Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

Thymosin increases production of T-cell growth factor by normal human peripheral blood lymphocytes

The in vitro incubation of phytohemagglutinin-stimulated peripheral blood lymphocytes with thymosin results in a marked and reproducible increase in production of T-cell growth factor, which is dose dependent and most pronounced in the first 24 hr of culture. Incubation of lymphocytes with thymosin alone failed to induce any production of T-cell growth factor. The biological activity of thymosin fraction 5 cannot be attributed to the activity of thymosin alpha 1, one of the well-characterized peptide components of fraction 5. These data provide the basis for (i) a potential mechanism for the in vivo immunorestorative effects of thymosin in primary and secondary immunodeficiencies and (ii) identification of an additional, but as yet undefined, immunoregulatory component of thymosin fraction 5.

Determination of vesicle size distributions by freeze-fracture electron microscopy

The most common electron microscopic technique for obtaining information on size distributions of uncollapsed membrane vesicles is based on the method of van Venetie (1980). This technique involves the sizing of only those vesicles that were freeze fractured at their equatorial planes. As a result, only a small number of images can be used to generate size distributions. Further, the technique is susceptible to systematic error. An alternate approach is to consider the complete distribution of image sizes and use this distribution to determine the average size and distribution of the vesicles. It is shown that the mean vesicle size is 4/pi times the mean image size. As well, a parameter, m, which can be determined from the image distribution, can be used to characterize the vesicle distribution. The advantage of this new approach is that images of all vesicles are used, leading to a statistically better determination of vesicle sizes.

Diastolic hypotension in pediatric patients with asthma receiving continuous albuterol

OBJECTIVES

Concerns have been raised regarding cardiac side effects of continuous high-dose albuterol nebulization in status asthmaticus management. Our study goal was to determine prevalence and potential risk factors for hypotension development during continuous albuterol administration in pediatric patients.

METHODS

A retrospective cohort study was conducted at Children's Memorial Hermann Hospital from 1 January 2011 to 31 August 2012. A total of 152 patients admitted to pediatric intensive or intermediate care units who received continuous albuterol nebulization for management of status asthmaticus were analyzed.

RESULTS

Diastolic hypotension, defined as a value < 50 mmHg or <5th percentile of normal for age, developed in 90% of patients and a positive correlation with increasing doses of albuterol was demonstrated. The overall median time to onset of hypotension was 4 h (interquartile range (IQR): 2-6.5) and was significantly lower among patients admitted to the intensive care unit rather than intermediate care (p = 0.005). The odds of hypotension were 82% lower among patients who received fluid boluses prior to continuous albuterol nebulization. None of the potential risk factors demonstrated statistical significance.

CONCLUSIONS

Diastolic hypotension is a common occurrence among patients who receive continuous albuterol nebulization for status asthmaticus. Total albuterol dose appeared to be directly related to risk of developing diastolic hypotension. Administration of supplemental fluid boluses before continuous nebulized albuterol appeared to provide a significant protective effect. The clinical impact and the significance of diastolic hypotension and the importance of prophylactic administration of intravenous fluid boluses in patients experiencing status asthmaticus are yet to be determined.

The Effect of Comprehensive Medical Care on the Long-Term Outcomes of Children Discharged from the NICU with Tracheostomy

Background:

Survival of infants with complex care has led to a growing population of technology-dependent children. Medical technology introduces additional complexity to patient care. Outcomes after NICU discharge comparing Usual Care (UC) with Comprehensive Care (CC) remain elusive.

Objective:

To compare the outcomes of technology-dependent infants discharged from NICU with tracheostomy following UC versus CC.

Methods:

A single site retrospective study evaluated forty-three (N=43) technology-dependent infants discharged from NICU with tracheostomy over 5½ years (2011-2017). CC provided 24-hour accessible healthcare-providers using an enhanced medical home. Mortality, total hospital admissions, 30-days readmission rate, time-to-mechanical ventilation liberation, and time-to-decannulation were compared between groups.

Results:

CC group showed significantly lower mortality (3.4%) versus UC (35.7%), RR, 0.09 [95%CI, 0.12-0.75], P=0.025. CC reduced total hospital admissions to 78 per 100 child-years versus 162 for UC; RR, 0.48 [95% CI, 0.25-0.93], P=0.03. The 30-day readmission rate was 21% compared to 36% in UC; RR, 0.58 [95% CI, 0.21-1.58], P=0.29). In competing-risk regression analysis (treating death as a competing-risk), hazard of having mechanical ventilation removal in CC was two times higher than UC; SHR, 2.19 [95% CI, 0.70-6.84]. There was no difference in time-to-decannulation between groups; SHR, 1.09 [95% CI, 0.37-3.15].

Conclusion:

CC significantly decreased mortality, total number of hospital admissions and length of time-to-mechanical ventilation liberation.

Anti-inflammatory effect of prophylactic macrolides on children with chronic lung disease: a protocol for a double-blinded randomised controlled trial

INTRODUCTION

Recent studies suggest that the high mortality rate of respiratory viral infections is a result of an overactive neutrophilic inflammatory response. Macrolides have anti-inflammatory properties, including the ability to downregulate the inflammatory cascade, attenuate excessive cytokine production in viral infections, and may reduce virus-related exacerbations. In this study, we will test the hypothesis that prophylactic macrolides will reduce the severity of respiratory viral illness in children with chronic lung disease by preventing the full activation of the inflammatory cascade.

METHODS AND ANALYSIS

A randomised double-blind placebo-controlled trial that will enrol 92 children to receive either azithromycin or placebo for a period of 3-6 months during two respiratory syncytial virus (RSV) seasons (2015-2016 and 2016-2017). We expect a reduction of at least 20% in the total number of days of unscheduled face-to-face encounters in the treatment group as compared with placebo group. Standard frequentist and Bayesian analyses will be performed using an intent-to-treat approach.

DISCUSSION

We predict that the prophylactic use of azithromycin will reduce the morbidity associated with respiratory viral infections during the winter season in patients with chronic lung disease as evidenced by a reduction in the total number of days with unscheduled face-to-face provider encounters.

ETHICS AND DISSEMINATION

This research study was approved by the Institutional Review Board of the University of Texas Health Science Center in Houston on 9 October 2014. On completion, the results will be published.

TRIAL REGISTRATION NUMBER

NCT02544984.

The Case for the Use of Nurse Practitioners in the Care of Children with Medical Complexity

Although children with medically complex illness represent less than one percent of the total pediatric population, their health care expenditures and health care system utilization far exceed the numbers of other pediatric patients. Nurse practitioners, with their educational background focused on health care promotion and education, are uniquely qualified to reduce this inequity with cost effective care. Currently, nurse practitioners are used in a variety of health care settings and can provide acute and chronic care. Incorporating nurse practitioners at each step in the care of children with medical complexity can improve the quality of life for these children and their families, increase family satisfaction and decrease costs.