Biomedical subjects
Publications and source records attributed to Barbara Phillips.
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While grading the strength of recommendations and the quality of underlying evidence enhances the usefulness of clinical guidelines, the profusion of guideline grading systems undermines the value of the grading exercise. An American College of Chest Physicians (ACCP) task force formulated the criteria for a grading system to be utilized in all ACCP guidelines that included simplicity and transparency, explicitness of methodology, and consistency with current methodological approaches to the grading process. The working group examined currently available systems, and ultimately modified an approach formulated by the international GRADE group. The grading scheme classifies recommendations as strong (grade 1) or weak (grade 2), according to the balance among benefits, risks, burdens, and possibly cost, and the degree of confidence in estimates of benefits, risks, and burdens. The system classifies quality of evidence as high (grade A), moderate (grade B), or low (grade C) according to factors that include the study design, the consistency of the results, and the directness of the evidence. For all future ACCP guidelines, The College has adopted a simple, transparent approach to grading recommendations that is consistent with current developments in the field. The trend toward uniformity of approaches to grading will enhance the usefulness of practice guidelines for clinicians.
PURPOSES: The purpose of this analysis was to investigate the prevalence and correlates of restless legs syndrome (RLS) symptoms in the 2005 National Sleep Foundation (NSF) Sleep in America 2005 Poll. The NSF poll is an annual telephone interview of a random, representative sample of US adults. METHODS: The NSF 2005 poll included 1,506 adults. Their mean age was 49 years, and 775 were women. RESULTS: Symptoms of RLS that included unpleasant feelings in the legs for at least a few nights a week, which were worse at night, were reported by 9.7% of individuals in this poll, including 8% of men and 11% of women. Those from the northeast United States were much less likely to be at risk than those from other regions of the country (p < 0.05). Those who were unemployed (p < 0.05) or smoked daily (p < 0.5) were more likely to be at risk for RLS, as were those with hypertension, arthritis, gastroesophageal reflux disease, depression, anxiety, and diabetes (p < 0.05 for all). Adults who were at risk for RLS appeared to also be at increased risk for sleep apnea and insomnia (p < 0.05), and were more likely to stay up longer than they planned, to take longer than 30 min to fall asleep, to drive when drowsy, and to report daytime fatigue than those who were not at risk (p < 0.05 for all). They were also more likely to report being late to work, missing work, making errors at work, and missing social events because of sleepiness than other respondents in the poll (p < 0.05 for all). CONCLUSIONS: RLS is significantly associated with medical and psychiatric conditions, other sleep disorders, unfavorable lifestyle behaviors, and adverse effects on daytime function. Chest physicians who practice sleep medicine need to be able to identify and manage RLS, which is prevalent and is associated with considerable morbidity.
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BACKGROUND: Obstructive sleep apnea (OSA) is a common medical condition with significant adverse consequences, but OSA remains undiagnosed in many individuals. The Berlin questionnaire is a validated instrument that is used to identify individuals who are at risk for OSA. DESIGN: We conducted an analysis of data from the Sleep in America 2005 Poll of The National Sleep Foundation (NSF). The NSF poll is an annual telephone interview of a representative sample of US adults. PARTICIPANTS: The 2005 NSF poll included 1,506 adults. The mean age of participants was 49 years (775 were women). MEASUREMENTS: The Berlin questionnaire was embedded in the NSF poll. This instrument includes questions about snoring, witnessed apneas, self-reported hypertension, and daytime sleepiness. Height and weight were included for the calculation of body mass index (BMI). The NSF poll included detailed demographic information and extensive questions related to all aspects of sleep. RESULTS: Of the 1,506 respondents, 26% (31% of men and 21% of women) met the Berlin questionnaire criteria indicating a high risk of OSA. The risk of OSA increased up to age 65 years. A significant number of obese individuals (57%) were at high risk for OSA. Those whose Berlin questionnaire scores indicated a high risk for OSA were more likely to report subjective sleep problems, a negative impact of sleep on quality of life, and a chronic medical condition than those who were at lower risk. CONCLUSIONS: As many as one in four American adults could benefit from evaluation for OSA. Considering the serious adverse health and quality-of-life consequences of OSA, efforts to expedite diagnosis and treatment are indicated.
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STUDY OBJECTIVES: We investigated the prevalence and hazard ratios for insomnia complaints in a large cohort of middle-aged men and women. DESIGN: The Atherosclerosis Risk in Communities Study is a prospective study of cardiovascular disease. Using multivariate regression analysis, we predicted the likelihood of endorsing the insomnia complaints by age, sex, alcohol intake, smoking, diabetes, heart disease, menopausal status, use of hypnotics, hypertension, depressive symptoms, education level, body mass index, respiratory symptoms, and pulmonary function status. We predicted the hazard ratios (HR) of death at 6.3 +/- 1.1 year by endorsement of insomnia complaints and by hypnotic use controlling for covariates. SETTING: North American communities. PARTICIPANTS: 13563 participants aged 45 to 69 years at baseline INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The prevalence of insomnia complaints in this cohort was 23%. Predictors of insomnia complaints were female sex (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.45-0.70 for men), annual family income below 50,000 dollars (OR 1.23, CI 1.09-1.40), age 40 to 49 years (OR 1.29, CI 1.11-1.50), depressive symptoms (OR 5.05, CI 4.60-5.55), heart disease (OR 1.89, CI 1.67-2.14), severe airflow obstruction (OR 1.61, CI 1.17-2.22), pulmonary symptoms (OR 1.71, CI 1.5-1.95), and restrictive lung disease (OR 1.27, CI 1.10-1.47). After controlling for covariates, insomnia complaints were not associated with an increased risk for death (OR 1.01, CI 0.85-1.21), nor was the use of hypnotics (OR 1.38, CI 0.90-2.13). CONCLUSIONS: In this cohort, the prevalence of insomnia complaints was 23%. After controlling for confounders, neither insomnia complaints nor hypnotic use predicted increased mortality over 6.3 years.
The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post-resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.
The Royal College of Anaesthetists, the Royal College of Physicians, the Intensive Care Society and the Resuscitation Council (UK) have published new resuscitation standards. The document provides advice to UK healthcare organisations, resuscitation committees and resuscitation officers on all aspects of the resuscitation service. It includes sections on resuscitation training, resuscitation equipment, the cardiac arrest team, cardiac arrest prevention, patient transfer, post resuscitation care, audit and research. The document makes several recommendations. Healthcare institutions should have, or be represented on, a resuscitation committee that is responsible for all resuscitation issues. Every institution should have at least one resuscitation officer responsible for teaching and conducting training in resuscitation techniques. Staff with patient contact should be given regular resuscitation training appropriate to their expected abilities and roles. Clinical staff should receive regular training in the recognition of patients at risk of cardiopulmonary arrest and the measures required for the prevention of cardiopulmonary arrest. Healthcare institutions admitting acutely ill patients should have a resuscitation team, or its equivalent, available at all times. Clear guidelines should be available indicating how and when to call for the resuscitation team. Cardiopulmonary arrest should be managed according to current national guidelines. Resuscitation equipment should be available throughout the institution for clinical use and for training. The practice of resuscitation should be audited to maintain and improve standards of care. A do not attempt resuscitation (DNAR) policy should be compiled, communicated to relevant members of staff, used and audited regularly. Funding must be provided to support an effective resuscitation service.
BACKGROUND: CPAP remains the treatment of choice for Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS), but compliance with CPAP is poor. Of many interventions tried to improve CPAP compliance, only education and humidification have been shown to be of benefit. Our purpose was to develop and pilot test a video to enhance patient understanding of obstructive sleep apnea and of the purpose, logistics, and benefits of CPAP use in patients newly diagnosed with OSAHS. A patient's CPAP compliance in the first few weeks after starting its use is predictive of long-term compliance with CPAP treatment. It is imperative that patients grasp at the outset both the severity of OSAHS and the effectiveness of CPAP therapy. METHODS: An educational video script was written based on recommendations for patient educational video materials and covering identified misconceptions about OSAHS and perceived barriers to CPAP use. The videotape is 15 min in length and features two middle-aged males, one African-American and one Euro-American, discussing OSAHS and CPAP in a factory break room. RESULTS: In a randomized two-group design with a control group, patients with newly diagnosed OSAHS, and who viewed the CPAP educational video on their first clinic, were significantly more likely to use their machine and to return for a 1-month clinic visit than were those in the control group. CONCLUSION: Viewing of a patient education video at the initial visit was found to significantly improve the rate of return for the follow-up visit.
Untreated sleep apnea is a risk factor for hypertension, and CPAP treatment effects a blood pressure reduction comparable to that of pharmacologic monotherapy. Nevertheless, many current papers addressing the rapid increase in prevalence of hypertension and purporting to outline its management do not mention looking for or treating sleep apnea as a strategy. In addition to hypertension, virtually every adverse cardiovascular condition has been strongly associated with sleep disordered breathing in cross-sectional studies. There are also small prospective studies of the relationship between sleep-disordered breathing (SDB) and coronary heart disease and atrial fibrillation. Further, treatment studies show improvement or reduced risk of most cardiovascular sequelae of SDB with CPAP treatment. Beyond hypertension, which is well established, the strongest relationships between SDB and cardiovascular disease appear to be with congestive heart failure and bradyarrhythmias. Prospective studies are needed to confirm these relationships and to further delineate the risk.
PURPOSE: We assess the effect of consumer-directed care on the emotional, physical, and financial well-being of the primary informal caregivers of the Medicaid beneficiaries who voluntarily joined Arkansas's Cash and Counseling demonstration. DESIGN AND METHODS: The demonstration randomly assigned beneficiaries to a program in which they could direct their own disability-related supportive services (the treatment group) or rely on traditional agency services (the control group). We constructed outcome measures from telephone interviews with 1,433 caregivers who provided beneficiaries with the most unpaid assistance at baseline, and we used multivariate regression models to estimate program effects. Interviews occurred between February 2000 and April 2002, 10 months after beneficiaries' random assignment. RESULTS: At follow-up, treatment group caregivers provided fewer hours of assistance than did their control group counterparts, on average, and they reported better emotional, physical, and financial well-being. IMPLICATIONS: Permitting interested Medicaid beneficiaries to direct their own in-home supportive services reduces burden on informal caregivers, which may help reduce beneficiaries' nursing home use.
PURPOSE: This study describes the experiences of workers hired under consumer direction. DESIGN AND METHODS: Medicaid beneficiaries who volunteered for the Cash and Counseling demonstration were randomly assigned to the treatment group, which could participate in the consumer-directed program, or the control group, which was referred to agency care. Paid workers for both groups were surveyed about 10 months after demonstration enrollment. RESULTS: Directly hired workers for the treatment group were nearly always the consumers' friends or relatives. The two groups received similar wages and both were highly satisfied with their working conditions and the supervision they received. Compared with agency workers, directly hired workers who lived with or were related to the consumer were more likely to report emotional strain and a desire for more respect from the consumer's family; however, no such differences were observed for directly hired workers who were not relatives. Directly hired workers and agency workers providing comparable amounts of care reported similar levels of injury and physical strain, although directly hired workers received less formal training. IMPLICATIONS: The Cash and Counseling model does not appear to cause adverse consequences for the hired workers. Directly hired workers report high levels of job satisfaction and do not suffer physical or emotional hardship beyond what might be expected for individuals providing care to relatives. However, states might be able to reduce emotional strain and injuries by providing educational materials and referrals for consumers, their families, and workers, and by having counselors monitor workers' well-being.
OBJECTIVE: As the largest provider of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome health care services, the Department of Veterans Affairs (VA) has launched a national quality improvement program. As a first step, an assessment of how care for veterans with HIV/acquired immunodeficiency syndrome was organized was conducted. METHODS: Structured surveys were administered to senior HIV clinicians in 118 VA facilities, about local approaches to structuring, staffing, and delivering HIV health services. RESULTS: HIV care was chiefly delivered in special VA-based HIV clinics. HIV-related services were widely available on site, with non-VA referrals being more commonly needed to meet long-term care needs. Urban VA facilities had greater HIV caseloads, were more likely to have separate HIV clinics, and had greater access to HIV expertise, whereas rural practices focused on primary care-based models and tended to rely on off-site VA HIV experts. CONCLUSIONS: Understanding the organization and management of VA-based HIV services will help design systematic quality improvement efforts and meet the treatment needs of HIV-infected veterans.
This review focuses on restless legs syndrome (RLS) and Parkinson's disease (PD). These conditions are frequently encountered in clinical sleep medicine and are among the most important of the "nonapnea" sleep disorders. RLS and PD share many features, including derangement of central dopaminergic systems as the putative cause, akathisia, and nocturnal motor fluctuations. In addition, both conditions increase in prevalence with aging, exhibit a beneficial response to dopaminergic therapy, and cause marked sleep disturbances. They frequently overlap, with about 20% of patients with PD having symptoms of RLS. Both conditions appear to have a genetic predisposition that is "turned on" by environmental factors. Adverse responses to levodopa occur in both RLS and PD, manifested as rebound and augmentation in RLS and as fluctuations in motor response and dyskinesias in PD. Newer dopaminergic agents are helpful in the management of both conditions.
PURPOSE: To identify and model the effects of sleep loss and fatigue on resident-physicians' professional lives and personal well-being. METHOD: In 2001-02, 149 residents at five U.S. academic health centers and from six specialties (obstetrics-gynecology, emergency medicine, family medicine, internal medicine, pediatrics, surgery) were recruited for the study. Residents were all in good standing in their programs. In a mixed-methods design, focus groups consisted of an average of seven (range, three to 14) individuals in the same year of training and residency program, for a total of 60 interns and 89 senior residents. Trained moderators conducted focus groups using a standardized, semistructured discussion guide. Participants also completed a 30-item quantitative questionnaire assessing sleepiness and workplace sleep attitudes that included the Epworth Sleepiness Scale (ESS). RESULTS: Residents described multiple adverse effects of sleep loss and fatigue on learning and cognition; job performance, including professionalism and task performance; and personal life, including personal well-being and relationships with spouse or significant other and family. Only 16% of the sample scored within the "normal" range on the ESS; 84% scored in the range for which clinical intervention is indicated. Sleepiness was consistent across institution, specialty, years of training, age, gender, marital status, and having children. CONCLUSIONS: More residents perceived that sleep loss and fatigue had major impact on their personal lives during residency, leaving many personal and social activities and meaningful personal pleasures deferred or postponed. Sleep loss and fatigue also had major impact on residents' abilities to perform their work. This finding further substantiates the growing concern about the potential impact on professional development. These observations should be taken into account in developing new training guidelines and educational interventions for housestaff.
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