Development and evaluation of a measure to assess restorative sleep

BACKGROUND

There are validated measures assessing insomnia and disturbed sleep, but few psychometrically sound instruments to assess perceptions of the restorative or inadequate properties of sleep are available.

STUDY OBJECTIVES

To develop and evaluate a new instrument, the Restorative Sleep Questionnaire (RSQ).

DESIGN AND SETTING

Focus groups were conducted using participants with and without nonrestorative sleep complaints. Questions were designed to elicit the feelings and experiences people have about their sleep and their view of daytime consequences of sleep. Expert panels confirmed the importance of nonrestorative sleep (NRS) as a frequently encountered problem either with or without other sleep complaints. The resulting RSQ was administered in three studies: (1) a telephone interview with healthy controls and individuals with sleep problems; (2) a randomized clinical trial of patients with primary insomnia assessed by polysomnography (PSG); (3) a PSG study of subjects with NRS complaints.

MEASUREMENT AND RESULTS

Across all studies, the new measures were shown to be significantly correlated with health-related quality of life (HRQL) domains hypothesized to be related to NRS. The RSQ had good psychometric properties (α > 0.90; rtest-retest > 0.80), and factor analysis confirmed the unidimensionality of the measure. The RSQ was able to distinguish between healthy controls, patients with primary insomnia, and insomnia patients with isolated NRS complaints but without PSG defined sleep onset, duration, or maintenance problems. Normal sleepers reported sleep that was about a standard deviation more restorative than that of those with NRS on the RSQ.

CONCLUSIONS

The results of the study provide support for the reliability and validity of the RSQ as a measure of NRS in subjects with and without self-reported or PSG confirmed sleep initiation and maintenance difficulties.

CLINICALTRIALSGOV IDENTIFIERS

NCT00655369; NCT00705601.

Engaging patients and stakeholders in research proposal review: the patient-centered outcomes research institute

The inaugural round of merit review for the Patient-Centered Outcomes Research Institute (PCORI) in November 2012 included patients and other stakeholders, as well as scientists. This article examines relationships among scores of the 3 reviewer types, changes in scoring after in-person discussion, and the effect of inclusion of patient and stakeholder reviewers on the review process. In the first phase, 363 scientists scored 480 applications. In the second phase, 59 scientists, 21 patients, and 31 stakeholders provided a "prediscussion" score and a final "postdiscussion" score after an in-person meeting for applications. Bland-Altman plots were used to characterize levels of agreement among and within reviewer types before and after discussion. Before discussion, there was little agreement among average scores given by the 4 lead scientific reviewers and patient and stakeholder reviewers. After discussion, the 4 primary reviewers showed mild convergence in their scores, and the 21-member panel came to a much stronger agreement. Of the 25 awards with the best (and lowest) scores after phase 2, only 13 had ranked in the top 25 after the phase 1 review by scientists. Five percent of the 480 proposals submitted were funded. The authors conclude that patient and stakeholder reviewers brought different perspectives to the review process but that in-person discussion led to closer agreement among reviewer types. It is not yet known whether these conclusions are generalizable to future rounds of peer review. Future work would benefit from additional data collection for evaluation purposes and from long-term evaluation of the effect on the funded research.

How does non-nutritive sucking support infant feeding?

Fifty nine premature infants participated in a randomized controlled study to determine the effectiveness of non-nutritive sucking (NNS). It was predicted that NNS would not accelerate the development of full oral feeding or early language skills as sometimes perceived in practice. However, it was predicted that using NNS as a strategy to support parents to identify and respond to early communication and oral readiness signs would increase confidence in infant management and enable quicker discharge home. Infants were aged 26-35 weeks gestation. Infants with no significant difficulties were randomly assigned to one of three groups; Group 1, NNS pre-tube feeding (n=19); Group 2, NNS on onset of tube feeding (n=20) and Group 3, Control (n=20). Follow-up occurred at 6 months. There were no significant differences with number of days to full oral feeding between the groups receiving NNS and the Control group, χ2(2, n=59)=4.33, p=.115. A significant difference in number of days in hospital between the Control group and the other two groups was found χ2 (2, n=59)=7.678, p=.022. Significant changes were noted with the development of more normal sucking patterns in Groups 1-3. At 6 months there were no significant differences in receptive or expressive language skills between all groups. NNS had no significant impact on the transition to full oral feeding or later language development. There was a significant difference in the number of days in hospital between the Control group and the other two groups which involved parents in identification of early communication signs. Possible reasons for this change and future directions are discussed.

Very low energy electron microscopy of graphene flakes

Commercially available graphene samples are examined by Raman spectroscopy and very low energy scanning transmission electron microscopy. Limited lateral resolution of Raman spectroscopy may produce a Raman spectrum corresponding to a single graphene layer even for flakes that can be identified by very low energy electron microscopy as an aggregate of smaller flakes of various thicknesses. In addition to diagnostics of graphene samples at larger dimensions, their electron transmittance can also be measured at very low energies.

Improving dementia care: the role of screening and detection of cognitive impairment

The value of screening for cognitive impairment, including dementia and Alzheimer's disease, has been debated for decades. Recent research on causes of and treatments for cognitive impairment has converged to challenge previous thinking about screening for cognitive impairment. Consequently, changes have occurred in health care policies and priorities, including the establishment of the annual wellness visit, which requires detection of any cognitive impairment for Medicare enrollees. In response to these changes, the Alzheimer's Foundation of America and the Alzheimer's Drug Discovery Foundation convened a workgroup to review evidence for screening implementation and to evaluate the implications of routine dementia detection for health care redesign. The primary domains reviewed were consideration of the benefits, harms, and impact of cognitive screening on health care quality. In conference, the workgroup developed 10 recommendations for realizing the national policy goals of early detection as the first step in improving clinical care and ensuring proactive, patient-centered management of dementia.

The validity and reliability of iridology in the diagnosis of previous acute appendicitis as evi-denced by appendectomy

Iridology is defined as a photographic science that identifies pathological and functional changes within organs via biomicroscopic iris assessment for aberrant lines, spots, and discolourations. According to iridology, the iris does not reflect changes  during  anaesthesia,  due  to  the  drugs inhibitory  effects  on  nerves  impulses,  and  in cases of organ removal, it reflects the pre-surgical condition.The profession of Homoeopathy is frequently associated with iridology and in a recent survey (2009)  investigating  the  perceptions  of  Masters of  Technology  graduates  in  Homoeopathy  of University of Johannesburg, iridology was highly regarded as a potential additional skill requirement for assessing the health status of the patient.This  study  investigated  the  reliability  of iridology  in  the  diagnosis  of  previous  acute appendicitis, as evidenced by appendectomy. A total of 60 participants took part in the study. Thirty of the 60 participants had an appendectomy due to acute appendicitis, and 30 had had no prior history  of  appendicitis.  Each  participant’s  right iris  was  documented  by  photography  with  the use  of  a  non-mydriatic  retinal  camera  that  was reset for photographing the iris. The photographs were then randomized by an external person and no identifying data made available to the three raters.  The  raters  included  the  researcher,  who had little experience in iridology and two highly experienced  practising  iridologists.  Data  was obtained  from  the  analyses  of  the  photographs wherein  the  presence  or  absence  of  lesions (implying acute appendicitis) was indicated by the raters. None of the three raters was able to show a significant  success  rate  in  identifying  correctly the  people  with  a  previous  history  of  acute appendicitis and resultant appendectomies from those  who  had  no  previous  history  of  acute appendicitis.  Therefore the outcome of this study indicated an outcome that was subject to chance.The  null  hypothesis  that  states  that appendectomy due to acute appendicitis does not manifest in corresponding lesions in the iris, is supported. It is in the opinion of the researchers that the  association  of  iridology  with  homoeopathic practice may harm the credibility of the profession and that further research on iridology is needed to disprove this conviction. (S Afr Optom 2013 72(3) 127-132)

A topological paradigm for hippocampal spatial map formation using persistent homology

An animal's ability to navigate through space rests on its ability to create a mental map of its environment. The hippocampus is the brain region centrally responsible for such maps, and it has been assumed to encode geometric information (distances, angles). Given, however, that hippocampal output consists of patterns of spiking across many neurons, and downstream regions must be able to translate those patterns into accurate information about an animal's spatial environment, we hypothesized that 1) the temporal pattern of neuronal firing, particularly co-firing, is key to decoding spatial information, and 2) since co-firing implies spatial overlap of place fields, a map encoded by co-firing will be based on connectivity and adjacency, i.e., it will be a topological map. Here we test this topological hypothesis with a simple model of hippocampal activity, varying three parameters (firing rate, place field size, and number of neurons) in computer simulations of rat trajectories in three topologically and geometrically distinct test environments. Using a computational algorithm based on recently developed tools from Persistent Homology theory in the field of algebraic topology, we find that the patterns of neuronal co-firing can, in fact, convey topological information about the environment in a biologically realistic length of time. Furthermore, our simulations reveal a "learning region" that highlights the interplay between the parameters in combining to produce hippocampal states that are more or less adept at map formation. For example, within the learning region a lower number of neurons firing can be compensated by adjustments in firing rate or place field size, but beyond a certain point map formation begins to fail. We propose that this learning region provides a coherent theoretical lens through which to view conditions that impair spatial learning by altering place cell firing rates or spatial specificity.

A qualitative assessment of the concept of dependence in Alzheimer's disease

BACKGROUND

The Dependence Scale (DS) was designed to assess levels of patient need for care due to deficits typical of Alzheimer's disease (AD). This study examined content validity of the DS based on input from patients, caregivers, and clinicians.

METHODS

Qualitative interviews with experts, patients, and caregivers were used to collect information on the concept of dependence and to assess content validity.

RESULTS

Nine clinicians rated item relevance ''high'' with consensus on the primacy of functional abilities and dependence in the measurement of AD progression. Twenty-two US, 11 UK, and 14 informal caregivers from Spain participated in focus groups; 18 patients participated in 3 separate focus groups. Discussion supported DS hierarchy of dependence, capture of mild-to-severe dependence, suitability of response options, and short recall time frame.

CONCLUSIONS

Clinicians, caregivers, and patients support content validity of the DS in mild-to-moderate AD. The DS may be valuable to capture dependence within future clinical dementia trials.

The Congestion Quantifier Five-Item Test for Nasal Congestion: Refinement of the Congestion Quantifier Seven-Item Test

Background

Patients report that nasal congestion is the most bothersome symptom of allergic rhinitis (AR). Recently, a short, patient-reported congestion screener questionnaire, the Congestion Quantifier Seven-Item Test (CQ7), was developed to identify a level of congestion that may warrant patients seeking evaluation and possible treatment. We explored further item reduction of the CQ7 and examined the psychometric properties of this reduced set of items in a 15-day study of patients with confirmed AR or self-identified and clinician-confirmed congestion.

Methods

The CQ7 was subjected to item reduction methods and the psychometric properties of the reduced set of items were assessed.

Results

Two items were dropped—sinus pressure/pain and impact on work/school—because of lower item-rest correlations. The resulting Congestion Quantifier Five-Item screener (CQ5) performed comparably with the CQ7. Internal consistency reliability of both instruments were identical (alpha = 0.93); test–retest reliability from baseline to day 15 was similar (CQ7, alpha = 0.85; CQ5, alpha = 0.79). Both instruments were comparable in discriminating patients and controls (CQ7, area under the curve [AUC] = 0.97; CQ5, AUC = 0.96). A CQ5 score of 6 provided optimum balance of sensitivity (89.4%), specificity (88.6%), and correct classification (89%) for detecting congestion.

Conclusions

The CQ5, a patient-reported outcome screener, is slightly shorter but equally reliable, valid, and responsive as the CQ7 for evaluating differences in levels of severity of nasal congestion. It may have wider applicability than the CQ7 because of exclusion of the work/school impact item.

Should older adults be screened for dementia? It is important to screen for evidence of dementia!

Multiple arguments for considering routine dementia screening have been presented. Furthermore, dementia diagnoses are widely unrecognized. As a result, persons with dementia are missing important clinical care and treatment interventions. By distinction, the problems of defining, diagnosing, and treating mild cognitive impairment (MCI) are not yet resolved, and MCI is not ready for a screening recommendation. Dementia screening approaches, including cognitive testing and functional assessment, must be evaluated on their scientific merits, including sensitivity and specificity for recognizing affected individuals in at-risk populations. Screening tests must be "cost-worthy", with the benefits of true-positive test results justifying the costs of testing and resolving false-positive cases, with due consideration for proper diagnostic evaluation and potential harms. With the tremendous number of new cases projected in the near future and the expected emergence of beneficial therapies, considerably more research is needed to develop more efficient screening systems.

Should older adults be screened for dementia?

The question of whether to screen for dementia and Alzheimer's disease (AD) has been discussed in many forums throughout the world. Generally, medical advisory groups and policy-making groups have recognized the importance of early diagnosis but have uniformly avoided making recommendations to screen at-risk populations. This presentation reflects the support for reconsidering the importance of screening individuals at risk or above a certain age. In this statement, the majority of the authors support the consideration of dementia risk factors in individuals at age 50, with routine yearly screening after 75. Other authors remain concerned that the benefits of treatments of early disease do not yet support a general screening recommendation. These statements are made to encourage progress toward the development of a consensus regarding the widespread institution of screening policy. Accordingly, members of the worldwide scientific community are invited to add their perspective by contributing short commentaries (1500 words) on this subject.

Quality of life and disability in patients with treatment-failure gout

OBJECTIVE

The relationship between self-reported quality of life and disability and disease severity was evaluated in subjects with treatment-failure gout (n = 110) in a prospective, 52-week, observational study.

METHODS

Subjects had symptomatic crystal-proven gout of at least 2 years' duration and intolerance or refractoriness to conventional urate-lowering therapy. Serum uric acid (sUA) concentration, swollen and tender joint counts, frequency and severity of gout flares, tophus assessments, comorbidities, and patient-reported outcomes data [Medical Outcomes Study Short Form-36 (SF-36), Health Assessment Questionnaire-Damage Index] were collected. Analyses included correlations of patient-reported outcomes with clinical variables and changes in clinical status.

RESULTS

Mean age of study subjects was 59 years. Mean scores on SF-36 physical functioning subscales were 34.2-46.8, analogous to persons aged >or= 75 years in the general population. Subjects with more severe gout at baseline had worse health-related quality of life (HRQOL) in all areas (p < 0.02 for all measures), compared to patients with mild-moderate disease. Number of flares reported in past year, number of tender joints, swollen joints, and tophi correlated significantly with some or all HRQOL and disability measures. sUA was not significantly correlated with any HRQOL or disability measure. Subjects with comorbidities experienced worse physical, but not mental, functioning.

CONCLUSION

Severe gout is associated with poor HRQOL and disability, especially for patients who experience more gout flares and have a greater number of involved joints. Subject perceptions of gout-related functioning and pain severity appear to be highly sensitive indicators of HRQOL and disability.