Many studies have investigated whether sleep affects cognitively unmodulated reactivity to emotional stimuli. These studies operationalize emotion regulation by using subjective and/or objective measures to compare pre- and post-sleep reactivity to the same emotional stimuli. Findings have been inconsistent: some show that sleep attenuates emotional reactivity, whereas others report enhanced or maintained reactivity. Across-study methodological differences may account for discrepant findings. To resolve the questions of whether sleep leads to the attenuation, enhancement, or maintenance of emotional reactivity, and under which experimental conditions particular effects are observed, we undertook a synthesized narrative and meta-analytic approach. We searched PubMed, PsycINFO, PsycARTICLES, Web of Science, and Cochrane Library databases for relevant articles, using search terms determined a priori and search limits of language = English, participants = human, and dates = January 2006–June 2021. Our final sample included 24 studies that investigated changes in emotional reactivity in response to negatively and/or positively valenced material compared to neutral material over a period of sleep compared to a matched period of waking. Primary analyses used random effects modeling to investigate whether sleep preferentially modulates reactivity in response to emotional stimuli; secondary analyses examined potential moderators of the effect. Results showed that sleep (or equivalent periods of wakefulness) did not significantly affect psychophysiological measures of reactivity to negative or neutral stimuli. However, self-reported arousal ratings of negative stimuli were significantly increased post-sleep but not post-waking. Sub-group analyses indicated that (a) sleep-deprived participants, compared to those who slept or who experienced daytime waking, reacted more strongly and negatively in response to positive stimuli; (b) nap-exposed participants, compared to those who remained awake or who slept a full night, rated negative pictures less negatively; and (c) participants who did not obtain substantial REM sleep, compared to those who did and those exposed to waking conditions, had attenuated reactivity to neutral stimuli. We conclude that sleep may affect emotional reactivity, but that studies need more consistency in methodology, commitment to collecting both psychophysiological and self-report measures, and should report REM sleep parameters. Using these methodological principles would promote a better understanding of under which conditions particular effects are observed.
BACKGROUND AND OBJECTIVES: National guidelines recommend a 5- to 7-day course of antibiotics for most skin and soft-tissue infections (SSTIs). Our aim was to increase the percentage of pediatric patients receiving 5 to 7 days of oral antibiotics for SSTIs in our pediatric urgent care clinics (UCCs) from 60% to 75% by December 31, 2021. METHODS: We performed cause-and-effect analysis and surveyed UCC providers to uncover reasons for hesitation with short antibiotic courses for SSTIs. Plan- Do-Study-Act (PDSA) cycle 1 provided an update on current guidelines for UCC providers and addressed providers’ concerns. PDSA cycle 2 modified the electronic health record to display antimicrobial prescription sentences from shortest to longest duration. PDSA cycle 3 provided project outcome and balancing measure updates to UCC providers at regular intervals. We created a monthly report of patients 90 days and older in UCCs with a final diagnosis of SSTIs. We used a Shewhart control chart to identify special cause variations. RESULTS: After completing our PDSA cycles, we found that the percentage of children receiving 5 to 7 days of oral antibiotics for SSTIs exceeded 85%. The improvement was sustained over multiple months. There was no increase in the proportion of patients returning to the UCCs with an SSTI diagnosis within 14 days. CONCLUSIONS: By addressing primary drivers uncovered through quality improvement methodology, we shortened the antibiotic course for children seen in our UCCs with SSTIs. Outpatient antimicrobial stewardship programs may apply similar methods to other diagnoses to further improve duration of antibiotic prescriptions.
Background Acute otitis media (AOM) is the most common diagnosis for which antibiotics are prescribed in pediatrics. National guidelines recommend offering a safety net antibiotic prescription (SNAP) to select patients, to be filled if symptoms worsen or do not improve within 48-72 hours. However, clinicians continue to prescribe immediate antibiotics for most cases of AOM. Our goal was to increase the percentage of eligible patients diagnosed with AOM in our pediatric urgent care (PUC) clinics who are offered a SNAP from our baseline of 7.7% to 40% within nine months. Methods A multidisciplinary team of PUC clinicians, an Infectious Diseases physician, and a data analyst, used quality improvement (QI) methodology to identify barriers to offering SNAP (Figure 1). Patients without chronic ear conditions were considered eligible for SNAP if they had no or mild otalgia for < 48 hours, fever < 39oC, no otorrhea, and for patients ≤ 24 months old, if they had only unilateral AOM. We analyzed all encounters of patients ≥ 6 months old with a discharge diagnosis of AOM from three PUC clinics during baseline (October 2020 – September 2021) and study (October 2021 – March 2022) periods. Interventions included clinician education, standardized discharge instructions, electronic health record updates to improve documentation, and educational flyers for clinicians and families. Our outcome measure was the percentage of eligible encounters during which SNAP was offered. Our process measure was the percentage of AOM encounters in which SNAP eligibility was documented. Our balancing measure was the percentage of patients returning with AOM symptoms within 14 days. Results We reviewed 12,502 encounters from October 2020 through March 2022. At baseline, clinicians documented SNAP eligibility in 5.5% of AOM encounters and offered SNAP to 7.7% of eligible patients. By March 2022, clinicians documented SNAP eligibility in 58.9% of AOM encounters and offered SNAP to 40.7% of eligible patients (Figure 2). There was no change in our balancing measure. UCL: Upper control limit. LCL: Lower control limit. Conclusion Using QI methodology, we increased the percentage of eligible patients with AOM who were offered SNAP, reducing antibiotic exposure in PUC clinics. Efforts are ongoing to further improve this process. Disclosures Brian R. Lee, PhD, MPH, CDC: Grant/Research Support|Merck: Grant/Research Support.
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Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. Children with SSTIs often receive > 7 days of antibiotics, although current guidelines recommend 5-7 days for most diagnoses. At Children’s Mercy Hospital (CMH) urgent care clinics (UCC), only 58% patients received the recommended 5-7 days of antibiotics. We aimed to increase the percentage of patients receiving 5-7 days of oral antibiotics for SSTIs from 58% to 75% by December 31st, 2021. Methods We formed a multidisciplinary team in April 2020. A provider survey assessed factors influencing prescribing habits. We completed cause-and-effect analyses and developed a driver diagram (Figure 1). Interventions were chosen based on the potential for highest impact and lowest effort. Our first Plan-Do-Study-Act (PDSA) cycle provided an update on current guidelines for UCC providers. The second PDSA cycle updated prescription sentences in the electronic health record (EHR) and organized them from shortest to longest duration. The third PDSA cycle provided a project update via email to UCC providers. Our outcome measure is the percentage of patients receiving 5-7 days of antibiotics for SSTIs. Process measure is the number of updated prescriptions used. Balancing measure is the number of patients returning for SSTI within 14 days of their visit. Results are displayed using a run chart. Results After initiation of the project in April 2020, the percentage of patients receiving 5-7 days of antibiotics increased to 68% (Figure 2). This percentage increased to our goal of 75% after the 1st PDSA cycle (October-December 2020), 80% following the second PDSA cycle in February 2021, and 90% following the third PDSA cycle in April 2021. There was no change in balancing measure numbers. Run Chart Conclusion Prior to our project, only 58% of children seen in CMH UCCs for SSTIs received the recommended antibiotic duration. By addressing the primary drivers uncovered through QI methodology, we surpassed our goal of 75%. Additional PDSA cycles are planned along with expansion to other departments. This work will allow us to expand antibiotic stewardship efforts to other infectious diagnoses as well. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)
Background Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on the latter. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5–7 days for most diagnoses. Objectives To determine the baseline percentage of patients receiving antibiotic prescriptions for >7 days for SSTIs in urgent care clinics (UCC)s of a pediatric health system and to evaluate factors that influence providers towards longer durations. Methods We built a report that extracted patient encounters from the three UCCs based on International Classification of Diseases (ICD)-10 codes for common SSTIs including impetigo, abscesses, cellulitis, erysipelas, folliculitis, paronychia, and animal bites. Data was pulled from June 2019 through June 2020. The report included patient age, concomitant diagnoses, antibiotics prescribed and their duration. We excluded encounters if the patient was transferred to the emergency department or admitted, the patient was younger than 3 months of age, no antibiotics were prescribed, or if there was a concurrent infectious diagnosis affecting antibiotic duration. We sent a 22-question survey to UCC providers to understand prescribing habits particularly focusing on factors prompting administration of longer antibiotic courses. Findings From June 2019-June 2020, we reviewed 2,575 encounters; we excluded 208 of those (8%). 823 (35%) of patients received >7 days of antibiotics for SSTIs while 1181 (50%) received 5–7 days and 35 (1%) received <5 days of antibiotics. 328 (14%) received topical therapy only. Most common antibiotics prescribed included cephalexin, clindamycin, and trimethoprim-sulfamethoxazole. A mild improvement in the 5–7 days duration was noted through our study period (Figure 1). The survey was sent to 50 providers with 27 responding (54% response rate). Of providers surveyed, 5 (19%), 7 (26%), and 8 (29%), expressed being uncomfortable with a 5-day treatment course for cellulitis, erysipelas, and abscesses respectively. Barriers for shorter treatment courses included concern for acute rheumatic fever development, parental pressure, fear of complications, and accustomed antibiotic duration. Conclusion A third of children with SSTIs in our UCCs receive long courses of antibiotics. A mild improvement noted in our study period may be due to existing antibiotic stewardship interventions. Specific provider concerns leading to overprescribing will be targeted by quality improvement efforts.
AimsThe aim of the study was to investigate the potential association between gambling disorder and symptoms of sleep problems including insomnia and hypersomnolence. Gambling disorder is a behavioural addiction featuring persistent, recurrent gambling resulting in distress and impairment of function. Lifetime prevalence of gambling disorder is estimated at 0.6–0.9%, though high quality data in the UK are lacking. Psychiatric comorbidity is common; as are physical health problems such as hypertension. The association between sleep problems and other addictions such as alcohol misuse disorder, smoking and substance misuse has been established; however, research into gambling disorder and sleep problems is limited. It was hypothesised that, compared to controls, individuals with gambling disorder would have significantly greater disturbance of sleep, as indicated by increased scores in: 1) specific sleep items on the Hamilton Anxiety Rating Scale (HAMA) and Hamilton Rating Scale for Depression (HAMD), 2) total score on the HAMA and HAMD and 3) the Epworth Sleepiness Scale (ESS).MethodsA secondary analysis of a subset of previously published data by Grant and Chamberlain (2018) on gambling and impulsivity. A total of 152 non-treatment seeking adults, aged 18–29 years, who had gambled at least five times in the past year were recruited. Individuals were stratified into three groups: controls, those at risk of gambling disorder, and those with gambling disorder, as per DSM-5 criteria. One-way ANOVAs with post-hoc tests were conducted. These were used to show whether the three groups differed significantly in their scores in the sleep items and total scores of the HAMA and HAMD, and the ESS.ResultsThe HAMD scale demonstrated a significant increase in all patterns of insomnia for members of the disorder group, when compared to controls. The increase was particularly marked for middle and late insomnia. The HAMA item score demonstrated significantly worse sleep quality in the disorder group, compared to at risk and control groups. Total scores on the HAMA and HAMD scales were also significantly higher in the disorder group, reaching the thresholds for clinical significance for anxiety and depression. ESS scores were not significantly different between groups.ConclusionGlobal disruptions in sleep, as well late- and middle-insomnia, were found to be significantly higher in gambling disorder than controls. Symptoms of anxiety and depression were also significantly higher in the gambling disorder group. Further research could have implications for the identification and treatment of sleep disorders and psychiatric comorbidities in gambling disorder.
Ovarian cancer is the leading cause of death among gynecological cancers. There are many risk factors that can increase a woman’s susceptibility to breast and ovarian cancers, some of which are modifiable. However, non-modifiable risks for breast and ovarian cancer include the presence of genetic mutations (BRCA) increase the risk of these diseases. The purpose of this review was to identify factors, reported in the literature, known to affect women’s decision to get genetic testing for BRCA1 and BRCA2 mutations for hereditary breast and ovarian cancer. A total of 31 studies that met the inclusion criteria were included in this review. Several internal and external factors, influencing women’s decision to getting tested for BRCA mutations, were identified and explained. Implications for clinical practice were provided.
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