Feasibility and parental perception of home sleep studies during COVID-19: a tertiary sleep centre experience

OBJECTIVE

Rapid implementation of home sleep studies during the first UK COVID-19 'lockdown'-completion rates, family feedback and factors that predict success.

DESIGN

We included all patients who had a sleep study conducted at home instead of as inpatient from 30 March 2020 to 30 June 2020. Studies with less than 4 hours of data for analysis were defined 'unsuccessful'.

RESULTS

137 patients were included. 96 underwent home respiratory polygraphy (HRP), median age 5.5 years. 41 had oxycapnography (O₂/CO₂), median age 5 years. 56% HRP and 83% O₂/CO₂ were successful. A diagnosis of autism predicted a lower success rate (29%) as did age under 5 years.

CONCLUSION

Switching studies rapidly from an inpatient to a home environment is possible, but there are several challenges that include a higher failure rate in younger children and those with neurodevelopmental disorders.

Time to get to sleep

Struggling to fall or to stay asleep? It's a common problem and can be particularly challenging when working irregular and antisocial hours. Michael Farquhar offers some advice on how to increase your chances of getting the rest you need.

Obstructive Sleep Apnoea Contributes to Executive Function Impairment in Young Children with Down Syndrome

OBJECTIVE/BACKGROUND

Children with Down syndrome (DS) commonly experience difficulties with executive function (EF). They are also vulnerable to obstructive sleep apnoea (OSA). OSA is associated with EF deficits in typically developing children. A recent study reported an association between OSA and cognitive deficits in 38 school-aged children with DS. We experimentally investigated EF behaviours in young children with DS, and their association with OSA.

PARTICIPANTS AND METHODS

Children with DS were recruited to take part in a larger study of OSA (N = 202). Parents of 80 children (50 male) aged 36 to 71 months (M = 56.90, SD = 10.19 months) completed the Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P). Of these 80 children, 69 were also successfully studied overnight with domiciliary cardiorespiratory polygraphy to diagnose OSA.

RESULTS

Obstructive apnoea/hypopnoea index was in the normal range (0-1.49/h) for 28 children but indicated OSA (≥1.5/h) in 41 children. Consistent with previous research, we found a large effect for children experiencing particular weaknesses in working memory, planning and organising, whilst emotional control was a relative strength. OSA was associated with poorer working memory (β = .23, R2 = .05, p = .025), emotional control (β = .20, R2 = .04, p = .047) and shifting (β = .24, R2 = .06, p = .023).

CONCLUSIONS

Findings suggest that known EF difficulties in DS are already evident at this young age. Children with DS already have limited cognitive reserve and can ill afford additional EF deficit associated with OSA. OSA is amenable to treatment and should be actively treated in these children to promote optimal cognitive development.

Obstructive Sleep Apnoea Contributes to Executive Function Impairment in Young Children with Down Syndrome

OBJECTIVE/BACKGROUND

Children with Down syndrome (DS) commonly experience difficulties with executive function (EF). They are also vulnerable to obstructive sleep apnoea (OSA). OSA is associated with EF deficits in typically developing children. A recent study reported an association between OSA and cognitive deficits in 38 school-aged children with DS. We experimentally investigated EF behaviours in young children with DS, and their association with OSA.

PARTICIPANTS AND METHODS

Children with DS were recruited to take part in a larger study of OSA (N = 202). Parents of 80 children (50 male) aged 36 to 71 months (M = 56.90, SD = 10.19 months) completed the Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P). Of these 80 children, 69 were also successfully studied overnight with domiciliary cardiorespiratory polygraphy to diagnose OSA.

RESULTS

Obstructive apnoea/hypopnoea index was in the normal range (0-1.49/h) for 28 children but indicated OSA (≥1.5/h) in 41 children. Consistent with previous research, we found a large effect for children experiencing particular weaknesses in working memory, planning and organising, whilst emotional control was a relative strength. OSA was associated with poorer working memory (β = .23, R2 = .05, p = .025), emotional control (β = .20, R2 = .04, p = .047) and shifting (β = .24, R2 = .06, p = .023).

CONCLUSIONS

Findings suggest that known EF difficulties in DS are already evident at this young age. Children with DS already have limited cognitive reserve and can ill afford additional EF deficit associated with OSA. OSA is amenable to treatment and should be actively treated in these children to promote optimal cognitive development.

Fifteen-minute consultation: Managing sleep problems in children and young people with ADHD

Sleep difficulties are common in children and young people presenting with features of attention-deficit/hyperactivity disorder (ADHD). Sleep problems may be both an effect of and a contributor to ADHD symptomatology, as well as having a significant impact on both individual and family functioning and well-being. There are often complex interacting contributing factors. Assessment of children presenting with symptoms suggestive of possible ADHD should include routine enquiry about sleep. Ongoing management of children with diagnosed ADHD should include regular reassessment and review of sleep. When sleep difficulties are present, we discuss how to further assess these, including the role of investigations, and a structured management strategy.

Medical and gynecological comorbidities in adult women with Turner syndrome: our multidisciplinary clinic experience

Objective: Women with Turner syndrome (TS) are at increased risk for chronic health conditions. Reports describing the presence of comorbidities in older adult women with TS are limited. This study aimed to examine the prevalence of endocrine, gynecological, and other chronic medical conditions in a cohort of adult TS patients.Methods: A retrospective chart review was conducted on patients seen between 1 February 2015 and 1 July 2018 in a multidisciplinary TS clinic at a university-based ambulatory hospital in Toronto, Canada. All women seen at the TS clinic with a diagnosis of TS aged >18 years were included. The prevalence of diseases was determined overall and stratified by age (<40 and ≥40 years). Statistical comparisons were done using the chi-square test. The main study outcomes included the presence of comorbidities.Results: Of 122 adult women with TS, 24.5% had hypothyroidism, 16% had dysglycemia, and 27.9% had decreased bone mass. Hypothyroidism and dysglycemia were more common among older women (respectively age ≥40 years vs. age <40 years: 36.7% vs. 17.8%, p = 0.018; and 24.5% vs. 5.5%, p = 0.023). Gynecological conditions were identified in 35% of patients and were more common among older women (42.8% age ≥40 years vs. 13.7% age <40 years, p = 0.003). Overall, 41% had hearing impairment, 36.1% had cardiac abnormalities, 14.8% had hypertension, 18.8% had renal abnormalities, and 9% had celiac disease.Conclusions: The results of this study indicate a high prevalence of medical conditions in women with TS, especially those ≥40 years of age. Our study underscores the importance of multidisciplinary adult TS clinics for ongoing screening and management of comorbidities.

Cardiorespiratory sleep studies at home: experience in research and clinical cohorts

OBJECTIVE

To evaluate the success rates of home cardiorespiratory polygraphy in children under investigation for sleep-disordered breathing and parent perspectives on equipment use at home.

DESIGN

Prospective observational study.

SETTING

Sheffield, Evelina London and Southampton Children's Hospitals.

PATIENTS

Data are reported for 194 research participants with Down syndrome, aged 0.5-5.9 years across the three centres and 61 clinical patients aged 0.4-19.5 years from one centre, all of whom had home cardiorespiratory polygraphy including respiratory movements, nasal pressure flow, pulse oximetry, body position and motion.

MAIN OUTCOME MEASURES

Percentage of home cardiorespiratory studies successfully acquiring ≥4 hours of artefact-free data at the first attempt. Parental report of ease of use of equipment and preparedness to repeat home diagnostics in the future.

RESULTS

143/194 (74%; 95% CI 67% to 79%) of research participants and 50/61 (82%; 95% CI 71% to 90%) of clinical patients had successful home cardiorespiratory polygraphy at the first attempt. Some children required multiple attempts to achieve a successful study. Overall, this equated to 1.3 studies per research participant and 1.2 studies per clinical child. The median artefact-free sleep time for successful research studies was 515 min (range 261-673) and for clinical studies 442 min (range 291-583). 84% of research and 87% of clinical parents expressed willingness to repeat home cardiorespiratory polygraphy in the future. 67% of research parents found the equipment 'easy or okay' to use, while 64% of clinical parents reported it as 'easy' or 'very easy'.

CONCLUSIONS

Home cardiorespiratory polygraphy offers an acceptable approach to the assessment of sleep-disordered breathing in children.

Home oximetry to screen for obstructive sleep apnoea in Down syndrome

OBJECTIVE

Children with Down syndrome are at high risk of obstructive sleep apnoea (OSA) and screening is recommended. Diagnosis of OSA should be confirmed with multichannel sleep studies. We aimed to determine whether home pulse oximetry (HPO) discriminates children at high risk of OSA, who need further diagnostic multichannel sleep studies.

DESIGN

Cross-sectional prospective study in a training sample recruited through three UK centres. Validation sample used single-centre retrospective analysis of clinical data.

PATIENTS

Children with Down syndrome aged 0.5-6 years.

INTERVENTION

Diagnostic multichannel sleep study and HPO.

MAIN OUTCOME MEASURES

Sensitivity and specificity of HPO to predict moderate-to-severe OSA.

RESULTS

161/202 children with Down syndrome met quality criteria for inclusion and 25 had OSA. In this training sample, the best HPO parameter predictors of OSA were the delta 12 s index >0.555 (sensitivity 92%, specificity 65%) and 3% oxyhaemoglobin (SpO₂) desaturation index (3% ODI)>6.15 dips/hour (sensitivity 92%, specificity 63%). Combining variables (delta 12 s index, 3% ODI, mean and minimum SpO₂) achieved sensitivity of 96% but reduced specificity to 52%. All predictors retained or improved sensitivity in a clinical validation sample of 50 children with variable loss of specificity, best overall was the delta 12 s index, a measure of baseline SpO₂ variability (sensitivity 92%; specificity 63%).

CONCLUSIONS

HPO screening could halve the number of children with Down syndrome needing multichannel sleep studies and reduce the burden on children, families and health services alike. This approach offers a practical universal screening approach for OSA in Down syndrome that is accessible to the non-specialist paediatrician.

Fifteen-minute consultation: problems in the healthy paediatrician-managing the effects of shift work on your health

"You're not healthy unless your sleep is healthy"Professor William Dement, Stanford University, one of the founders of modern sleep medicineSleep is fundamental to good health. Healthcare professionals receive little teaching on the importance of sleep, particularly with respect to their own health when working night shifts. Knowledge of basic sleep physiology, together with simple strategies to improve core sleep and the ability to cope with working nights, can result in significant improvements both for healthcare professionals and for the patients they care for.

Narcolepsy Following Yellow Fever Vaccination: A Case Report

Narcolepsy with cataplexy is a rare, but important differential diagnosis for daytime sleepiness and atonic paroxysms in an adolescent. A recent increase in incidence in the pediatric age group probably linked to the use of the Pandemrix influenza vaccine in 2009, has increased awareness that different environmental factors can “trigger” narcolepsy with cataplexy in a genetically susceptible population. Here, we describe the case of a 13-year-old boy with narcolepsy following yellow fever vaccination. He carries the HLA DQB1*0602 haplotype strongly associated with narcolepsy and cataplexy. Polysomnography showed rapid sleep onset with rapid eye movement (REM) latency of 47 min, significant sleep fragmentation and a mean sleep latency of 1.6 min with sleep onset REM in four out of four nap periods. Together with the clinical history, these findings are diagnostic of narcolepsy type 1. The envelope protein E of the yellow fever vaccine strain 17D has significant amino acid sequence overlap with both hypocretin and the hypocretin receptor 2 receptors in protein regions that are predicted to act as epitopes for antibody production. These findings raise the question whether the yellow fever vaccine strain may, through a potential molecular mimicry mechanism, be another infectious trigger for this neuro-immunological disorder.

Fifteen-minute consultation on problems in the healthy child: sleep

Sleep-related issues are common reasons children present to health professionals. Many factors can adversely affect sleep quality, and there are many associations of inadequate sleep, including behavioural problems, obesity and accidental injury. We review the current evidence, and suggest practical management strategies to promote better sleep, and hopefully, better functioning for child and family alike.

Pulmonary hypertension in chronic neonatal lung disease

Pulmonary hypertension is an uncommon but significantly challenging complication of chronic neonatal lung disease [CNLD] as it occurs in the "new bronchopulmonary dysplasia [BPD]". The presence of pulmonary hypertension may be sub-clinical and is often overlooked as it is not considered in all but the more severe cases of children with CNLD. Whilst the mainstays of therapy are supplemental oxygen and time and the majority of children will have resolution of their pulmonary hypertension with lung growth, the advent of newer pharmacological treatments has offered stability and perhaps a better prognosis for more severe cases of pulmonary hypertension.

Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup

Breathlessness is common in advanced disease and can have a devastating impact on patients and carers. Research on the management of breathlessness is challenging. There are relatively few studies, and many studies are limited by inadequate power or design. This paper represents a consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. The aims of this paper are to facilitate the design of adequately powered multi-centre interventional studies in breathlessness, to suggest a standardised, rational approach to breathlessness research and to aid future 'between study' comparisons. Discussion of the physiology of breathlessness is included.

Measurement of breathlessness in advanced disease: A systematic review

BACKGROUND

There is a plethora of assessment tools available to measure breathlessness, the most common and disabling symptom of advanced cardio-respiratory disease. The aim of this systematic review was to identify all measures available via standard search techniques and review their usefulness for patients with advanced disease.

METHODS

A systematic literature search was performed in Medline. All studies focusing on the development or evaluation of tools for measuring breathlessness in chronic respiratory disease, cardiac disease, cancer, or MND were identified. Their characteristics with regard to validity, reliability, appropriateness and responsiveness to change were described. The tools were then examined for their usefulness in measuring significant aspects of breathlessness in advanced disease.

RESULTS

Thirty-five tools were initially identified, two were excluded. Twenty-nine were multidimensional of which 11 were breathlessness-specific and 18 disease-specific. Four tools were unidimensional, measuring the severity of breathlessness. The majority of disease-specific scales were validated for chronic obstructive pulmonary disease (COPD), few were applicable in other conditions. No one tool assessed all the dimensions of this complex symptom, which affects the psychology and social functioning of the affected individual and their family--most focused on physical activity.

CONCLUSION

As yet there is no one scale that can accurately reflect the far-reaching effects of breathlessness on the patient with advanced disease and their family. Therefore, at present, we would recommend combining a unidimensional scale (e.g. VAS) with a disease-specific scale (where available) or a multidimensional scale in conjunction with other methods (such as qualitative techniques) to gauge psychosocial and carer distress for the assessment of breathlessness in advanced disease.

Defining patients as palliative: hospital doctors' versus general practitioners' perceptions

There appears to be a lack of consensus on the classification of individual patients as 'for palliative care', although the extent of this is unknown. General practitioners (GPs) of 213 patients with a palliative diagnosis of lung or colo-rectal cancer were sent a one-page questionnaire to assess information sent by hospital doctors, and to establish the GPs' perception of patients' palliative status. A total of 185 questionnaires were returned (87% response rate). Of those GPs receiving information from the hospital, one in four rated the adequacy as less than positive; 26% reportedly received no information or received it 'too late'. In 20% of cases, GPs did not perceive patients as palliative, although hospital records suggested that they were, and death certificates received later potentially confirmed this. There was, however, no significant difference between GPs allocating a patient to palliative status or not, in terms of the promptness or adequacy of information received from the hospital, as rated by the GP. There was a significant difference in survival between patients whom GPs perceived as for palliative care and those they did not ('palliative' patients died, on average, 117 days earlier). Possible explanations of the differing perceptions of patients' palliative status are discussed. The findings have implications for patient care in the community, patients' informed choices, and palliative care research.

General practitioners' views of working with team midwifery

This report presents the results of a survey of general practitioners (GPs) working alongside a midwifery team in south-east England. Sixty-nine per cent of the GPs thought team midwifery was a good idea in theory. However, just 37% thought it was working well locally and 56% reported that they would like to go back to working in the way they did before. Of greatest concern was the decline in interprofessional communications and the loss of continuity for patients. Therefore, team midwifery, as implemented in this locality, may not attain the goals aimed at by the organisation of care in this way.

Continuity of care in maternity services: women's views of one team midwifery scheme

OBJECTIVE

To describe the views of women using one team midwifery scheme and compare them with women using more traditional models of midwifery care.

DESIGN

Postal and interview survey of 1482 consecutive women delivering over a six-month period.

SETTING

Hospital and community in the South-East of England.

SAMPLES

Three groups of women were surveyed: (1) the Study Group consisted of women who delivered either at Hospital A or at home, and who received their antenatal, intrapartum and postnatal care from one of seven midwifery teams; (2) Comparison Group A consisted of women who received their antenatal and postnatal care from traditionally organised community midwives who were delivered by hospital midwives at Hospital A; and (3) Comparison Group B consisted of women who received their antenatal and postnatal care from traditionally organised community midwives who were delivered by hospital midwives at Hospital B.

METHODS

Postal questionnaires and interviews, and an audit of midwife contacts.

MAIN OUTCOME MEASURES

Process of care and satisfaction with care.

FINDINGS

88% of women responded. Women cared for under the team scheme exhibited no overall advantages in terms of satisfaction with various aspects of their care. Women cared for under the traditional model of care were the most satisfied with antenatal care. They had reported the highest percentage of named midwives, the highest continuity of carer antenatally and were the most likely to say that they had formed a relationship with their midwives. The majority of women who had met their delivering midwives previously did report that it made them feel more at ease, however, the majority of those who had not met their delivering midwives previously reported that it did not affect them one way or the other.

CONCLUSION

In the team scheme, attempts to increase continuity of carer throughout pregnancy, labour and the postnatal period appear to have occurred at the expense of continuity in the ante- and postnatal periods. From the women's perspective the findings of this study support the view that the smaller the size of midwifery teams the better. The current focus on continuity throughout pregnancy and childbirth and the postnatal period may be misguided, if it is provided at the expense of continuity of carer in pregnancy and the postnatal period.

Working with team midwifery: health visitors' views of one team midwifery scheme

The fragmented nature of maternity services in the UK has led to the introduction of various forms of team midwifery scheme. The aim of such schemes is usually to increase continuity through the provision of antenatal, intrapartum and postnatal care to women by a small team of midwives. Few published studies of this organization of midwifery care exist, and even fewer consider the impact of such schemes on related health professionals. This paper presents the results of an independent survey of health visitors working alongside one team midwifery scheme in the south-east of England. Eighty per cent of the health visitors thought that team midwifery was a good idea in theory; however, just 27% thought it was working well locally and 70% reported that they would like to go back to working in the way they did before the introduction of team midwifery. The survey highlighted the health visitors' concerns in relation to team midwifery locally. Two issues were paramount: firstly a reported deterioration in interdisciplinary communications, and secondly a perceived loss of continuity for the women. Thus team midwifery, as implemented in this locality, may not attain the goals aimed at by the organization of care in this way.

Elderly people's definitions of quality of life

The subject of this paper is the definition and measurement of the concept of quality of life, and questions the operationalization of quality of life simply in terms of health status measures and scales of functional ability. It is based on a review of the literature, and the initial analyses of the first stage of a study designed to identify individual's views of the quality of their lives and to test the relevance of various scales used to measure quality of life. The study focuses on older people living at home in two contrasting areas of south east England, and demonstrates not only that older people can talk about, and do think about, quality of life, but also highlights how quality of life varies for different age groups of the elderly population living at home, in different geographical areas. In addition, early conclusions also indicate that there is more to quality of life than health; indeed, social contacts appear to be as valued components of a good quality of life as health status. This study deals with issues high on the agenda of the current debate on quality of life and its measurement; it has implications for those involved in both quality of life research and in health and social service policy for older people.

Definitions of quality of life: a taxonomy

Quality of life is of central concern in evaluative research; improved quality of life is probably the most desirable outcome of all health care policies. However, definitions of quality of life are as numerous and inconsistent as the methods of assessing it. Stemming from a larger piece of work looking at the definition and measurement of quality of life, this paper highlights the lack of a consensus definition of quality of life by means of a taxonomy of definitions that emerge from the literature. The paper describes and gives examples of four main types of definition which make up the taxonomy: global (type I); component (type II); focused (type III); and combination definitions (type IV). In addition, an outline of factors influencing the definition of quality of life is given, and an alternative strategy for both defining and measuring the concept (the use of lay definitions) is suggested.

Elderly housebound: changes over time

This article, which completes the research discussed in recent articles in Nursing Standard (1, 2), describes the changes in the ability of very elderly frail people to go outdoors. The sample members were first interviewed in 1987 when they were aged 85 or over, and followed up in 1990. Cross-sectional analyses showed that the groups who could not get outside alone or at all in either 1987 or 1990 were more likely to be taking prescribed medication, had poorer functional ability, reported problems with eyesight and aches/pains/stiffness in muscles/joints, had poorer emotional well-being, spent most of their days 'just sitting', and wanted more help with activities of daily living. There were, however, no differences in their social network characteristics, or their use of services.

Functional ability of very elderly people

This article, which expands on the research discussed four weeks ago in Nursing Standard, describes the circumstances of very elderly people with different levels of functional ability, and how their ability's changed over a 2.5 year period. In particular, it focuses on the needs of those with poor functional ability, who were found to be more likely to have health problems, poorer emotional well-being, almost no friends in their social networks, and greater needs for help (or more help) from services such as chiropody. Few received services specific to rehabilitation and social support, although this group were more likely to receive a greater amount of help, in terms of instrumental aid, with tasks of daily living.

Elderly people's use of services: a survey

This article describes some of the findings of a longitudinal survey of three samples of older people living at home in East London and Mid Essex. It describes the service use and need for community services of the three samples at their baseline interviews, and then looks at how their patterns of use and need changed by the time of their follow-up interviews. It shows that older people are generally using services appropriately, but that there are still unmet needs. Service use was found to increase with age as health and functional ability declined. Further findings will be published shortly.

Changes in life satisfaction over a two and a half year period among very elderly people living in London

Research evidence concerning the contributions of social networks and support to the subjective wellbeing (i.e. life satisfaction) of older persons is not consistent. This paper reports the results of an investigation of the effects life satisfaction at baseline, social network type and health status, on life satisfaction at follow-up at two and a half years later among people ages 85+ living in the East end of London. The percentage of the total variation in overall life satisfaction which was explained by the model was 47%. Baseline life satisfaction score explained most of this (43%), and the remaining variation was explained largely by functional status and age. Previous analyses of baseline life satisfaction reported that health and functional status had accounted for most of the variation between groups, far more than social network and support variables.

Health beliefs: a cultural division?

Uptake of preventive health programmes seems to be related to people's underlying motivations, attitudes and beliefs about health and illness. Current theories used to account for variance in behaviours by social group (such as the health belief model and locus of control model) explain only some of the variance in these motivations and attitudes, and have not been adequately tested on women from different ethnic minority groups. Health beliefs have important implications for nursing given the role of the nurse in health promotion and patient teaching. This paper identifies and compares the health beliefs of women of Asian origin and white indigenous women living in an inner-London borough, through in-depth semi-structured interviews, and considers the findings in relation to health promotion practices and the role of the nurse. The Asian women rated their health as worse than the white women; this requires further study. Comments and views gathered about the causes of various diseases indicated that it may be unrealistic to fit a person's health beliefs into a distinct model. Beliefs about disease appeared to be culturally sensitive; health education, therefore, must also be culturally sensitive.

Associations with social networks, social support, health status and psychiatric morbidity in three samples of elderly people

The effects of social network structure, support and physical health status on psychiatric morbidity were investigated among 1415 people over retirement age who took part in three independent but comparable surveys in London (urban area) and Essex (semi rural area). Multivariate analysis showed that the model explained between 14.3% and 28.6% of the variation in psychiatric morbidity in the three samples. Poor health status was a more powerful predictor of psychiatric morbidity than the social network variables. Age and sex contributed little to the model. The model was strongest among the two samples of Hackney respondents.

Use of services in old age: data from three surveys of elderly people

It has been suggested that home sharers, particularly spouses, act as substitutes for formal health and social care provision. This hypothesis was investigated in relation to three independent samples of elderly people, using comparable methodology in London (urban area) and Essex (semi-rural area). The uniqueness of the study lies in the ability to make comparisons between younger and older elderly people, in particular with those aged 85 and over. Utilisation of health and social services was found to be higher in the urban area, and it increased with age. Marital status was not associated with service use nor with contact with general practitioners in any age group or area. The social network variables analysed had little or no predictive ability in relation to recency of contact with general practitioners (GPs). Household size was associated with total use of health and social services, and social services in particular. The multivariate analysis confirmed that household size was a strong predictor of use of home help and meals on wheels services; functional status was the best predictor of use of district nursing services.