A qualitative study of sleep in young breast cancer survivors: "No longer able to sleep through the night"

Sleep disturbance is common among women with breast cancer and is associated with greater symptom distress and poorer outcomes. Yet, for the unique subgroup of young women with breast cancer (YWBC), there is limited information on sleep. To address the gap in our understanding of sleep health in YWBC, we explored their perspective on sleep quality, sleep changes over time, contributing factors, and any strategies used to promote sleep. As part of an explanatory sequential mixed method study, we recruited a sub-sample of 35 YWBC (≤ 50 years of age at the time of diagnosis) from the larger quantitative study phase. These participants were within the first 5 years since diagnosis and completed primary and systemic adjuvant therapy. We conducted virtual semi-structured interviews, transcribed them verbatim, and analyzed data with an interpretive description approach. YWBC experience difficulty falling asleep, waking up at night, and not feeling refreshed in the morning. They attributed interrupted sleep to vasomotor symptoms, anxiety/worry, ruminating thoughts, everyday life stressors, and discomfort. The sleep disturbance was most severe during and immediately after treatment but persisted across the 5 years of survivorship. The participants reported trying pharmacologic and non-pharmacologic strategies to improve the quantity and quality of their sleep. Future research would benefit from longitudinal designs to capture temporal changes in sleep and develop interventions to improve sleep health. Clinically, assessment of sleep health is indicated for YWBC related to the prevalence of disturbed sleep. IMPLICATIONS FOR CANCER SURVIVORS: Early access to sleep assessment and management, ideally before cancer treatment, would be beneficial for young breast cancer survivors. In addition, cancer treatment plans should include physical and psychological symptoms, especially those reported by women in this study: vasomotor symptoms, anxiety and worry, discomfort, and pain.

Costs and Resource Utilization of People with Stable Heart Failure and Insomnia: Evidence from a Randomized Trial of Cognitive Behavioral Therapy for Insomnia

OBJECTIVES

Nearly half of patients with chronic heart failure (HF) report insomnia symptoms. The purpose of this study was to examine the impact of CBT-I versus HF self-management on healthcare costs and resource utilization among patients with stable chronic HF who participated in a clinical trial of the effects of CBT-I compared to HF self-management education (attention control) over 1 year.

METHODS

We measured resource utilization as self-reported (medical record review) physician office visits, emergency department visits, and inpatient admissions at 3-month intervals for 1 year after enrollment. Costs were estimated by applying price weights to visits and adding self-reported out-of-pocket and indirect costs. Univariate comparisons were made of resource utilization and costs between CBT-I and the HF self-management group. A generalized linear model (GLM) was used to model costs, controlling for covariates.

RESULTS

The sample included 150 patients [79 CBT-I; 71 self-management (M age = 62 + 13 years)]. The CBT-I group had 4.2 inpatient hospitalizations vs 4.6 for the self-management group (p = .40). There were 13.1 outpatient visits, in the CBT-I compared with 15.4 outpatient visits (p-value range 0.39-0.81) for the self-management group. Total costs were not significantly different in univariate or ($7,813 CBT-I vs. $7,538 self-management), p = .96) or multivariable analyses.

CONCLUSIONS

Among patients with both HF and insomnia, CBT-I and HF self-management were associated with similar resource utilization and total costs. Additional research is needed to estimate the value of CBT-I relative to usual care and other treatments for insomnia in patients with HF.

An Evolutionary Concept Analysis in People With Heart Failure-Symptom Clusters or Symptom Cluster Profiles?

The concept of symptom clusters in heart failure (HF) has been defined and measured inconsistently. We used Rodgers' evolutionary method to review related concepts in the HF literature. Symptom clusters and symptom cluster profiles are characterized by multiple symptoms, a synergistic relationship, and result in a myriad of poor outcomes. Researchers should carefully consider the conceptual differences underpinning symptom clusters and symptom cluster profiles and choose the appropriate concept aligned with their research questions, empirical methods, and target HF population.

A Cross-Sectional Study of Cognitive Function, Illness Perceptions, and Immunosuppression Medication Adherence After Heart Transplantation

BACKGROUND

There are few studies that examine relationships between cognitive function, illness perceptions, and medication adherence after heart transplantation, limiting the development of effective adherence-promoting interventions.

OBJECTIVE

The purpose of this study was to describe relationships between cognitive function, illness perceptions, and medication adherence among heart transplant recipients.

METHODS

A cross-sectional, observational design was used. Measures included the telephone-Montreal Cognitive Assessment (t-MoCA©), Patient Health Questionnaire-9, Brief Test of Adult Cognition by Telephone, Basel Assessment of Adherence to Immunosuppressive Medications Scale, and the Brief Illness Perceptions Questionnaire. Descriptive statistics, point-biserial correlations, Pearson's correlations, and logistic regression were used to describe relationships.

RESULTS

Of the 35 participants (mean age: 61 years [SD: 10.3], 71.4% male, 71.4% white), 31.4% (n = 11) were classified as nonadherent to their immunosuppression medications. Higher immediate word recall, indicating better episodic memory (memory for autobiographical and recent events), and higher illness coherence scores were associated with not missing doses of medication. Higher t-MoCA© total scores, indicating normal cognitive function, and lower depression scores were associated with taking medications on time. More than 22% (n = 8) of participants scored less than 19 on the t-MoCA©, an indication of mild cognitive impairment.

CONCLUSION

Cognitive impairment may be more common among heart transplant recipients than what is currently recognized, and specific domains of cognitive function were related to medication adherence after transplantation in this study. Future studies should include longitudinal evaluations of cognitive function, depression, and medication adherence. Consideration of these relationships is needed when designing adherence-promoting interventions for this population.

Daytime symptom trajectories among adults with stable heart failure and insomnia: evidence from a randomised controlled trial of cognitive behavioural therapy for insomnia

People with heart failure (HF) experience a high symptom burden and prevalent insomnia. However, little is known about daytime symptom trajectories after cognitive behavioural therapy for insomnia (CBT-I). In this study we describe: (1) daytime symptom trajectories among adults with insomnia and stable HF over 1 year, (2) how symptom trajectories differ between CBT-I versus HF self-management interventions, and (3) associations between demographic, clinical, and sleep characteristics, perceived stress, health-related quality of life (HRQoL), functional performance and daytime symptoms trajectories. We retrospectively analysed data from a randomised controlled trial of CBT-I versus HF self-management (NCT0266038). We measured sleep, perceived stress, HRQoL, and functional performance at baseline and symptoms at baseline, 3, 6, and 12 months. We conducted group-based trajectory modelling, analysis of variance, chi-square, and proportional odds models. Among 175 participants (mean [standard deviation] age 63.0 [12.9] years, 57.1% male, 76% White), we found four daytime symptom trajectories: (A) low improving symptoms (38.3%); (B) low psychological symptoms and high improving physical symptoms (22.8%); (C) high improving symptoms (24.0%); and (D) high not improving symptoms (14.9%). The CBT-I versus the HF self-management group had higher odds of belonging to Group A compared to other trajectories after controlling for baseline fatigue (odds ratio = 3.27, 95% confidence interval 1.39-7.68). The difference between the CBT-I and the HF self-management group was not statistically significant after controlling for baseline characteristics. Group D had the highest body mass index, perceived stress, and insomnia severity and the lowest cognitive ability, HRQoL, and functional performance. Research is needed to further evaluate factors contributing to symptom trajectories.

Correlates of cognition among people with chronic heart failure and insomnia

PURPOSE

This study aimed to describe cognitive characteristics and their associations with demographic and clinical factors among adults with chronic heart failure (HF) and insomnia.

METHODS

We performed a cross-sectional analysis of baseline data from the HeartSleep Study (NCT#02,660,385), a randomized controlled trial designed to evaluate the effects of cognitive-behavioral therapy for insomnia. Demographic characteristics and health history were obtained. We measured sleep characteristics with the Insomnia Severity Index, the PROMIS Sleep Disturbance Questionnaire, and wrist actigraphy. Sleepiness, stress, and quality of life were measured with validated questionnaires. Measures of cognition included frequency of lapses on the psychomotor vigilance test and the PROMIS cognitive abilities scale where ≥ 3 lapses and a score of ≤ 50, respectively, suggested impairment. These variables were combined into a composite score for multivariable analyses.

RESULTS

Of a sample that included 187 participants (58% male; mean age 63.1 [SD = 12.7]), 77% had New York Heart Association class I or II HF and 66% had HF with preserved ejection fraction. Common comorbidities were diabetes (35%), hypertension (64%), and sleep apnea (54%). Impaired vigilant attention was associated with non-White race, higher body mass index, less education, and more medical comorbidities. Self-reported cognitive impairment was associated with younger age, higher body mass index, and pulmonary disease. On adjusted analysis, significant risk factors for cognitive impairment included hypertension (OR 1.94), daytime sleepiness (OR 1.09), stress (OR 1.08), and quality of life (OR 0.12).

CONCLUSIONS

Impaired cognition is common among people with chronic HF and insomnia and associated with hypertension, daytime sleepiness, stress, and poor quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: Insomnia Self-management in Heart Failure; NCT#02,660,385.

Sleep-related predictors of cognition among adults with chronic insomnia and heart failure enrolled in a randomized controlled trial of cognitive behavioral therapy for insomnia

STUDY OBJECTIVES

Cognitive impairment and insomnia are common in chronic heart failure (HF). We examined the effects of cognitive behavioral therapy for insomnia (CBT-I) and the extent to which demographic, clinical, symptom, and functional characteristics predicted cognition among people with chronic HF and insomnia who participated in a randomized controlled trial of CBT-I.

METHODS

Participants with HF were randomized to group-based CBT-I or an attention control (HF self-management education). Outcomes were measured over 1 year. We measured psychomotor vigilance and self-reported cognitive ability (PROMIS Cognitive Abilities Scale), clinical and demographic characteristics, history of sleep apnea, fatigue, pain, insomnia (Insomnia Severity Index), sleepiness (Epworth Sleepiness Scale), Six Minute Walk, EuroQoL Quality of Life, and wrist actigraphy (sleep characteristics and rest-activity rhythms). We used cosinor analysis to compute rest-activity rhythms and general linear models and general estimating equations to test the effects of predictors over 1 year.

RESULTS

The sample included 175 participants (mean age = 63 SD = 12.9 Years; 43% women). There was a statistically significant group-time effect on self-reported cognitive function and increases in the proportion of participants, with < 3 psychomotor vigilance lapses in the CBT-I group. Controlling for group-time effects and baseline cognition, decreased sleepiness, improved rest-activity rhythms, and 6-minute walk distance predicted a composite measure of cognition (psychomotor vigilance lapses and self-reported cognition).

CONCLUSIONS

CBT-I may improve cognition in adults with chronic HF. A future fully powered randomized controlled trial is needed to confirm the extent to which CBT-I improves multiple dimensions of cognition.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Cognitive Behavioral Therapy for Insomnia: A Self-Management Strategy for Chronic Illness in Heart Failure; URL: https://clinicaltrials.gov/ct2/show/NCT02660385; Identifier: NCT02660385.

CITATION

Redeker NS, Conley S, O'Connell M, Geer JH, Yaggi H, Jeon S. Sleep-related predictors of cognition among adults with chronic insomnia and heart failure enrolled in a randomized controlled trial of cognitive behavioral therapy for insomnia. J Clin Sleep Med. 2023;19(6):1073-1081.

Rest-activity rhythms predict time to hospitalizations and emergency department visits among participants in a randomized control of adults with heart failure and insomnia

BACKGROUND

We examined the effects of insomnia and diurnal rest-activity rhythms (RARs) on time to hospitalizations and emergency department (ED) visits in a randomized controlled trial of cognitive behavioral therapy for insomnia among people with chronic heart failure (HF) and insomnia.

METHODS

Among 168 HF patients, we measured insomnia, CPAP use, sleep, symptoms, and 24-h wrist actigraphy and computed the circadian quotient (strength of the RAR) from wrist actigraphy and computed cox-proportional hazard and frailty models.

RESULTS

Eighty-five (50.1%) and ninety-one (54.2%) participants had at least one hospitalization or ED visit, respectively. NYHA class and comorbidity predicted time to hospitalizations and ED visits, while younger age and male sex predicted earlier hospitalizations. Low ejection fraction predicted time to first cardiac event and composite events. Independent of clinical and demographic predictors, a lower circadian quotient and more severe pain significantly predicted earlier hospitalizations. A more robust circadian quotient, more severe insomnia, and fatigue predicted earlier ED visits independent from clinical and demographic factors. Pain and fatigue predicted composite events.

CONCLUSION

Insomnia severity and RARs independently predicted hospitalizations and ED visits independent of clinical and demographic variables. Further research is necessary to determine whether improving insomnia and strengthening RARs improves outcomes among people with HF.

CLINICAL TRIALS REGISTRATION

NCT02660385.

Disability research must be a priority for nurses to advance health equity

Disability results from an interplay between health conditions and environmental and personal factors. People with disabilities face substantial and ongoing health inequities; however, research to mitigate these inequalities is lacking. There is an urgent need for a better understanding of the multilevel factors that influence health outcomes in people with visible and invisible disabilities across all the lenses of the National Institute of Nursing Research strategic plan. Disability research must be a priority of nurses and the National Institute of Nursing Research to advance health equity for all.

Sleep, Stress, and Symptoms Among People With Heart Failure During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic raised concerns about the effects of stress on sleep and mental health, particularly among people with chronic conditions, including people with heart failure (HF).

OBJECTIVE

The aim of this study was to examine changes in sleep, sleep-related cognitions, stress, anxiety, and depression among people with HF who participated in a randomized controlled trial of cognitive behavioral therapy for insomnia before the COVID-19 pandemic.

METHODS

Participants self-reported sleep characteristics, symptoms, mood, and stress at baseline, 6 months after cognitive behavioral therapy for insomnia or HF self-management education (attention control), and during the pandemic.

RESULTS

The sample included 112 participants (mean age, 63 ± 12.9 years; 47% women; 13% Black; 68% New York Heart Association class II or III). Statistically significant improvements in sleep, stress, mood, and symptoms that occurred 6 months post treatment were sustained during the pandemic.

CONCLUSIONS

Improving sleep and symptoms among people with HF may improve coping during stressful events, and cognitive behavioral therapy for insomnia may be protective.

Symptom Cluster Profiles Among Adults with Insomnia and Heart Failure

OBJECTIVE/BACKGROUND

Both heart failure (HF) and insomnia are associated with high symptom burden that may be manifested in clustered symptoms. To date, studies of insomnia have focused only on its association with single symptoms. The purposes of this study were to: (1) describe daytime symptom cluster profiles in adults with insomnia and chronic HF; and (2) determine the associations between demographic and clinical characteristics, insomnia and sleep characteristics and membership in symptom cluster profiles.

PARTICIPANTS

One hundred and ninety-five participants [M age 63.0 (SD12.8); 84 (43.1%) male; 148 (75.9%) New York Heart Association Class I/II] from the HeartSleep study (NCT0266038), a randomized controlled trial of the sustained effects of cognitive behavioral therapy for insomnia (CBT-I).

METHODS

We analyzed baseline data, including daytime symptoms (fatigue, pain, anxiety, depression, dyspnea, sleepiness) and insomnia (Insomnia Severity Index), and sleep characteristics (Pittsburgh Sleep Quality Index, wrist actigraphy). We conducted latent class analysis to identify symptom cluster profiles, bivariate associations, and multinomial regression.

RESULTS

We identified three daytime symptom cluster profiles, physical (N = 73 participants; 37.4%), emotional (N = 12; 5.6%), and all-high symptoms (N = 111; 56.4%). Body mass index, beta blockers, and insomnia severity were independently associated with membership in the all-high symptom profile, compared with the other symptom profile groups.

CONCLUSIONS

Higher symptom burden is associated with more severe insomnia in people with stable HF. There is a need to understand whether treatment of insomnia improves symptom burden as reflected in transition from symptom cluster profiles reflecting higher to lower symptom burden.

Trajectory of self-care in people with stable heart failure and insomnia after two self-care interventions

OBJECTIVE

To describe (1) self-care trajectories among adults with heart failure (HF) and insomnia over 1-year; (2) the extent to which trajectories varied between cognitive behavioral therapy for insomnia (CBT-I) or HF self-care intervention; and (3) the associations between self-care trajectories and clinical and demographic characteristics, sleep, symptoms and stress, and functional performance.

METHODS

We conducted secondary analysis of data from a randomized controlled trial of the effects of CBT-I compared with HF self-care education among adults with stable HF and insomnia. We used the Self-Care of Heart Failure Index v6.2. The analytic approaches included t-tests, group-based trajectory modeling, ANOVA, and chi-square.

RESULTS

We included 175 participants (M age=63.0 (12.9) years, White, N = 100]. We found four self-care trajectories: Low self-care (N = 47, 26.8%); Moderate self-care (N = 68, 38.9%): Adequate self-care (N = 42, 24.0%); and Optimal self-care (N = 18, 10.3%). There was no difference in self-care trajectories between interventions. The low self-care group had the most severe baseline fatigue, anxiety, and perceived stress, and lowest cognitive abilities.

CONCLUSION

Both interventions prevented declining self-care. Future research is needed to determine the most efficacious intervention to improve self-care trajectories.

PRACTICE IMPLICATIONS

Healthcare providers should provide ongoing self-care support for those with persistently low and moderate self-care.

Treatment Fidelity in a Randomized Controlled Trial of Cognitive Behavioral Therapy for Insomnia in Heart Failure

BACKGROUND

Cognitive behavioral therapy for insomnia (CBT-I) is an efficacious treatment for people with chronic insomnia, including those with heart failure (HF). Treatment fidelity evaluation is needed to ensure study validity and reliability.

OBJECTIVE

The aim of this study was to apply the National Institutes of Health Behavioral Change Consortium framework to ensure adequate treatment fidelity in a randomized controlled trial of CBT-I for people with stable HF.

METHODS

We describe strategies to ensure treatment fidelity in study design, provider training, and treatment delivery. We measured treatment receipt (observation and self-report) and enactment of CBT-I strategies (self-report and actigraphy). We used the Dysfunctional Beliefs and Attitudes About Sleep Scale and the Sleep Disturbance Questionnaire to indicate sleep-related beliefs and cognitions. We computed descriptive statistics for demographic characteristics, treatment receipt, and enactment variables. We compared baseline and post-intervention dichotomous sleep behaviors using the two-sided Wilcoxon rank-sum test. We calculated the root mean square of successive difference in time of sleep onset and midpoint (actigraphy) to indicate day-by-day variability in bed and wake times.

RESULTS

Most participants completed the CBT-I intervention and follow-up assessments and attended each group or make-up session. Most correctly computed their sleep efficiency and completed their homework. Most participants used the sleep tracker and reported using strategies to improve their sleep schedules. There was a significant decrease in actigraph-measured light intensity during the 30 minutes and 1 hour before bedtime between baseline and post-intervention and no statistically significant changes in light intensity after waking or in nap frequency. Most of those who woke during the night got out of bed, consistent with recommendations. There were significant improvements on all of the Dysfunctional Beliefs and Attitudes About Sleep items and total score and all but one item on the Sleep Disturbance Questionnaire.

DISCUSSION

Preserved treatment fidelity may explain the large and sustained effects in people with HF found in our trial. Further research is needed to evaluate CBT-I's effectiveness and implementation strategies among people with HF in real-world clinical settings.

Coping, Symptoms, and Insomnia among People with Heart Failure during the Covid-19 Pandemic

AIM

Increases in stress, symptoms of anxiety and depression and sleep problems have been reported during the Covid-19 pandemic, and people with chronic medical conditions such as heart failure (HF) are especially vulnerable. The purpose of this study was to examine the extent to which sleep characteristics, sleep-related cognitions, anxiety, depression, perceived stress, and changes in these phenomena over time predict ways of coping with pandemic-related stress among participants in the HeartSleep study, a randomized controlled trial of the effects of cognitive behavioral therapy for insomnia (CBT-I) in people with HF.

METHODS

Participants completed questionnaires to elicit sleep characteristics, daytime symptoms, mood and stress at baseline, six-months after the intervention and during the Covid-19 pandemic. We added measures of coping during the pandemic (June-August 2020).

RESULTS

The sample included 112 participants (M age = 63 ± 12.9 years; 47% women; 13% Black; 68% NY Heart Class II or III). Participants (43%) reported pandemic-related stressors and most often used secondary control coping. Insomnia severity, anxiety, depression, perceived stress, and sleep-related cognitions predicted secondary control coping (positive thinking, cognitive restructuring, acceptance, distraction), involuntary engagement (physiological arousal, rumination) and involuntary disengagement (emotional numbing).

CONCLUSIONS

Insomnia and mood disturbance are important determinants of coping and responses to stress. Improving sleep and symptoms among people with HF may improve coping during stressful events, and CBT-I may have protective effects.

Symptom cluster profiles following traumatic orthopaedic injuries

BACKGROUND

Millions of Americans experience traumatic orthopaedic injuries (TOIs) annually. Post-injury symptoms of acute stress disorder (ASD), anxiety, depression, pain, and sleep disturbance are common. Symptoms often present in clusters. Symptom cluster profiles phenotypically characterize TOI survivors' experiences with clustered symptoms. Expression of brain-derived neurotrophic factor (BDNF) may contribute to the biological underpinnings of symptom cluster profile membership.

METHODS

We recruited hospitalized TOI survivors within 72 hours of injury. We measured symptoms of ASD with the Acute Stress Disorder Scale and symptoms of anxiety, depression, pain, and sleep disturbance with Patient-Reported Outcomes Measurement Information System (PROMIS) short forms. We measured serum BDNF concentrations with enzyme-linked immunosorbent assay (ELISA) and identified rs6265 genotypes with TaqMan real-time PCR. We performed latent profile analysis to identify the symptom cluster profiles. We identified the variables associated with symptom cluster profile membership with unadjusted and adjusted multinomial logistic regression.

RESULTS

We identified 4 symptom cluster profiles characterized by symptom severity that we labelled Physical Symptoms Only, and Mild, Moderate, and Severe Psychological Distress. Age, self-identified Black race, resilience, and serum BDNF concentrations were associated with lower odds, and female sex with higher odds, of being in the Psychological Distress clusters. Clinical characteristics and rs6265 genotypes were not associated with symptom cluster profile membership.

CONCLUSION

TOI survivors experience distinct symptom cluster profiles. Sociodemographic characteristics and serum BDNF concentrations, not clinical characteristics, were associated with symptom cluster profile membership. These findings support comprehensive symptom screening and treatment for all TOI survivors and further evaluating BDNF as a biomarker of post-injury symptom burden.

Adapting the Health Stigma and Discrimination Framework to understand the association between stigma and sleep deficiency: A systematic review

OBJECTIVE

Sleep deficiency and sleep disorders disproportionally affect socially disadvantaged and marginalized individuals and groups. Recent evidence suggests that stigma, a social process characterized by labeling, stereotyping, and prejudice, is associated with sleep characteristics.

PURPOSE

Guided by the Health Stigma and Discrimination Framework, the purpose of this systematic review is to describe associations between dimensions of stigma and sleep deficiency and to identify future directions for research.

METHODS

We searched the OVIDPsycINFO, OVIDEMASE, OVIDMEDLINE, and CINAHL databases for empirical research studies that reported relationships between the 3 dimensions of stigma-internalized, perceived, and anticipated-and characteristics of sleep deficiency-duration, continuity/efficiency, timing, alertness/sleepiness, quality, and disorders.

RESULTS

Of 1717 articles, 15 met our inclusion criteria. The most frequently assessed dimensions of stigma were internalized and perceived stigma. Characteristics of sleep deficiency were measured by self-report and included sleep quality, duration, trouble sleeping, and insomnia symptoms. We found consistent evidence that stigma, whether internalized, perceived, or anticipated, is associated with self-reported characteristics of sleep deficiency.

CONCLUSIONS

This evidence base can be further strengthened with prospective studies that incorporate both multidimensional measures of stigma and objective measures of sleep characteristics. We outline research implications that can clarify underlying mechanisms and more precisely define the relationships between stigma and sleep and inform interventions to address stigma, improve sleep, and reduce the health inequities that disproportionately affect individuals from socially disadvantaged and marginalized groups.

Sleep Deficiency: A Symptoms Perspective: Exemplars from Chronic Heart Failure, Inflammatory Bowel Disease, and Breast Cancer

Sleep deficiency is associated with disabling daytime symptoms, including excessive daytime sleepiness (EDS) and fatigue. The purpose of this article is to discuss the contributions of sleep deficiency and sleep disorders to fatigue and EDS among people with chronic conditions. We use exemplars from the literature on chronic heart failure, inflammatory bowel disease, and breast cancer to (1) describe the prevalence of fatigue and EDS and their consequences; (2) examine the evidence for the contributions of sleep deficiency and sleep disorders to these symptoms; and (3) recommend implications for future research and practice.

0573 Daytime and Nighttime Sleep and Symptoms of Depression and Anxiety in Adults with Inflammatory Bowel Disease

Introduction

Inadequate sleep duration and daytime napping are associated with symptoms of depression and anxiety in the general population. People with autoimmune diseases frequently experience poor sleep and depressive and anxious symptoms; however, little is known about how sleep might contribute to depressive and anxious symptoms in this population. The purpose of this study was to explore the associations between nighttime sleep and naps and depressive and anxious symptoms in adults with inflammatory bowel disease (IBD).

Methods

We conducted a cross-sectional feasibility study of adults with IBD (Crohn’s disease and ulcerative colitis) ages 18 to 60 years recruited from a single academic IBD center. We measured depressive and anxious symptoms using the Patient-Reported Outcomes Measurement Information System (PROMIS) measures. We elicited nighttime sleep [sleep duration, efficiency, and wake after sleep onset (WASO)] using wrist-worn actigraphs (Philips Spectrum Plus) and elicited naps and perceived sleep quality (analog scale 0-100) with sleep diaries over 10 days.

Results

We included 35 adults [age M = 37.8 (14.0); female N = 21 (60.0%); Crohn’s disease N = 18 (51.4%); clinical remission N= 22 (63.9%)]. Mean depression (51.4 SD= 9.1) and anxiety (52.6 SD = 9.9) were over the population-based cut-offs. Additionally, nightly sleep duration was short (M = 391.9 minutes SD = 52.5). Sleep efficiency (M = 83.0% SD = 5.5) was low, and WASO (M = 41.8 minutes SD = 19.9) was high. Twenty-one (60%) participants reported taking at least one nap (median = 2, range 1-7) over the 10 days. Depressive and anxious symptoms were higher in people who napped than those who did not nap with a moderate effect size (Cohen’s d = -.309, -.466 respectively). Sleep quality was correlated with symptoms of depression (r = .622, p &lt; .001) and anxiety (r = .638, p &lt; .001). No other sleep characteristics were associated with depressive and anxious symptoms (r &lt; .1, p &gt; .59).

Conclusion

Health care providers should assess for the presence of depression and anxiety in people with IBD who regularly nap and report poor sleep quality. Future research regarding the treatment of sleep, depression, and anxiety is needed in this population.

Support (If Any)

American Nurses Foundation

0206 Rest-Activity Rhythms are Associated with Sleep Characteristics and Cognitive Functions in People with Heart Failure Over 6 Months

Introduction

People with Heart failure (HF) often suffer from sleep deprivation and poor cognitive function. The purpose of this study was to examine the extent to which repeatedly measured rest-activity rhythms (RARs) measured with wrist actigraphy predict sleep characteristics and cognitive function in people with HF.

Methods

We measured insomnia severity (ISI), sleep quality (Pittsburgh sleep quality index: PSQI), sleepiness (Epworth sleepiness scale: ESS), psychomotor vigilance (Psychomotor vigilance test: PVT), and quality of life (Euroqol 5D) among people with HF patients who participated in a randomized controlled trial of cognitive behavioral therapy for insomnia vs. HF self-management education at baseline, 3-, and 6-months post-intervention. We performed cosinor analysis with 24-hour rest-activity counts obtained with 7 days of wrist actigraphy at each time point and calculated the circadian quotient, which represents the strength of RARs. We used the Generalized Linear Mixed Model with random intercepts to examine the association between the circadian quotient, sleep characteristics, cognitive function, and quality of life after adjusting for time-group interactions over 6 months. Statistical significance for standardized coefficients was accepted at 5% type I error.

Results

The analysis included 162 participants with HF and insomnia (Insomnia severity index &gt;7) who completed actigraph monitoring for at least 7 days at baseline There was no significant change in the mean circadian quotient (Mean=0.78, SD=0.16) over 6 months. After adjusting for significant intervention effects, a greater circadian quotient was statistically associated with lower insomnia severity (-0.11±0.05), sleepiness (-0.12±0.05), sleep quality (-0.15±0.05), longer sleep duration (0.33±0.04) and better sleep efficiency (0.13±0.05). The circadian quotient was positively associated with cognitive function measured by fewer PVT lapses (-0.11±0.05) and quality of life (0.12±0.05).

Conclusion

In addition to the significant intervention effects for insomnia, HF patients may benefited from strengthening RAR to improve sleep characteristics, cognitive function, and quality of life. Further research to assess the contributions of RAR in people who received the intervention for insomnia and the HF self-education separately is recommended.

Support (If Any)

R01NR016191 and P20NR014126

0590 Factors Associated with Sleep Health in Young Women After Breast Cancer Treatment

Introduction

Poor sleep health adversely affects quality of life and prognosis in cancer survivors, yet there is limited evidence on sleep health in young women with breast cancer (YWBC). The purpose of this study was to identify sociodemographic, clinical, and psychosocial factors associated with sleep health.

Methods

We conducted a cross-sectional study. Eligible participants were women diagnosed with stage I-III breast cancer ≤ 50 years of age and within 5 years from primary cancer treatment. Sociodemographic, clinical, and psychosocial data were collected through an online survey. Sleep health and psychosocial data were assessed by the Pittsburgh Sleep Quality Index (PSQI), PROMIS depression and anxiety, and the McMaster Family Device General Functioning subscale. Data were analyzed with logistic regression. A PSQI cut-off score of &gt;8 was used to define poor sleep health based on the study data and the cancer sleep literature.

Results

The sample included 159 YWBC with a mean age of 43.6 years (SD=6.8), the majority of whom were non-Hispanic White (84%) and completed chemotherapy or radiotherapy (&gt;70%). Half of the participants were premenopausal at diagnosis and became peri- or postmenopausal after treatment. The mean global PSQI was 9.3 (SD=3.6) and 55% reported poor sleep health. About half of the participants slept &lt;7 hours per night, 87% spent &gt;15 minutes falling asleep, and 58% reported taking medication to sleep. Non-White underrepresented groups (OR=7.56, p&lt;.01), more severe night sweats (OR=9.00, p&lt;.001), no history of endocrine therapy (OR=2.73, p&lt;.05), more severe anxiety (OR=1.08, p&lt;.01) and depression (OR=1.06, p&lt;.05), and poorer family functioning (OR=3.78, p&lt;.001) were associated with poor sleep health.

Conclusion

The findings suggest that poor sleep health is a significant clinical problem in YWBC. Sleep assessment, education, and appropriate referrals should be part of routine survivorship care. Social determinants of health such as race and ethnicity and family functioning warrant further investigation related to sleep health. Future studies are needed to confirm the relationships of sociodemographic and clinical factors, psychological symptoms, and family functioning with sleep health.

Support (If Any)

The Global Korean Nursing Foundation.

0448 Self-care trajectories and sleep characteristics in people with heart failure and insomnia

Introduction

Sleep disturbance is common among people with heart failure (HF) and associated with poor self-care. The purpose of this study, a secondary analysis of data from a randomized controlled trial of the sustained effects of cognitive behavioral therapy for insomnia compared to HF self-management, was to examine the extent to which these interventions improved HF self-care trajectories and the associations between changes in sleep and self-care trajectories.

Methods

We measured changes in self-care maintenance (daily activities), management (symptom management), and confidence (self-efficacy), components of self-care (SC: Self-care of Heart Failure Index) and self-reported sleep characteristics [Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), daytime sleepiness (PROMIS Sleep Impairment)] at baseline and 3, 6, and 12 months post-intervention. We used group-based trajectory modeling to identify self-care trajectories and generalized linear models to identify the associations between changes in sleep and SC trajectories.

Results

We included 175 participants [N = 91 HS; age M = 63 years (12.9); n = 110 (57.1%) male; n = 133 (76.0%) White]. At baseline, SC maintenance, management, and confidence were poor overall [M = 66.3 (16.4); 53.4 (23.8); 68.1 (20.3), respectively]. We identified four self-care trajectories. Class A (poor SC maintenance & management; moderate confidence: N = 47, 26.9%); Class B (low self-care management & confidence, moderate maintenance: N = 68, 38.9%): Class C (high maintenance & management, low confidence; N = 42, 24.0%); Class D (high on all SC: N = 18, 10.3%). There was no significant difference in changes in self-care over time between HS and HH, but both groups improved at 3 and 6 months on self-care maintenance, and self-care management improved at 12 months over baseline (p &lt; .05). Participants in all classes improved on insomnia severity and sleepiness (p&lt; .05) over time.

Conclusion

We found that insomnia and sleepiness improved even those with poor self-care suggesting that adequate HF SC may not be needed to improve insomnia. Future research is needed to determine if a combination of HF self-management and CBT-I improves SC trajectories in this population.

Support (If Any)

R01NR016191 and P20NR014126

Cognitive Behavioral Therapy for Insomnia has sustained effects on insomnia, fatigue, and function among people with chronic heart failure and insomnia: The HeartSleep Study

STUDY OBJECTIVES

Insomnia is common among adults with chronic heart failure (HF) and associated with daytime symptoms and decrements in function. The purpose of this randomized controlled trial (RCT) was to evaluate the sustained effects over one year of CBT-I (Healthy Sleep: HS) compared with HF self-management education (Healthy Hearts; attention control: HH) on insomnia severity, sleep characteristics, symptoms, and function among people with stable HF. The primary outcomes were insomnia severity, actigraph-recorded sleep efficiency, and fatigue.

METHODS

We randomized adults with stable HF with preserved or reduced ejection fraction who had at least mild insomnia (Insomnia severity index >7) in groups to HS or HH (4 sessions/8 weeks). We obtained wrist actigraphy and measured insomnia severity, self-reported sleep characteristics, symptoms (fatigue, excessive daytime sleepiness, anxiety, depression), and six-minute walk distance at baseline, within one month of treatment, and at 6 and 12 months. We used general linear mixed models (GLMM) and generalized estimating equations (GEE) to evaluate the effects.

RESULTS

The sample included 175 participants (M age = 63 +12.9 years; 43% women; 18% Black; 68% New York Heart Association Class II or II; 33%; LVEF < 45%) randomized to HS (n = 91) or HH (N = 84). HS had sustained effects on insomnia severity, sleep quality, self-reported sleep latency and efficiency, fatigue, excessive daytime sleepiness, and six-minute walk distance at 12 months.

CONCLUSIONS

CBT-I produced sustained improvements in insomnia, fatigue, daytime sleepiness, and objectively measured physical function among adults with chronic HF, compared with a robust HF self-management program that included sleep hygiene education.

342 CBT-I Has Sustained Effects on Insomnia Versus Heart-Failure Self-Management Education among Adults with Chronic Heart Failure

Introduction

Insomnia is common among adults with chronic heart failure (HF), often not explained by sleep apnea (SA), and associated with daytime symptoms and poor daytime function. The purpose of this randomized controlled trial was to evaluate the sustained effects of cognitive behavioral therapy for insomnia (CBT-I) on insomnia severity and sleep characteristics over 6 months among adults with stable chronic HF.

Methods

We included adults with HF who had at least mild insomnia [Insomnia Severity Index (ISI) &gt; 8] and no more than mild SA or SA treated with continuous positive airway pressure. We randomized in groups to 8 weeks of group CBT-I (Healthy Sleep: HS) [4 group sessions + calls on alternate weeks] or attention control (Healthy Hearts: HH) [HF self-management education + brief sleep hygiene] in the same format. We administered the ISI, the Pittsburgh Sleep Quality Index (PSQI), the Dysfunctional Beliefs & Attitudes about Sleep Scale (DBAS), and the Sleep Disturbance Questionnaire (SDQ) at baseline (T0), 2 weeks after treatment ended (T1) and at 6 months (T2). Statistical analysis included descriptive statistics and mixed effects models with random intercepts and slopes.

Results

The sample include 175 participants (HS: N = 91; 62 + 13 years; 58% Male; 15% Black; 68% NY Heart Class II-III) (HH: N = 84; 64 + 12.5 years; 56% Male; 17% Black; 70% NY Heart Class II-III). There was no significant difference at baseline in demographic characteristics or the mean ISI [HS: 15.3 (4.5); HH: 14.4 (4.5)], but a greater percentage in the HS group had clinical/moderate-severe insomnia (ISI &gt; 15) (HS: 60.4% vs. HH: 47%). The CBT-I intervention (HS) was associated with significant improvement in insomnia severity (ISI: p = .001), sleep quality (PSQI: p = .002), and sleep-related cognitions (DBAS: p = .0006; SDQ: p = .0138), and a modest effect on self-reported sleep duration (46 vs. 20 mins, p = .054), but no effect on sleep efficiency. At 6 months, 12.9% of the HS group, compared with 24.9% of the HH group had clinical insomnia.

Conclusion

CBT-I has sustained effects on insomnia, sleep-quality, and sleep-related cognitions in people with HF.

Support (if any)

R01NR01691 (NSR, PI)

Sleep Disturbance Is Associated With the Presence of Portosystemic Collaterals in Patients With Compensated Cirrhosis

Disturbed sleep is common among patients with cirrhosis. The extent to which this is associated with the different stages of compensated cirrhosis is unknown. This study examines whether the presence of portosystemic collaterals, an indicator of clinically significant portal hypertension, is associated with sleep disturbance in compensated cirrhosis. We conducted a cross-sectional study among patients with compensated cirrhosis, comparing sleep characteristics, sleep quality, and excessive daytime sleepiness between 21 patients without and 21 patients with portosystemic collaterals. Patients were assessed with wrist actigraphy, Pittsburgh Sleep Quality Index, and the Epworth Sleepiness Scale. Collateral presence was determined by imaging and esophagogastroduodenoscopy. Differences in sleep characteristics were analyzed using t tests and computed effect sizes. Multivariable linear regression analysis was used to evaluate the association between collaterals and sleep disturbance while controlling for possible confounders. The group of patients with collaterals had greater beta-blocker and tobacco use, lower albumin, and higher international normalized ratio compared to the group without collaterals. Patients with collaterals had more sleep fragmentation (Cohen's d = -0.86), lower sleep efficiency (Cohen's d = 0.59), and lower total sleep time (Cohen's d = 0.75) than patients without collaterals. The presence of collaterals was independently associated with greater sleep fragmentation (P = 0.046) and greater daytime sleepiness (P = 0.030). Conclusion: Patients with compensated cirrhosis complicated by portosystemic collaterals experienced more sleep disturbance than those without collaterals.

Day-to-day Relationships between Physical Activity and Sleep Characteristics among People with Heart Failure and Insomnia

OBJECTIVE

Examine the bidirectional relationships between within-person day-to-day fluctuations in physical activity (PA) and sleep characteristics among people with heart failure (HF) and insomnia.

PARTICIPANTS

Ninety-seven community-dwelling adults [median age 61.9 (interquartile range 55.3,70.9) years, female 41%] with stable HF and insomnia (insomnia severity index >7).

METHODS

This sub-study longitudinally analyzed 15 consecutive days and nights of wrist actigraphy recordings, that were collected for baseline data prior to participation in a randomized controlled trial of cognitive behavioral therapy for insomnia. We used two-level mixed models of within- (daily) and between-participants variation to predict daytime PA counts/minutes from sleep variables (total sleep time, sleep efficiency) and predict sleep variables from PA.

RESULTS

PA counts/minutes were low compared to prior cohorts that did not have HF (209 (166,259)) and negatively associated with NYHA class (standardized coefficient β_s = -0.14, p < .01), age (β_s = -0.13, p = .01), comorbidities (β_s = -0.19, p < .01), and body mass index (β_s = -0.12, p = .04). After adjustment for all significant covariates, the within-participant association of total sleep time with next-day PA was estimated to be positive among participants with NYHA class II-IV HF (β_s = 0.09, p = .01), while the within-participant association of PA with same-night total sleep time was estimated to be positive among participants aged ≥60 years (β_s = 0.10, p = .03).

CONCLUSIONS

Depending upon age and HF class, daytime PA was associated with longer same-night sleep and/or longer sleep was associated with greater next-day PA. Among those with more advanced HF, realistic sleep improvements were associated with clinically meaningful PA gains the next day.

Anxiety Symptoms After Orthopedic Injury: A Systematic Review

BACKGROUND

Millions of Americans are injured each year, with 75% suffering orthopedic injuries. Those with orthopedic injury often experience postinjury symptoms, such as anxiety, that negatively influence long-term outcomes. The purpose of this systematic review was to evaluate (1) the prevalence of anxiety symptoms chronologically in relation to time of orthopedic injury, (2) the associations of anxiety symptoms with other symptoms in individuals with orthopedic injury, and (3) the associations between anxiety symptoms and functional performance and mental health outcomes in individuals with orthopedic injury.

METHODS

The databases CINAHL, Ovid MEDLINE, Ovid PsycInfo, Ovid Embase, ProQuest, and ClinicalTrials.gov were searched on June 25, 2020. Studies were selected for review if (1) participants were 16 years or older, (2) the prevalence of anxiety symptoms was listed, (3) anxiety symptoms were assessed using a validated instrument, (4) the study was published in English, and (5) more than 50% of the participants suffered orthopedic injury to the appendicular skeleton or pelvic ring.

RESULTS

Anxiety symptoms were present in 11.5%-55.9% of individuals up to 10 years after orthopedic injury and often co-occurred with those of depression, pain, and posttraumatic stress disorder to negatively influence functional performance and mental health outcomes.

CONCLUSIONS

Anxiety symptoms post-orthopedic injury are highly prevalent and persistent. Anxiety symptoms are associated with other distressing symptoms and influence long-term outcomes. These findings highlight the need to screen for and treat anxiety symptoms following orthopedic injury and may help in designing future self-management interventions.

Perceived Stress, Subjective, and Objective Symptoms of Disturbed Sleep in Men and Women with Stable Heart Failure

Objective/Background: Sleep disturbance is prevalent among patients with heart failure (HF) and is associated with increased morbidity and mortality. Stress also affects health and quality of life among patients with cardiovascular disease and likely plays a prominent role in HF. However, little is known about the associations between stress and sleep among HF patients.Participants: One hundred fifty-three stable New York Heart Association (NYHA) Classification I-IV HF patients with at least low symptoms of insomnia (M_age:63.0 ± 12.8, 42% Women).Methods: We examined baseline stress, sleep disturbance, and sleep-related characteristics from a randomized controlled trial of cognitive behavioral therapy for insomnia, including the Perceived Stress Scale, Insomnia Severity Index, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Sleep Disturbance Questionnaire, Dysfunctional Beliefs about Sleep Scale, PROMIS Cognitive Ability, SF-36 Mental Health, and wrist actigraphy. We used Pearson correlations and general linear models to assess stress-sleep associations, including the potential moderating effects of sex and symptom severity (NYHA).Results: There were moderate-to-large correlations between stress and self-reported sleep disturbance, dysfunctional beliefs about sleep, cognitive ability, and mental health (p's < 0.01). High stress was associated with more objectively-measured (i.e., actigraph-assessed) awakenings and sleep fragmentation among women than men (β = - 0.04, p < 0.01; β = - 0.71, p = 0.04). Relationships between stress and objectively-measured sleep did not vary by symptom severity.Conclusions: Perceived stress is related to sleep disturbance among HF patients, and effects may be sex-dependent. Subsequent research should determine the temporal links between sleep and stress, and optimal opportunities for intervention among HF patients.

Sleep Characteristics and Rest-Activity Rhythms Are Associated with Gastrointestinal Symptoms Among Adults with Inflammatory Bowel Disease

BACKGROUND

Sleep disturbance is common in inflammatory bowel disease (IBD) and is associated with poorer quality of life and increased disease activity; however, sleep is a multidimensional process, and little is known about specific sleep characteristics and rest-activity rhythms (RARs) in this population.

AIMS

The purposes were to (1) describe sleep characteristics and RARs; (2) compare sleep characteristics and RARs and GI symptoms by disease activity; and (3) describe associations between sleep characteristics, RARs, and GI symptoms among adults with IBD.

METHODS

We conducted a cross-sectional study of adults with IBD. We measured sleep characteristics and RARs (continuous wrist actigraphy); GI symptoms (PROMIS-GI); and disease activity (physicians' global assessment). We conducted cosinor and nonparametric analyses to compute RAR variables and bivariate analyses to address the aims.

RESULTS

The sample included 37 participants [age M = 38 years (SD = 13.8) and 21 (56.8%) female], of whom 23 (60.6%) were in remission. Sleep efficiency [M = 82.91% (SD 5.35)] and wake after sleep onset (WASO) [M = 42.26 min (SD 18.57)] were not associated with disease activity. Inter-daily stability of the RAR was associated with heartburn/reflux (r = - .491, p = .005) and gas/bloating (r = - .469, p = .008). Intra-daily variability of the RAR was associated with heartburn/reflux (r = .421, p = .018).

CONCLUSIONS

People with IBD may have disrupted RARs, which are associated with GI symptoms. Research is needed to improve understanding of these associations and to develop interventions to improve these characteristics in adults with IBD.

Symptom cluster profiles following traumatic orthopedic injuries: A protocol

Traumatic injuries affect millions of Americans annually, resulting in $671 billion in healthcare costs and lost productivity. Postinjury symptoms, like pain, sleep disturbance, anxiety, depression, and stressor-related disorders are highly prevalent following traumatic orthopedic injuries (TOI) and may contribute to negative long-term outcomes. Symptoms rarely present in isolation, but in clusters of two or more symptoms that co-occur to affect health in aggregate. Identifying symptom cluster profiles following TOI may identify those at highest risk for negative outcomes. Dysregulation of brain-derived neurotrophic factor (BDNF) is a potential biological mechanism responsible for symptom cluster profile membership after TOI and may be targeted in future precision-health applications. The purpose of this paper is to present the protocol of a cross-sectional study designed to identify symptom cluster profiles and measure the extent to which the BDNF val66met mutation and serum concentration of BDNF are associated with membership in symptom cluster profiles. We plan to recruit 150 TOI survivors within the first 72 h of injury. The study aims are to (1) describe TOI survivors' membership in symptom cluster profiles, indicated by pain, sleep disturbance, and symptoms of anxiety, depression, and stressor-related disorders, immediately following a TOI; (2) examine associations between demographic and clinical factors and symptom cluster profile membership among TOI survivors; (3) test the hypothesis that low serum concentrations of BDNF are associated with membership among symptom cluster profiles following TOI; and (4) test the hypothesis that the presence of the val66met mutation on one or both alleles of the BDNF gene is associated with membership among symptom cluster profiles following TOI.

Evaluating Recruitment Strategies for a Randomized Clinical Trial with Heart Failure Patients

Recruiting participants with chronic medical conditions is time-consuming and expensive. Electronic medical record databases and patient portals may enable outreach to larger numbers of patients in comparison to face-to-face methods. We aimed to describe the yields, benefits, and limitations of recruitment strategies used for a randomized clinical trial of cognitive behavioral therapy for insomnia among patients with chronic stable heart failure (NCT02660385). We used multiple recruitment strategies including clinic-based recruitment, letters to patients identified from electronic databases, the patient portal, brochures and posters placed in clinics, presentations to heart failure support groups, and online advertising. We screened 10,291 medical records, enrolled 231 participants, and 195 participants completed baseline data collection. We enrolled 92 (23%) participants using clinic-based recruitment, 24 and 29 (6% and 10%) using letters to patients from two electronic databases, and 42 (55%) via the patient portal. Multiple recruitment strategies and flexibility are needed to achieve recruitment goals.

Daytime and Nighttime Sleep Characteristics and Pain Among Adults With Stable Heart Failure

BACKGROUND

Pain and sleep disturbance are common among patients with heart failure (HF) and are associated with symptom burden, disability, and poor quality of life. Little is known about the associations between specific sleep characteristics and pain in people with HF.

OBJECTIVE

The aim of this study was to describe the relationships between nocturnal sleep characteristics, use of sleep medication, and daytime sleep characteristics and pain among people with HF.

METHODS

We conducted a cross-sectional study of stable participants with HF. We administered the SF36 Bodily Pain Scale, Pittsburgh Sleep Quality Index, and Sleep Habits Questionnaire and obtained 3 days of wrist actigraphy and 1 night of home unattended polysomnography. We conducted bivariate analyses and generalized linear models.

RESULTS

The sample included 173 participants (mean [SD] age, 60 [16.1] years; 65.3% [n = 113] male). Insomnia symptoms (P = .0010), sleep duration (P = .0010), poor sleep quality (P = .0153), use of sleep medications (P = .0170), napping (P = .0029), and daytime sleepiness (P = .0094) were associated with increased pain. Patients with the longest sleep duration, who also had insomnia, had more pain (P = .0004), fatigue (P = .0028), daytime sleepiness (P = .0136), and poorer sleep quality (P < .0001) and took more sleep medications (P = .0029) than did those without insomnia.

CONCLUSIONS

Pain is associated with self-reported poor sleep quality, napping, daytime sleepiness, and use of sleep medication. The relationship between pain and sleep characteristics differs based on the presence of insomnia and sleep duration. Studies are needed to evaluate the causal relationships between sleep and pain and test interventions for these cooccurring symptoms.

A systematic review and meta-analysis of behavioral sleep interventions for adolescents and emerging adults

In the United States, more than two-thirds of adolescents and one-third of emerging adults report habitual short sleep duration, which is a known risk factor for psychological distress. The primary aim of this systematic review and meta-analysis was to evaluate the effect of behavioral sleep-promoting interventions on the sleep characteristics (e.g., total sleep time and sleep efficiency) of adolescents and emerging adults (aged 12-25 y) who do not have a sleep disorder. The secondary aim was to determine the effect of behavioral sleep-promoting interventions on psychological distress. Multiple electronic databases were searched for relevant randomized controlled trials (RCTs) published in English. Fourteen RCTs were included in the qualitative synthesis (N = 932), seven were included in the meta-analysis (n = 711) to address the primary aim, and three (n = 253) were included to address the secondary aim. The pooled standardized mean difference for sleep-promoting interventions after treatment for total sleep time was 34.92 min (95% CI: 8.70, 61.14). Sleep-promoting interventions had no significant effect on sleep efficiency. More RCTs that involve adolescents and emerging adults are needed to determine the effect of sleep-promoting interventions on reducing psychological distress in this high-risk age group.

Rest-activity rhythms, daytime symptoms, and functional performance among people with heart failure

Sleep disturbance and decreased daytime activity are well-described among people with chronic heart failure (HF) who suffer from disabling daytime symptoms and poor function. Alterations in the circadian rhythmicity of rest-activity may also be associated with these outcomes. However, little is known about the associations between rest-activity rhythms (RARS), symptoms, and functional performance or the extent to which they are explained by sleep characteristics among people with HF. The purpose of this study is to evaluate parametric and non-parametric circadian characteristics of RARs and the associations between these variables, daytime symptoms, and functional performance among patients with stable heart failure (HF). We recruited adults with stable HF from HF disease management programs. Participants wore wrist actigraphs for 3 d, completed one night of unattended polysomnography and the Six Minute Walk Test, and reported daytime symptoms and physical function. We performed cosinor, non-parametric, and spectral analyses to evaluate the rest-activity rhythms and computed bivariate correlations between the rest-activity rhythm, demographics, daytime symptoms, and functional performance. We conducted multiple regression analysis to examine how RARs contribute to daytime symptoms and functional performance after controlling for insomnia and covariates. The sample included 135 participants [Mean age = 60.6 (16.1) y, n = 88 (65.2%) male]. Older age, greater comorbidity, and poorer New York Heart Association (NYHA) Class, and more EEG arousals were associated with greater intra-daily variability of the RAR. More robust rhythmicity represented by the circadian quotient was associated with better NYHA class and less sleep fragmentation. A higher circadian quotient was significantly associated with lower fatigue, depression, and sleepiness, and better functional performance after controlling for insomnia and clinical and demographic characteristics. Circadian parameters of rest-activity are associated with symptoms and functional performance among people with HF independent of insomnia or sleep disordered breathing. Interventions targeted at improving the stability and strength of rest-activity rhythms may improve symptom and functional outcomes for these patients.

The Feasibility of Measuring Sleep and Circadian Characteristics in Adults with Inflammatory Bowel Disease

Interest in sleep and circadian research in inflammatory bowel disease (IBD) (Crohn's disease and ulcerative colitis) is growing; however, few studies have objectively measured sleep or circadian rhythms in people with these conditions. The purpose was to determine the feasibility of the use of wrist actigraphy, electronic sleep/activity diaries, and participant-collected saliva among adults with both active and inactive IBD. We conducted a 10-day feasibility study of adults aged 18 years to 60 years with IBD. We measured sleep and rest-activity rhythms with wrist actigraphy, self-reported sleep/activity using electronic diaries, and participant-collected saliva to compute salivary dim light melatonin onset. All 37 (100%) participants wore the wrist actigraphs, 91.8% (N = 34) participants completed at least 15 of the 18 electronic diaries, and 34 (91.9%) completed the saliva collection. It is feasible to use wrist actigraphy and electronic sleep/activity diaries in adult participants with inflammatory bowel disease.

Effects of Cognitive Behavioral Therapy for Insomnia on Sleep, Symptoms, Stress, and Autonomic Function Among Patients With Heart Failure

Background: Insomnia is common among patients with stable heart failure (HF) and associated with inflammation and altered autonomic function. Purpose: The purposes of this study were to examine the effects of cognitive behavioral therapy for insomnia (CBT-I) on the Hypothalamic Pituitary (HPA) Axis, autonomic function, inflammation, and circadian rhythmicity and the associations between these biomarkers and insomnia, sleep characteristics, symptoms, functional performance, and sleep-related cognitions. Methods: We conducted a subanalysis of a pilot randomized controlled trial (RCT, NCT02827799) whose primary aim was to test the effects of CBT-I on insomnia. We randomized 51 patients with stable Class II-IV HF to CBT-I (n = 30) or attention control (n = 21). Participants completed wrist actigraphy and self-reported insomnia severity, sleep characteristics, sleep-related cognitions, daytime symptoms, and functional performance. We measured day and nighttime urinary free cortisol, melatonin sulfate, epinephrine, and norepinephrine at baseline, and two weeks after CBT-I and computed general linear models and partial correlations. Results: CBT-I had no effects on the biomarkers, but there were statistically significant negative cross-sectional correlations between the ratio of day and night urinary free cortisol and sleep disturbance, anxiety, fatigue, depression, and negative sleep cognitions. Increases in the ratio between day and night cortisol were associated with statistically significant improvements in fatigue, depression, sleep duration, and sleep-related cognitions. Conclusions: Biomarkers of stress and autonomic function are associated with sleep, sleep-related symptoms, and cognitions among people with chronic HF. Future studies are needed to identify potential causal relationships and the impact of sleep interventions.

Agreement between actigraphic and polysomnographic measures of sleep in adults with and without chronic conditions: A systematic review and meta-analysis

Wrist actigraphy (ACT) may overestimate sleep and underestimate wake, and the agreement may be lower in people with chronic conditions who often have poor sleep and low activity levels. The purpose of this systematic review is to compare the agreement between ACT and polysomnographic (PSG) measures of sleep in adults without chronic conditions and sleep complaints (healthy) and with chronic conditions. We conducted a systematic review and meta-analysis using PRISMA guidelines. We searched PubMed, OVIDEMBASE, OVIDMEDLINE, OVIDPsycINFO, CENTRAL, CINAHL, ClinicalTrials.gov, International Clinical Trials Registry, and Open Grey. We included 96 studies with a total of 4134 participants, of whom 762 (18.4) were healthy adults and 724 (17.5%) were adults with chronic conditions. Among adults with chronic conditions, ACT overestimated TST, compared to PSG [M = 22.42 min (CI 95%: 11.92, 32.91 min)] and SE [M = 5.21% (CI 95%: 1.41%-9.00%)]. ACT underestimated SOL [M = -7.70 min (CI 95%: -15.22, -0.18 min)], and WASO [M = -10.90 min (CI 95%: -26.01, 4.22 min)]. These differences were consistently larger between ACT and PSG sleep measures compared to healthy adults. Research is needed to better understand factors that influence the agreement between ACT and PSG among people with chronic conditions.

Longitudinal Changes in Symptom Cluster Membership in Inflammatory Bowel Disease

PURPOSE

To describe changes in symptom cluster membership over 1 year and to examine which demographic and clinical factors predict changes in symptom cluster membership among adults with inflammatory bowel disease.

DESIGN

A retrospective longitudinal study of the Crohn's & Colitis Foundation of America Partners Cohort from 2012 to 2015.

METHODS

We measured symptoms of pain interference, fatigue, sleep disturbance, depression, and anxiety. We used latent transition analysis to describe changes in symptom cluster membership (baseline, 6 months, and 12 months) and multinomial regressions to examine factors associated with symptom cluster membership transition.

FINDINGS

Four groups were identified (N = 5,296): high symptom burden (32.3%-35.3%), low symptom burden (24.2%-27.1%), physical symptoms (19.0%-20.9%; pain, fatigue, sleep disturbance), and psychological symptoms (20.0%-21.5%; depression, anxiety). The probability of staying in the same group was .814 to .905. Moving from active disease into remission was associated with moving from the high burden to low burden and psychological symptom groups.

CONCLUSIONS

Symptom cluster membership was quite stable over 1 year. Research is needed to understand the underlying etiology of symptom clusters better and to develop interventions to reduce symptom burden in this vulnerable population.

CLINICAL RELEVANCE

Careful consideration of symptom management options should be done with patients to select options that are effective and potentially target multiple symptoms.

Discrepancy between wrist-actigraph and polysomnographic measures of sleep in patients with stable heart failure and a novel approach to evaluating discrepancy

Wrist-actigraphy is often used to measure sleep characteristics in a variety of populations, but discrepancies between actigraphic and polysomnographic measures have been noted in populations experiencing poor sleep quality. The purpose of this study is to examine the discrepancy between these measures and risk factors for discrepancy in people with heart failure using a novel index. We used sleep measures simultaneously recorded by actigraphy and polysomnography, and clinical data from a cross-sectional study of 155 patients with heart failure (age = 60.5 [16.1] years; 65.2% male) recruited from evidence-based heart failure disease management programmes. The discrepancy and consistency between the two measures were evaluated using Bland-Altman plots, intra-class correlations and a newly developed index that represents activity counts in wake episodes. Overall, participants had short total sleep time (327.7 [95.9] min) and poor sleep efficiency (71.3 [16.0]%) on polysomnography. The discrepancies between sleep measures were small in patients less than 60 years old, and there was excellent consistency (intra-class correlation = 0.81) compared with older patients who had poorer consistency (intra-class correlation = 0.53) on total sleep time. Higher daytime motor activity, poor sleep quality and more severe insomnia were associated with smaller discrepancies in older, but not younger, patients, and associations were more sensitively detected by the new index. These findings suggest the importance of aging, disability and co-morbidity that may influence motor activity from which sleep estimates are scored with actigraphy. The new index may be useful in identifying factors associated with the correspondence between actigraphy and polysomnography.

Identification of genetic variants associated with dengue or West Nile virus disease: a systematic review and meta-analysis

BACKGROUND

Dengue and West Nile viruses are highly cross-reactive and have numerous parallels in geography, potential vector host (Aedes family of mosquitoes), and initial symptoms of infection. While the vast majority (> 80%) of both dengue and West Nile virus infections result in asymptomatic infections, a minority of individuals experience symptomatic infection and an even smaller proportion develop severe disease. The mechanisms by which these infections lead to severe disease in a subset of infected individuals is incompletely understood, but individual host differences including genetic factors and immune responses have been proposed. We sought to identify genetic risk factors that are associated with more severe disease outcomes for both viruses in order to shed light on possible shared mechanisms of resistance and potential therapeutic interventions.

METHODS

We applied a search strategy using four major databases (Medline, PubMed, Embase, and Global Health) to find all known genetic associations identified to date with dengue or West Nile virus disease. Here we present a review of our findings and a meta-analysis of genetic variants identified.

RESULTS

We found genetic variations that are significantly associated with infections of these viruses. In particular we found variation within the OAS1 (meta-OR = 0.83, 95% CI: 0.69-1.00) and CCR5 (meta-OR = 1.29, 95% CI: 1.08-1.53) genes is significantly associated with West Nile virus disease, while variation within MICB (meta-OR = 2.35, 95% CI: 1.68-3.29), PLCE1 (meta-OR = 0.55, 95% CI: 0.42-0.71), MBL2 (meta-OR = 1.54, 95% CI: 1.02-2.31), and IFN-γ (meta-OR = 2.48, 95% CI: 1.30-4.71), is associated with dengue disease.

CONCLUSIONS

Despite substantial heterogeneity in populations studied, genes examined, and methodology, significant associations with genetic variants were found across studies within both diseases. These gene associations suggest a key role for immune mechanisms in susceptibility to severe disease. Further research is needed to elucidate the role of these genes in disease pathogenesis and may reveal additional genetic factors associated with disease severity.

Abstract P1-02-09: Targeting breast cancer stem cell state equilibrium through modulation of redox signaling

Breast cancer stem cells (BCSCs) maintain the plasticity to transition between quiescent mesenchymal- (M) and proliferative epithelial-like (E) states, but how this plasticity is regulated under metabolic/oxidative stress is poorly understood. Here, we show that M- and E-BCSCs exhibit markedly different sensitivities to the inhibitors of glycolysis and redox metabolism. Metabolic/Oxidative stress generated by 2DG/H2O2 or hypoxia promotes ROSlo M-BCSCs transition to their ROShi E-state. This transition is reversed by the antioxidant N-acetyl cysteine and facilitated by the activation of the AMPK-HIF1α axis. Moreover, E-BCSCs exhibit robust expression of NRF2/NFE2L2 and a wide variety of NRF2 downstream antioxidant responsive genes including the family of drug transporters and detoxification enzymes, NADPH production as well as the thioredoxin (TXN) and glutathione (GSH) antioxidant pathways. Suppression of NRF2 activity by a small-molecular inhibitor Trigonelline or shNRF2 mediated knockdown significantly decreased ALDH+ E- but not CD24-CD44+ M-BCSCs. This specific vulnerability of E-BCSCs to the inhibition of NRF2-mediated antioxidant defenses was also observed following inhibition of the downstream TXN and GSH antioxidant pathways, which promotes ROS-mediated differentiation and subsequent apoptosis of E-BCSCs. Co-inhibition of glycolysis and TXN/GSH pathways synergistically suppressed tumor growth and tumor initiating potential in two patient-derived xenograft models of triple negative breast cancer by eliminating both M- and E-BCSCs. Together, our studies reveal novel cellular and molecular mechanisms demonstrating how modulation of redox signaling regulates the equilibrium of two distinct BCSC states. These studies define the metabolic vulnerabilities of M- and E-BCSCs, and also provide a novel therapeutic approach to collectively target these distinct CSC states. As the CSC state equilibrium may be similarly regulated across a spectrum of tumors with diverse oncogenic drivers, this approach may have broad therapeutic applicability.

Citation Format: Luo M, Shang L, Brooks M, Jiagge E, Zhu Y, Conley S, Fath MA, Harouaka R, Merajver SD, Spitz DR, Wicha MS. Targeting breast cancer stem cell state equilibrium through modulation of redox signaling [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-02-09.

Symptom clusters in adults with inflammatory bowel disease

Symptoms (pain, fatigue, sleep disturbance, depression, and anxiety) in inflammatory bowel disease (IBD) are associated with reduced quality of life. Understanding how IBD symptoms cluster and the clinical and demographic factors associated with symptom clusters will enable focused development of symptom management interventions. The study purposes were to (i) identify symptom cluster membership among adults with IBD and (ii) examine associations between demographic (age, gender, race/ethnicity, and education) and clinical factors (smoking status, time since diagnosis, medication type, IBD type, disease activity), and membership in specific symptom cluster groups. We conducted a retrospective study of data from the Crohn's and Colitis Foundation of America's (CCFA) Partners Cohort and used Patient Reported Outcome Measurement Information System (PROMIS) measures to measure pain interference, fatigue, sleep disturbance, anxiety, and depression. The sample included 5,296 participants with IBD (mean age 44, 72% female). In latent class analysis (LCA), four groups of participants were identified based on symptoms: "low symptom burden" (26% of sample), "high symptom burden" (38%), "physical symptoms" (22%), and "psychological symptoms" (14%). In multinomial regression, female gender, smoking, corticosteroids, Crohn's disease, and active disease state were associated with membership in the high symptom burden group. Additional research is needed to test interventions that may be effective at reducing symptom burden for individuals with IBD.

Symptom Cluster Research With Biomarkers and Genetics Using Latent Class Analysis

The purpose of this article is to provide an overview of latent class analysis (LCA) and examples from symptom cluster research that includes biomarkers and genetics. A review of LCA with genetics and biomarkers was conducted using Medline, Embase, PubMed, and Google Scholar. LCA is a robust latent variable model used to cluster categorical data and allows for the determination of empirically determined symptom clusters. Researchers should consider using LCA to link empirically determined symptom clusters to biomarkers and genetics to better understand the underlying etiology of symptom clusters. The full potential of LCA in symptom cluster research has not yet been realized because it has been used in limited populations, and researchers have explored limited biologic pathways.