake-up times, and more regular sleep-wake schedules. These patterns have often been ascribed to both psychosocial and medical factors, but nearly all studies to-date have been cross-sectional. METHODS: The authors present self-reported sleep data from 31 elderly subjects followed over a decade. RESULTS: With aging, the number of nightly awakenings and daytime napping increased over time. Exploratory analyses suggested that individuals who lived with another person had earlier bedtimes, later wake-up times, and greater daytime napping. Intervening medical comorbidities also appeared to be associated with increased napping. CONCLUSION: These results confirm previous cross-sectional studies and suggest a complex biopsychosocial matrix for the timing and placement of sleep in elderly persons within the 24-hour day.

Sleep wake disturbances in people with cancer and their caregivers: state of the science.

PURPOSE/OBJECTIVES: To review the state of the science on sleep/wake disturbances in people with cancer and their caregivers. DATA SOURCES: Published articles, books and book chapters, conference proceedings, and MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library computerized databases. DATA SYNTHESIS: Scientists have initiated studies on the prevalence of sleep/wake disturbances and the etiology of sleep disturbances specific to cancer. Measurement has been limited by lack of clear definitions of sleep/wake variables, use of a variety of instruments, and inconsistent reporting of sleep parameters. Findings related to use of nonpharmacologic interventions were limited to 20 studies, and the quality of the evidence remains poor. Few pharmacologic approaches have been studied, and evidence for use of herbal and complementary supplements is almost nonexistent. CONCLUSIONS: Current knowledge indicates that sleep/wake disturbances are prevalent in cancer populations. Few instruments have been validated in this population. Nonpharmacologic interventions show positive outcomes, but design issues and small samples limit generalizability. Little is known regarding use of pharmacologic and herbal and complementary supplements and potential adverse outcomes or interactions with cancer therapies. IMPLICATIONS FOR NURSING: All patients and caregivers need initial and ongoing screening for sleep/wake disturbances. When disturbed sleep/wakefulness is evident, further assessment and treatment are warranted. Nursing educational programs should include content regarding healthy and disrupted sleep/wake patterns. Research on sleep/wake disturbances in people with cancer should have high priority.

Symptom interactions as mechanisms underlying symptom pairs and clusters.

PURPOSE: To present a summary of the potential shared or interactive mechanisms underlying an exemplar symptom pair: sleep disturbances and pain. ORGANIZING CONSTRUCT: Understanding of the multidimensional shared and interactive mechanisms underlying symptoms pairs and clusters has the potential to enhance symptom management. METHODS: Reviews of the literature were conducted to search for information on shared or interactive mechanisms underlying sleep disturbances and pain; minimal data were available. Relevant information about individual symptoms was outlined and categorized in areas often used to describe the multidimensional nature of symptoms, including the physiological, psychological, behavioral, and sociocultural domains. This information was examined for relationships and commonalities. CONCLUSIONS: Many potential shared and interactive mechanisms underlying the symptom pair of sleep disturbances and pain were identified. These results indicate the need for further work and theory development in this area. The symptom interactional framework is a beginning conceptual perspective designed to facilitate this work. Implications for interdisciplinary translational research designed to optimize symptom management are discussed.

Polysomnographic measures of nocturnal sleep in patients on chronic, intermittent daytime haemodialysis vs those with chronic kidney disease.

BACKGROUND: Numerous factors probably contribute to the high prevalence of sleep problems in haemodialysis (HD) patients including metabolic changes and treatment-related factors. In contrast, the sleep problems of patients with chronic kidney disease (CKD) may be more related to psychological factors rather than the metabolic changes associated with renal disease. Thus, the objective of this study was to compare polysomnographic measures of nocturnal sleep in a group of stable patients on chronic, intermittent daytime HD and an age- and gender-matched, metabolically comparable group with CKD, and evaluate the role that quality of life (including psychological factors) and the effects of treatment may play in sleep outcomes. METHODS: The sample included 16 patients on HD and eight patients with CKD all of whom were free from other significant physical and psychological morbidity. To assess for psychological, functional, family and economic responses to the disease and treatment, all subjects took the Ferrans and Powers Quality of Life Index. HD subjects received treatment three times a week and were adequately dialysed [Kt/V >1.2, equivalent to a weekly glomerular filtration rate (GFR) of 10-15 ml/min]; CKD subjects had an estimated GFR of 14.5 (+/-7.2; range 5.4-28.8) ml/min. All subjects underwent one night of laboratory-based polysomnography. Appropriate statistical procedures were used to explore group differences in sleep variables and their relationship to quality of life dimensions and the effect of treatment. RESULTS: The CKD patients reported significantly poorer functional and psychological quality of life; both groups had reduced total sleep time and sleep efficiency in comparison with normative data. However, HD subjects had less rapid eye movement sleep (P = 0.032). They also had a higher brief arousal index (P = 0.000), an independent predictor of which was treatment with HD, and respiratory disturbance index (P = 0.061). Less total sleep time, increased wake after sleep onset, lower sleep efficiency, higher periodic limb movement index, and longer latencies to sleep onset and rapid eye movement sleep were also noted in the HD group. Quality of life scores did not predict sleep variables in this small sample. CONCLUSIONS: The results suggest that the sleep problems of patients with CKD and those receiving chronic, intermittent daytime HD may have different aetiologies; functional and psychological factors may play a more prominent role in the former group, while intrinsic sleep disruption (arousals, apnoeas and limb movements) secondary to the effects of chronic, intermittent daytime HD may play a more significant role in the latter. The findings suggest that further exploration is warranted and that population-specific sleep-promoting interventions may be indicated.

A model for teaching research ethics.

A model is described for implementing a program in research ethics education in the face of federal and institutional mandates and current resource, disciplinary, and infrastructure limitations. Also discussed are the historical background, content and evaluation process of the workshop at the heart of the program, which reaches a diverse group of over 250 students per year--from first-year graduate students in basic research labs to clinical fellows. The workshop addresses central issues in both everyday laboratory ethics and in larger societal questions. Goals include improving overall awareness of ethics guidelines and philosophy and enhancing skills in identifying and then analyzing the ethical components of situations. Pedagogies used and their effectiveness and that of the overall workshop and extended program are addressed. Programs like these have initiated a shift in the culture of basic research, which is a critical need given the current atmosphere.

Sleep-wake disturbances in people with cancer part II: evaluating the evidence for clinical decision making.

PURPOSE/OBJECTIVES: To evaluate the quality of evidence on sleep-wake disturbances in people with cancer as a basis for clinical decision making and to discuss implications of the evidence for oncology clinicians, educators, and researchers. DATA SOURCES: Published, peer-reviewed articles. DATA SYNTHESIS: Members of the 2001 Oncology Nursing Society (ONS) Advanced Practice Nurse Retreat Evidence-Based Practice Sleep Working Group selected and evaluated data sources using criteria and processes outlined by ONS. CONCLUSIONS: The development of nursing science related to sleep-wake disturbances among people with cancer and the application of research findings to clinical decision making are limited by the quantity and quality of published evidence. IMPLICATIONS FOR NURSING: Clinicians are challenged to develop a plan of care that includes the assessment of sleep-wake disturbances and interventions to address them. Nurse educators are challenged to include sleep-wake content and skills to evaluate empirical data and interventions for sleep-wake disturbances in degree and continuing education curricula. Nurse researchers are challenged to specify consistent conceptual and operational definitions of key variables in sleep-wake models, use measurement instruments with evidence of reliability and validity, and design clinical trials to test interventions for sleep-wake disturbances among people with cancer.

Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment.

PURPOSE/OBJECTIVES: To provide an overview of normal sleep, describe common sleep disorders, and discuss underlying sleep regulatory processes and how cancer, cancer treatment, and associated patient responses may adversely affect sleep. DATA SOURCES: Published peer-reviewed articles and textbooks. DATA SYNTHESIS: The duration, structure, and timing of sleep have a profound impact on health, well-being, and performance. Patients with cancer may be at risk for disturbances in sleeping and waking resulting from disease- and nondisease-related circumstances that interfere with normal sleep regulation, including demographic, lifestyle, psychological, and disease- and treatment-related factors. CONCLUSIONS: Patients with cancer are at high risk for sleep-wake disturbances. IMPLICATIONS FOR NURSING: An understanding of normal sleep, sleep pathology, and the factors that can precipitate sleep disturbance provides a context for nurses to interpret sleep complaints in their patients, evaluate responses to sleep-promoting interventions, and guide decision making regarding referrals.

Sleep in infants and young children: part two: common sleep problems.

Approximately 25% of children younger than 5 years experience some type of sleep problem. Whether the problem is acute or chronic, significant disruption to the child's sleep can occur and have a negative impact on the child and family. This article is the second in a two-part series on sleep in infants and young children. The purpose of this article is to provide fundamental information regarding common pediatric sleep problems for the clinician to use when assessing a child's sleep behaviors or addressing parental concerns. The definition, impact, and clinical evaluation of sleep problems are discussed.

Sleep in infants and young children: Part one: normal sleep.

The importance of sleep to overall health and well-being is becoming increasingly appreciated; however, clinicians may not have a sound understanding of the fundamentals of sleep. This review of normal pediatric sleep is meant to provide a foundation for the pediatric nurse practitioner to develop and use in clinical practice. Key concepts such as normal sleep physiology including biological rhythms and stages of sleep are discussed. Developmental changes in sleep seen in the transition from infancy to young childhood are highlighted, and strategies for instituting and maintaining normal sleep behaviors are recommended. Part 2 of this series will address common sleep problems experienced by young children.