Fatigue is the most prevalent and distressing symptom experienced by patients receiving adjuvant chemotherapy for early stage breast cancer. Higher fatigue levels have been related to sleep maintenance problems and low daytime activity in patients who have received chemotherapy, but knowledge describing these relationships prior to chemotherapy is sparse. The Piper Integrated Fatigue Model guided this study, which describes sleep/wake, activity/rest, circadian rhythms, and fatigue and how they interrelate in women with Stage I, II, or IIIA breast cancer during the 48 hours prior to the first adjuvant chemotherapy treatment. The present report describes these variables in 130 females, mean age=51.4 years; the majority were married and employed. Subjective sleep was measured by the Pittsburgh Sleep Quality Index and fatigue was measured by the Piper Fatigue Scale. Wrist actigraphy was used to objectively measure sleep/wake, activity/rest, and circadian rhythms. Mean Pittsburgh Sleep Quality Index score was 6.73+/-3.4, indicating poor sleep. Objective sleep/wake results were within normal limits established for healthy individuals, except for the number and length of night awakenings. Objective activity/rest results were within normal limits except for low mean daytime activity. Circadian rhythm mesor was 132.3 (24.6) and amplitude was 97.2 (22.8). Mean Piper Fatigue Scale score was 2.56+/-2, with 72% reporting mild fatigue. There were significant relationships between subjective and objective sleep, but no consistent patterns. Higher total and subscale fatigue scores were correlated with most components of poorer subjective sleep quality (r=0.25-0.42, P< or =0.005).

The BT group showed improved sleep quality over time and better sleep (diary). Perceptions of improved sleep quality over time are not consistently associated with diary or actigraph, or result in lower fatigue.

This meta-analysis investigates differences between the effect sizes of physical punishment and alternative disciplinary tactics for child outcomes in 26 qualifying studies. Analyzing differences in effect sizes reduces systematic biases and emphasizes direct comparisons between the disciplinary tactics that parents have to select among. The results indicated that effect sizes significantly favored conditional spanking over 10 of 13 alternative disciplinary tactics for reducing child noncompliance or antisocial behavior. Customary physical punishment yielded effect sizes equal to alternative tactics, except for one large study favoring physical punishment. Only overly severe or predominant use of physical punishment compared unfavorably with alternative disciplinary tactics. The discussion highlights the need for better discriminations between effective and counterproductive use of disciplinary punishment in general.

Future research should ensure adequate assessment for symptoms of anxiety and depression when examining sleep disturbance in children. Likewise, research on anxiety and depression should include assessment for symptoms of disturbed sleep. Bridging the gap between these literatures should provide further insights into the etiologies of these disorders, increase symptom detection, and improve the clinical care of children and their families.

No abstract

Selection bias can be the most important threat to internal validity in intervention research, but is often insufficiently recognized and controlled. The bias is illustrated in research on parental interventions (punishment, homework assistance); medical interventions (hospitalization); and psychological interventions for suicide risk, sex offending, and juvenile delinquency. The intervention selection bias is most adequately controlled in randomized studies or strong quasi-experimental designs, although recent statistical innovations can enhance weaker designs. The most important points are to increase awareness of the intervention selection bias and to systematically evaluate plausible alternative explanations of data before making causal conclusions.

The BT group, on average, experienced significant improvement on global sleep quality compared with the HEC group, but not on objective sleep or fatigue outcomes.

Future testing using an experimental design will focus on increasing ISPP adherence and decreasing nighttime awakenings. Adopting behavioral techniques to promote sleep may result in improved sleep and lower fatigue after chemotherapy.