Effects of afternoon "siesta" naps on sleep, alertness, performance, and circadian rhythms in the elderly

STUDY OBJECTIVES: To determine the effects of a 90-minute afternoon nap regimen on nocturnal sleep, circadian rhythms, and evening alertness and performance levels in the healthy elderly. DESIGN AND SETTING: Nine healthy elderly subjects (4m, 5f, age range 74y-87y) each experienced both nap and no-nap conditions in two studies each lasting 17 days (14 at home, 3 in the laboratory). In the nap condition a 90-minute nap was enforced between 13:30 and 15:00 every day, in the no-nap condition daytime napping was prohibited, and activity encouraged in the 13:30-15:00 interval. The order of the two conditions was counterbalanced. PARTICIPANTS: N/A INTERVENTIONS: N/A MEASUREMENTS: Diary measures, pencil and paper alertness tests, and wrist actigraphy were used at home. In the 72 hour laboratory studies, these measures were augmented by polysomnographic sleep recording, continuous rectal temperature measurement, a daily evening single trial of a Multiple Sleep Latency Test (MSLT), and computerized tests of mood, activation and performance efficiency. RESULTS: By the second week in the "at home" study, an average of 58 minutes of sleep was reported per siesta nap; in the laboratory, polysomnography confirmed an average of 57 minutes of sleep per nap. When nap and no-nap conditions were compared, mixed effects on nocturnal sleep were observed. Diary measures indicated no significant difference in nocturnal sleep duration, but a significant increase (of 38 mins.) in 24-hour Total Sleep Time (TST) when nocturnal sleeps and naps were added together (p<0.025). The laboratory study revealed a decrease of 2.4% in nocturnal sleep efficiency in the nap condition (p<0.025), a reduction of nocturnal Total Sleep Time (TST) by 48 mins. in the nap condition (p<0.001) which resulted primarily from significantly earlier waketimes (p<0.005), but no reliable effects on Wake After Sleep Onset (WASO), delta sleep measures, or percent stages 1 & 2. Unlike the diary study, the laboratory study yielded no overall increase in 24-hour TST consequent upon the siesta nap regimen. The only measure of evening alertness or performance to show an improvement was sleep latency in a single-trial evening MSLT (nap: 15.6 mins., no nap: 11.5 mins., p<0.005). No significant change in circadian rhythm parameters was observed. CONCLUSIONS: Healthy seniors were able to adopt a napping regimen involving a 90-minute siesta nap each day between 13:30 and 15:00, achieving about one hour of actual sleep per nap. There were some negative consequences for nocturnal sleep in terms of reduced sleep efficiency and earlier waketimes, but also some positive consequences for objective evening performance and (in the diary study) 24-hour sleep totals. Subjective alertness measures and performance measures showed no reliable effects and circadian phase parameters appeared unchanged.     

Environmental surface cleanliness and the potential for contamination during handwashing

Effective handwashing (including drying) is important in infection control. The ability of the various stages of handwashing to decrease skin-surface microbial counts has been documented. However, an important element, environmental surface cleanliness, and the potential for contamination of hands during the process has not been well studied or quantified. An examination of the adenosine triphosphate (a measure of residual organic soil), bacterial, and staphylococcal load on ward handwash station surfaces, which could be touched during handwashing, is reported. Hand contact surfaces tested consisted of approximately 620 each of: faucet handles, soap dispenser activator mechanisms, and folded paper-towel dispenser exits. Failure rates in excess of benchmark clean values were higher with adenosine triphosphate assays than microbial counts. This could indicate the presence of a higher level of general organic debris (eg, skin cells) as opposed to microbial contamination or could reflect greater assay sensitivity. Faucet handles were more likely to be contaminated and be in excess of benchmark values than paper-towel dispenser exits. However, the latter are likely to be the final surface touched during the handwashing process and overall nearly 20% were above microbiologic benchmark values. Many of the organisms isolated were staphylococci and the results are discussed within the context of microbial cross-contamination and potential pathogen spread.     

Breast-conserving therapy with adjuvant paclitaxel and radiation therapy: feasibility of concurrent treatment

As commonly used, adjuvant paclitaxel after doxorubicin in high-risk breast cancer patients results in a prolonged delay of the onset of radiation therapy after breast-conserving surgery. Concurrent delivery of breast irradiation with paclitaxel would allow for earlier initiation of radiation. We report on the toxicity of concurrent paclitaxel and breast irradiation after doxorubicin and cyclophosphamide. Twenty-four patients were treated with concurrent breast radiation and paclitaxel. All patients received four cycles of doxorubicin and cyclophosphamide followed by four cycles of paclitaxel, 175 mg/m2 every 3 weeks. The radiation therapy started after the first cycle in 3 patients, after the second cycle in 16, and after the third in 5. The breast received 4680-5040 cGy external beam irradiation, followed by a boost of 1000-2000 cGy. Fifteen patients received supraclavicular irradiation, and a posterior axillary supplement was used in five patients. Median follow-up after completion of irradiation was 11.5 months (range 2-29 months) with 21 patients followed >or=6 months, 12 followed >or=12 months, and 7 followed >or=18 months. Using Radiation Therapy Oncology Group (RTOG) acute toxicity scoring criteria, 7 patients experienced grade 1 skin and/or soft tissue reactions and 17 patients had grade 2 reactions. The average total duration of radiation treatment was 49 days (range 41-57 days). Only eight patients had radiation therapy interruptions for a median of 3.5 days (range 2-8 days): two more than 5 days. None had a chemotherapy dose reduction. One patient discontinued paclitaxel after the third cycle due to bilateral upper extremity neuropathy. No cases of pneumonitis or brachial plexopathy were seen. Concurrent treatment with every 3-week paclitaxel and breast irradiation was well tolerated. Additional study is needed to determine optimal timing, long-term toxicity, and potential benefits of concurrent radiation therapy and paclitaxel.     

Fascia iliaca compartment block for femoral bone fractures in prehospital care

BACKGROUND AND OBJECTIVES: The fascia iliaca compartment block provides a faster and more consistent simultaneous blockade of the lateral cutaneous and femoral nerves than the "3 in 1" block. We studied the effectiveness of this technique for analgesia after a femoral bone fracture in pre-hospital care. METHODS: Patients with an isolated femoral shaft fracture were included. A fascia iliaca compartment block was performed on all of them. Twenty milliliters of lidocaine 1.5 % with epinephrine were injected under the fascia iliaca. The intensity of pain was measured using a simplified verbal scale (SVS) from 0 (no pain) to 4 (extreme pain). The SVS was noted before the block was performed, 10 minutes later, and then on admission to the trauma care center. Sensory blockade was evaluated using cold perception in the lateral, medial, and internal part of the thigh 10 minutes after block performance and on arrival at the trauma care center. RESULTS: Twenty-seven patients were enrolled in this study. The SVS was 3 (3-4) before the block, 1 (0-2) 10 minutes after the block, and 0 (0-1) when arriving at the trauma care center (P <.05). The SVS was lower when the internal part of the thigh was blocked. CONCLUSION: The fascia iliaca compartment block is a simple, inexpensive, and effective method of prehospital analgesia for femoral shaft fracture. A sensory block of the internal part of the thigh is an early predictive sign of optimal pain relief.     

Routine prophylactic antibiotics for arthroplasty patients receiving dental care. Is it necessary?

Much of the debate regarding the prophylactic use of antibiotics for patients who have had a total joint replacement has focussed on their use before dental procedures. Despite the fact that almost all orthopaedic surgeons routinely recommend antibiotics for patients with prosthetic joints who require dental treatment, there is little evidence of a definitive link between transient bacteraemia occurring during dental procedures and late infections around prosthetic joints. An extensive review of the literature reveals that most authors recommend prophylactic antibiotics in high-risk patients or in those who undergo extensive dental surgery.     

Glatiramer acetate (Copaxone): comparison of continuous versus delayed therapy in a six-year organized multiple sclerosis trial

The aim of this study was to assess the long-term safety and efficacy of glatiramer acetate (GA) for patients with multiple sclerosis (MS) who received active treatment versus those on placebo for approximately 30 months (24-35 months) before receiving GA during a six-year organized, prospective open label study. Entry required two relapses in the previous two years and an Expanded Disability Status Scale (EDSS) score of 0-5. Patients (251) were equally randomized to daily subcutaneous GA, 20 mg, or to placebo. After approximately 30 months, 208 patients continued in an open label study: 101 continued on GA and 107 switched from placebo to active drug. Groups were well matched at randomization and entry to the open label study. Patients always on GA showed a steady decline in relapses: a mean of 1.5 per year at entry, a mean of 0.42 over the entire six years (95% CI = 0.34-0.51), a 72% reduction (P = 0.0001). They averaged a relapse every four + years (yearly rate 0.23 in year six) and 26/101 remain relapse free. Patients did less well if on placebo for 30 months, but relapses then declined, and by year six the rates were similar. Of patients always on GA, 69% showed neurological improvement of > or = 1 EDSS steps or remained stable compared with 57% if GA treatment was delayed. Of relapse-free patients always on GA over six years, only three of 26 (11%) were worse by > or = 1 EDSS steps, whereas nine of 21 (43%) in the placebo/active group were worse (P < 0.03). Disability, measured every six months, showed that the group of patients always on GA was relatively stable over the six years, while the group who received placebo for the first two-and-a-half years did significantly less well. Daily injections of GA were well tolerated. This longest ever organized MS treatment trial shows that delaying therapy with GA increases the risk of neurologic disability, reinforcing the rationale for using GA as a first-line treatment early in the course of relapsing-remitting MS.     

Inhibition of neuronal nitric oxide synthase increases dopamine efflux from rat striatum

Summary. The physiological role of nitric oxide in the control of striatal dopamine release has not been fully established, therefore, the effect of neuronally produced nitric oxide (NO) on striatal dopamine (DA) efflux were investigated using in vivo microdialysis in anaesthetised and conscious rats. In the anaesthetised rat, the nitric oxide synthase inhibitors N^G-nitro-L-arginine methylester (L-NAME) and 7-nitroindazole monosodium salt (7-NINA) produced concentration-dependent increases in DA efflux. The L-NAME (1 mM)- and 7-NINA (1 mM)-induced increase was reduced by co-administration with the NO precursor, L-arginine (L-ARG; 1 mM) by 37% and 54% respectively, and was prevented by tetrodotoxin (TTX, 1 μM). Similarly, in conscious rats, L-NAME (1 mM) and 7-NINA (1 mM) increased DA efflux to 161% and 166% of basal efflux respectively. These data suggest that neuronally produced NO inhibits striatal DA efflux through an indirect mechanism. Received February 28, 2002; accepted September 24, 2002 Published online December 9, 2002 Acknowledgements This study was supported by the Medical Research Council, the Parkinson's Disease Society and the National Parkinson Foundation, Miami. MTS held a MRC Training Fellowship, SR is a Fellow of the National Parkinson Foundation, Miami. Authors' address: Prof. P. Jenner, Neurodegenerative Diseases Research Centre, Guy's, King's and St Thomas' School of Biomedical Sciences, King's College London, London, SE1 1UL, United Kingdom, e-mail: div.pharm@kcl.ac.uk Abbreviations DA dopamine; DOPAC 3,4-dihydroxyphenylacetic acid; HVA homovanillic acid; NO nitric oxide; D-NAME N^G-nitro-D-arginine methyl ester; L-NAME N^G-nitro-L-arginine methyl ester; NO nitric oxide; MAO-B monoamine oxidase-B; 7-NINA monosodium salt of 7-nitroindazole; NOS nitric oxide synthase