Awakenings? Patient and Hospital Staff Perceptions of Nighttime Disruptions and Their Effect on Patient Sleep.

STUDY OBJECTIVES: Although important to recovery, sleeping in the hospital is difficult because of disruptions. Understanding how patients, hospital physicians, and nurses perceive sleep disruptions and identifying which disruptions are associated with objective sleep loss can help target improvement initiatives. METHODS: Patients and hospital staff completed the Potential Hospital Sleep Disruptions and Noises Questionnaire (PHSDNQ). Cutoff points were defined based on means, and responses were dichotomized. Perceived percent disrupted for each item was calculated, and responses were compared across groups using chi-square tests. Objective sleep time of patients was measured using wrist actigraphy. The association between patient-reported disruptions and objective sleep time was assessed using a multivariable linear regression model controlling for subject random effects. RESULTS: Twenty-eight physicians (78%), 37 nurses (88%), and 166 of their patients completed the PHSDNQ. Patients, physicians, and nurses agreed that pain, vital signs and tests were the top three disrupters to patient sleep. Significant differences among the groups' perceptions existed for alarms [24% (patients) vs. 46% (physicians) vs. 27% (nurses), p < 0.040], room temperature (15% vs. 0% vs. 5%, p < 0.031) and anxiety (18% vs. 21% vs. 38%, p < 0.031). Using survey and actigraphy data from 645 nights and 379 patients, the presence of pain was the only disruption associated with lower objective sleep duration (minutes) [-38.1 (95% confidence interval -63.2, -12.9) p < 0.003]. CONCLUSION: Hospital staff and patients agreed that pain, vital signs and tests were top sleep disrupters. However, pain was associated with the greatest objective sleep loss, highlighting the need for proactive screening and management of patient pain to improve sleep in hospitals.

Individualized cost-effectiveness analysis of patient-centered care: a case series of hospitalized patient preferences departing from practice-based guidelines.

OBJECTIVE: To develop cases of preference-sensitive care and analyze the individualized cost-effectiveness of respecting patient preference compared to guidelines. METHODS: Four cases were analyzed comparing patient preference to guidelines: (a) high-risk cancer patient preferring to forgo colonoscopy; (b) decubitus patient preferring to forgo air-fluidized bed use; (c) anemic patient preferring to forgo transfusion; (d) end-of-life patient requesting all resuscitative measures. Decision trees were modeled to analyze cost-effectiveness of alternative treatments that respect preference compared to guidelines in USD per quality-adjusted life year (QALY) at a $100,000/QALY willingness-to-pay threshold from patient, provider and societal perspectives. RESULTS: Forgoing colonoscopy dominates colonoscopy from patient, provider, and societal perspectives. Forgoing transfusion and air-fluidized bed are cost-effective from all three perspectives. Palliative care is cost-effective from provider and societal perspectives, but not from the patient perspective. CONCLUSION: Prioritizing incorporation of patient preferences within guidelines holds good value and should be prioritized when developing new guidelines.

How should quality-of-life data be incorporated into a cost analysis of breast reconstruction? A consideration of implant versus free TRAM flap procedures.

BACKGROUND: Although studies have compared the costs of implant and transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction, none has considered how quality-of-life data would affect such an analysis. METHODS: A Markov decision analytic model was used. Medical costs associated with the two procedures were obtained from the Healthcare Cost and Utilization Project based on International Classification of Diseases, Ninth Revision (ICD-9) codes. The diagnosis-related group code associated with each ICD-9 code was referenced in Medicare's MedPAR database. A cost-to-charge ratio was calculated using hospital charges covered by Medicare and Medicare reimbursements for each diagnosis-related group code. This ratio was multiplied by the Healthcare Cost and Utilization Project database mean charge. Hypothetical utilities were used to perform a sensitivity analysis and determine the effects of quality-of-life data on costs. RESULTS: The mean lifetime cost was $14,080 for a free TRAM flap and $16,940 for an implant, a $2860 difference. Based on a sensitivity analysis, however, this cost difference decreased as age at initial procedure increased. Furthermore, a consideration of patient utility that increased the health-related quality-of-life score (based on a scale of 0 to 1) for implants even slightly relative to free TRAM flaps made the implants cost effective. The health-related quality-of-life difference needed to generate a cost per quality-adjusted life-year for breast implants below an acceptable threshold was extremely small (0.64 percent). CONCLUSIONS: To fully evaluate the cost difference between these procedures, a cost-effectiveness analysis must be performed that incorporates quality-of-life data. Such data would significantly affect assessments of the cost difference between implant and autogenous tissue reconstruction.

Efficacy of a rapamycin analog (CCI-779) and IFN-gamma in tuberous sclerosis mouse models.

Tuberous sclerosis complex (TSC) is a familial tumor disorder for which there is no effective medical therapy. Disease-causing mutations in the TSC1 or TSC2 gene lead to increased mammalian target of rapamycin (mTOR) kinase activity in the conserved mTOR signaling pathway, which regulates nutrient uptake, cell growth, and protein translation. The normal function of TSC1 and TSC2 gene products is to form a complex that reduces mTOR kinase activity. Thus, mTOR kinase inhibition may be a useful targeted therapeutic approach. Elevated interferon-gamma (IFN-gamma) expression is associated with decreased severity of kidney tumors in TSC patients and mouse models; therefore, IFN-gamma also has therapeutic potential. We studied cohorts of Tsc2+/- mice and a novel mouse model of Tsc2-null tumors in order to evaluate the efficacy of targeted therapy for TSC. We found that treatment with either an mTOR kinase inhibitor (CCI-779, a rapamycin analog) or with IFN-gamma reduced the severity of TSC-related disease without significant toxicity. These results constitute definitive preclinical data that justify proceeding with clinical trials using these agents in selected patients with TSC and related disorders.

Rac1 deletion in mouse neutrophils has selective effects on neutrophil functions.

Defects in myeloid cell function in Rac2 knockout mice underline the importance of this isoform in activation of NADPH oxidase and cell motility. However, the specific role of Rac1 in neutrophil function has been difficult to assess since deletion of Rac1 results in embryonic lethality in mice. To elucidate the specific role of Rac1 in neutrophils, we generated mice with a conditional Rac1 deficiency restricted to cells of the granulocyte/monocyte lineage. As observed in Rac2-deficient neutrophils, Rac1-deficient neutrophils demonstrated profound defects in inflammatory recruitment in vivo, migration to chemotactic stimuli, and chemoattractant-mediated actin assembly. In contrast, superoxide production is normal in Rac1-deficient neutrophils but markedly diminished in Rac2 null cells. These data demonstrate that although Rac1 and Rac2 are both required for actin-mediated functions, Rac2 is specifically required for activation of the neutrophil NADPH oxidase.