In England in Europe, Elizabeth Tyler focuses on two histories: the Encomium Emmae Reginae, written for Emma the wife of the Æthelred II and Cnut, and The Life of King Edward, written for Edith the ...wife of Edward the Confessor.Tyler offers a bold literary and historical analysis of both texts and reveals how the two queens actively engaged in the patronage of history-writing and poetry to exercise their royal authority. Tyler’s innovative combination of attention to intertextuality and regard for social networks emphasizes the role of women at the centre of Anglo-Saxon and Anglo-Norman court literature. In doing so, she argues that both Emma and Edith’s negotiation of conquests and factionalism created powerful models of queenly patronage that were subsequently adopted by individuals such as Queen Margaret of Scotland, Countess Adela of Blois, Queen Edith/Matilda, and Queen Adeliza.
Sleep and physical activity are both modifiable behavioural factors that are associated with better health and are potentially related. Following traumatic brain injury, damage to the brain caused by ...an external force, sleep disturbances are common. Exploring bidirectional relationships between sleep and physical activity might provide insight into whether increasing physical activity could decrease these sleep disturbances. The current study, therefore, examined inter‐ and intra‐individual temporal associations between sleep and daytime physical activity in 64 people with traumatic brain injury reporting sleep problems or fatigue (47 males; mean age, 40 years). Sleep and physical activity were measured using actigraphy with corroborating sleep diaries over 14 consecutive days. Multilevel models were used to examine inter‐ and intra‐individual associations between physical activity and sleep. Inter‐individual variations showed that earlier bedtimes, earlier wake‐up times and lower sleep efficiency were associated with more physical activity. Intra‐individual temporal variations showed no significant association of daytime physical activity with sleep duration or continuity. However, shorter sleep time and less wake after sleep onset than usual were associated with more time spent in light‐intensity activity the next day. Therefore, sleep may have more of an influence on physical activity than physical activity has on sleep in people with traumatic brain injury. In conclusion, the results do not confirm a potential beneficial effect of physical activity on sleep but suggest that improving sleep quality might be relevant to support of a physically active lifestyle in people with traumatic brain injury. Further research is necessary to confirm these results.
Accurate assessment of sleep can be fundamental for monitoring, managing and evaluating treatment outcomes within diseases. A proliferation of consumer activity trackers gives easy access to ...objective sleep. We evaluated the performance of a commercial device (Fitbit Alta HR) relative to a research‐grade actigraph (Actiwatch Spectrum Pro) in measuring sleep before and after a cognitive behavioural intervention in insomnia disorder. Twenty‐five individuals with DSM‐5 insomnia disorder (M = 50.6 ± 15.9 years) wore Fitbit and Actiwatch and completed a sleep diary during an in‐laboratory polysomnogram, and for 1 week preceding and following seven weekly sessions of cognitive‐behavioural intervention for insomnia. Device performance was compared for sleep outcomes (total sleep time, sleep latency, sleep efficiency and wake after sleep onset). The analyses assessed (a) agreement between devices across days and pre‐ to post‐treatment, and (b) whether pre‐ to post‐treatment changes in sleep assessed by devices correlated with clinical measures of change. Devices generally did not significantly differ from each other on sleep variable estimates, either night to night, in response to sleep manipulation (pre‐ to post‐treatment) or in response to changes in environment (in the laboratory versus at home). Change in sleep measures across time from each device showed some correlation with common clinical measures of change in insomnia, but not insomnia diagnosis as a categorical variable. Overall, the Fitbit provides similar estimates of sleep outside the laboratory to a research grade actigraph. Despite the similarity between Fitbit and Actiwatch performance, the use of consumer technology is still in its infancy and caution should be taken in its interpretation.
Aims/hypothesis
Sleeping difficulty has been associated with type 2 diabetes in some prior studies. Whether the observed associations are independent of health behaviours, other cardiovascular risk ...factors or other sleep disorders is unclear.
Methods
We analysed data from 133,353 women without diabetes, cardiovascular disease and cancer at baseline in the Nurses’ Health Study (NHS, 2000–2010) and the NHSII (2001–2011). Sleeping difficulty was assessed as having difficulty falling or staying asleep ‘all of the time’ or ‘most of the time’ at baseline (2000 in NHS and 2001 in NHSII).
Results
We documented 6,407 incident cases of type 2 diabetes during up to 10 years of follow-up. After adjustment for lifestyle factors at baseline, comparing women with and without sleeping difficulty, the multivariate-adjusted HR (95% CI) for type 2 diabetes was 1.45 (95% CI 1.33, 1.58), which changed to 1.22 (95% CI 1.12, 1.34) after further adjustment for hypertension, depression and BMI based on the updated repeated measurements. Women who reported all four sleep conditions (sleeping difficulty, frequent snoring, sleep duration ≤6 h and sleep apnoea in NHS or rotating shift work in NHSII) had more than a fourfold increased likelihood of type 2 diabetes (HR 4.17, 95% CI 2.93, 5.91).
Conclusions/interpretation
Sleeping difficulty was significantly associated with type 2 diabetes. This association was partially explained by associations with hypertension, BMI and depression symptoms, and was particularly strong when combined with other sleep disorders. Our findings highlight the importance of sleep disturbance in the development and prevention of type 2 diabetes.
OBJECTIVES
Peanut allergy in children is a population health problem. Evidence suggests early peanut introduction (EPI) for infants can reduce the development of peanut allergy. Primary care settings ...have not widely adopted guidelines recommending EPI. Peanut allergy prevention depends on primary care providers incorporating EPI guidelines into well-child check (WCC) encounters. We aimed to improve guideline adherence in a primary care setting by implementing a bundle of clinical decision support (CDS) tools.
METHODS
Using quality improvement methodology, the team developed a standardized work protocol and CDS tools within an electronic medical record (EMR) at 4, 6, and 9-month WCC encounters. The team executed changes and modifications through plan-do-study-act cycles and analyzed results with statistical process control charts.
RESULTS
We collected data from 445 WCC encounters from baseline through sustainability. EMR documentation of EPI guidance at 4, 6, and 9-month WCCs shifted from 13.9% to 83.5% over 12 months. Provider adoption of smart lists and templates increased from 2% to 73%, the distribution of home peanut introduction handouts increased from 5.2% to 54.1%, and caregiver-reported peanut ingestion increased from 0% to 34.6%. Diphtheria-tetanus-acellular pertussis vaccination rates remained at 100% for 6-month visits, and patient in-room time remained at 65 minutes.
CONCLUSIONS
Quality improvement methodology improved documentation of EPI guidance and increased reported peanut ingestion at routine WCC encounters without impacting other measures. Broader use of bundled CDS tools and EMR standardization could further improve guideline adherence and increase early peanut introduction to prevent peanut allergy in infants.
Objective: Insomnia and nightmares are central features of posttraumatic stress disorder (PTSD). However, often they are inadequately assessed and ineffectively resolved following gold-standard PTSD ...treatment. Here we: (a) evaluate effects of prolonged exposure (PE) on subjectively measured sleep and (b) present pilot results of an examination of whether adding sleep interventions (imagery rehearsal therapy IRT and cognitive-behavioral therapy for insomnia CBT-I) to PE improves treatment response, relative to PE alone, for night- and/or daytime PTSD symptoms among returning U.S. veterans and postdeployment personnel. Method: In a parallel-groups, randomized controlled trial, participants received 12 sessions of PE followed by IRT (5 weeks) and CBT-I (7 weeks) or PE followed by 12 weeks supportive care therapy (SCT). Results: PE did not improve sleep to a clinically meaningful degree, despite significant improvements in both Clinical Administered PTSD Scale and PTSD Checklist. Enhancing treatment with IRT/CBT-I led to greater improvements in insomnia (diary-recorded sleep efficiency) symptoms with large effect size, relative to SCT (p = .068, d = 1.07). There were large improvements in nightmare frequency relative SCT that did not reach statistical significance (p = .11, d = 0.90). Moreover, there was small improvement in daytime symptoms (Clinical Administered PTSD Scale) that did not reach statistical significance (p = .54, d = .31). Conclusion: The addition of targeted, validated sleep treatment improves effects of PE and improves nighttime symptoms. Thus, evidence-based sleep treatment should be considered in comprehensive PTSD treatment.
Clinical Impact Statement
Sleep problems, namely insomnia and nightmares, are a key part of posttraumatic stress disorder (PTSD). However current gold-standard exposure treatments for PTSD do not fully resolve sleep problems. Here we demonstrate that prolonged exposure reduced global PTSD symptoms but did not improve sleep. Subsequent evidence-based sleep interventions, imagery rehearsal therapy and cognitive-behavioral therapy for insomnia, improved nighttime, with a modest impact on daytime, symptoms. Results show need to specifically target both daytime and nighttime PTSD symptoms for optimal clinical outcomes.
Abstract
Patients with insomnia frequently report disturbing, or being disturbed by, their bedpartner. We aimed to (1) characterize how individuals with insomnia and their bedpartners influence each ...other’s sleep and (2) identify characteristics predicting vulnerability to wake transmission. Fifty-two couples (aged 19–82 years), where one individual was diagnosed with insomnia, participated. Sleep/wake patterns were monitored via actigraphy and sleep diaries for seven nights. Minute-by-minute sleep and wake concordance (simultaneous sleep/wake epochs), number of wake transmissions received (awakenings immediately preceded by wakefulness in the bedpartner), percent wake transmissions received (percentage of total awakenings that were transmitted), and percent of bedpartner’s wake minutes resistant to transmission (ability to sleep through bedpartner wakefulness) were calculated. Mixed-effects modeling assessed within-couple bedtime and chronotype differences as predictors of dyadic sleep. We described rates of sleep concordance (MPatient = 63.8%, MPartner = 65.6%), wake concordance (MPatient = 6.6%, MPartner = 6.6%), total transmissions received (MPatient = 5.5, MPartner = 6.9 per night), percent transmissions received (MPatient = 18.5%, MPartner = 23.4% of total awakenings), and percent minutes resistant (MPatient = 56.4%, MPartner = 58.6% of bedpartner’s wake time). Partners received wake transmissions at 1.25 times the rate of patients. Percent transmissions received was increased in couples with concordant bedtimes and individuals with later chronotype than their bedpartner. Patterns of chronotype and bedtime order predicting percent minutes resistant to transmission differed across the length of the rest interval. Transmission provides a novel characterization of how bedpartners influence sleep and provide insight into mechanisms of insomnia generation and maintenance. Understanding modifiable risk factors may provide ways to personalize insomnia treatments.
Clinical Trial Researching Effective Sleep Treatments (Project REST), ANZCTR Registration: ACTRN12616000586415
Literature suggests that adolescents may not accurately report sexual activity to their providers, impeding risk-based screening efforts for gonorrhea and chlamydia (GC/CT). We assessed the effect of ...a clinic-based universal GC/CT screening initiative on GC/CT screening frequency and detection of GC/CT infections among adolescents (boys and girls ≥13 years) and the association between positive GC/CT and documented sexual activity.
We conducted a pre-post analysis of a primary care clinic affiliated with an academic institution. The electronic medical record was queried to extract all adolescent well and acute encounters for the 12 months preimplementation and postimplementation of universal GC/CT screening in January 2015.
Eight hundred fifty-six encounters from 752 unique adolescents were included. Screening increased postimplementation (23.3% vs 61.4%, P < 0.001) of universal screening. Although there were similar rates of documented sexual activity preimplementation and postimplementation (14.6% vs 16.0%), a larger proportion of unknown sexual activity was documented (10.5% vs 23.7%, P < 0.001). Provider-level factors were the most frequent reasons for not screening. The absolute number of GC/CT cases increased, although the proportion of cases out of all eligible adolescents remained similar as more testing was completed (chlamydia, 5 of 752 vs 12 of 752; P = 0.09; gonorrhea, 0 of 752 vs 1 of 752; P = 0.32). Nearly half of positive chlamydia infections postimplementation appeared in adolescents who reported no sexual activity.
Universal screening in a primary care clinic increased screening and detection of cases of gonorrhea and chlamydia, including in adolescents who did not report sexual activity.
Can schools that boost student outcomes reproduce their success at new campuses? We study a policy reform that allowed effective charter schools in Boston, Massachusetts to replicate their school ...models at new locations. Estimates based on randomized admission lotteries show that replication charter schools generate large achievement gains on par with those produced by their parent campuses. The average effectiveness of Boston’s charter middle school sector increased after the reform despite a doubling of charter market share. An exploration of mechanisms shows that Boston charter schools compress the distribution of teacher effectiveness and may reduce the returns to teacher experience, suggesting the highly standardized practices in place at charter schools may facilitate replicability.
Solid state hydrogen–deuterium exchange with mass spectrometric analysis (ssHDX-MS) has been used to assess protein conformation and matrix interactions in lyophilized solids. ssHDX-MS metrics have ...been previously correlated to the formation of aggregates of lyophilized myoglobin on storage. Here, ssHDX-MS was applied to lyophilized monoclonal antibody (mAb) formulations and correlated to their long-term stability. After exposing lyophilized samples to D2O(g), the amount of deuterium incorporated at various time points was determined by mass spectrometry for four different lyophilized mAb formulations. Hydrogen–deuterium exchange data were then correlated with mAb aggregation and chemical degradation, which was obtained in stability studies of >2.5 years. Deuterium uptake on ssHDX-MS of four lyophilized mAb formulations determined at the initial time point prior to storage in the dry state was directly and strongly correlated with the extent of aggregation and chemical degradation during storage. Other measures of physical and chemical properties of the solids were weakly or poorly correlated with stability. The data demonstrate, for the first time, that ssHDX-MS results are highly correlated with the stability of lyophilized mAb formulations. The findings thus suggest that ssHDX-MS can be used as an early read-out of differences in long-term stability between formulations helping to accelerate formulation screening and selection.
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