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Pregnant women report disturbed sleep, including habitual snoring and insomnia. The co-occurrence among non-pregnant cohorts is 30%-50% with increased risk for adverse health outcomes. To date, no study has examined the comorbid status or impact in pregnant women.The prevalence of insomnia (INS) and habitual snoring (HS) were examined in 439 women in the third trimester (34.1 ± 3.7 weeks). Habitual snoring (snoring ≥3 times/week) was self-reported. Insomnia was determined using the Insomnia Symptom Questionnaire (ISQ).Four groups emerged: HS-/ISQ- (n = 161; 36.7%), HS-/ISQ+ (n = 146; 33.3%), HS+/ISQ- (n = 63; 14.4%), and HS+/ISQ+ (n = 69; 15.7%). Logistic regression models revealed both independent associations, as well as comorbid HS/INS status with excessive daytime sleepiness (aOR 3.8, 95%CI 2.3-6.5, p 0.001; aOR 2.2, 95%CI 1.1-4.4, p = 0.02; aOR 7.2, 95%CI 3.7-14.0, p 0.001, respectively). Only comorbid HS/INS was associated with gestational hypertension (aOR 3.2 95%CI 1.0-10.6, p = 0.048). Insomnia alone and HS alone were associated with a baby born large for gestational age (aOR 2.9 95%CI 1.2-7.1, p = 0.019 and aOR 3.5, 95%CI 1.1-11.1, p = 0.034 respectively) but however, the comorbid state was not significantly associated with LGA. Only women with HS alone were at increased odds of having an unplanned cesarean section (aOR 2.2 95%CI 1.0-4.6, p = 0.046).Both insomnia alone and comorbid insomnia/habitual snoring were associated with adverse outcomes even after accounting for confounders. These findings are clinically relevant since adverse pregnancy outcomes may have severe consequences for both mother and baby. In order to mitigate these outcomes, identifying viable treatment(s) for women at risk should be considered a high priority.

Changes in fetal movement are associated with increased risk of stillbirth after 28 weeks of pregnancy. The majority of studies have focussed on maternal perception of reduced fetal movements, which is associated with stillbirth via placental dysfunction. Recent studies have also described an association between a single episode of excessive fetal movements and late stillbirth. We present a hypothesis that a sudden episode of excessive fetal activity indicates fetal compromise relating to underlying disturbance of the in utero environment, which if it persists can lead to fetal death. The origin of the excessive fetal movements is unknown; they may represent fetal seizures induced by asphyxia or infection, an attempt to release cord entanglement or a change in fetal behaviour (inducing signs of distress) in response to a noxious stimulus. It is also possible that an increase in maternal anxiety may lead to increased perception of fetal activity. Current evidence regarding excessive fetal movements is sparse; there is no clinical guidance regarding how reporting of this symptom might relate to a fetus at risk and which management might reduce the risk of subsequent stillbirth. This could be addressed by prospective observational studies of mothers presenting with excessive fetal movements which could both explore the underlying pathophysiology and determine which investigations could identify fetal compromise in this population. The presence of fetal seizures or umbilical cord entanglement could be evaluated at the time of presentation by cardiotocography and ultrasonography of the fetus and cord. Exposure to infection or noxious stimuli could be evaluated by maternal history and measurement of maternal blood for inflammatory markers or toxins. Maternal anxiety could be assessed by validated anxiety scores. Fetal outcome following excessive fetal movements can be recorded after birth. In addition, the presence of perinatal asphyxia can be assessed using Apgar scores, assessment of fetal acidaemia or measurement of stress-related factors in umbilical cord blood. The placenta and cord can be systematically examined for signs of hypoxia, infection or umbilical cord compression. Such studies would provide evidence regarding the underlying cause of excessive fetal movement and how this symptom might relate to in utero compromise and stillbirth. Ultimately, this approach will determine whether excessive fetal movements can be used alongside reduced fetal movements as a tool to reduce the perinatal mortality rate. Refereed/Peer-reviewed

Introduction: Patient education has been shown to improve continuous positive airway pressure (CPAP) compliance in the treatment of obstructive sleep apnea (OSA). This is facilitated by improving patient awareness of both the goals of treatment, proper use of the device and consequences of inadequate treatment. The most obvious outcome of successful therapy is an improvement in excessive daytime sleepiness. However, it is hypothesized that the long-term benefits of disease prevention and lessening the severity of conditions known to be associated with untreated OSA are less well recognized by patients. The purpose of this study was to document the degree of patient awareness of conditions associated with OSA. It is anticipated that a lack of knowledge exists in some patient subgroups; that if educated more intensely about these associations might be more diligent in participating in the treatment of their OSA. Methods: This study was a cross-sectional survey of patients who had been prescribed positive airway pressure (PAP) therapy for OSA. This survey assessed patient knowledge of co-morbid medical conditions associated with untreated OSA. Results: The vast majority of participants failed to recognize all of the most common co-morbid conditions. Significant differences in awareness were noted between different age groups and genders. Conclusions: Patient education is important in achieving CPAP compliance. Patient education, as demonstrated by a relative lack of knowledge of associated co-morbidities, appears to be inadequate. Greater efforts at patient education during each and every patient encounter in the sleep disorders clinic are recommended.

Recurrent atrial fibrillation (AF) after successful cardioversion can be predicted by obstructive sleep apnea (OSA) diagnosed by polysomnography. However, it is not known whether the validated STOP-BANG questionnaire can predict AF recurrence after radiofrequency ablation (RFA). Our objective is to determine the prevalence of unrecognized OSA in patients with AF and its relation to freedom from AF after RFA.Validated surveys were administered to 247 consecutive AF patients following radiofrequency ablation from January to October 2011. OSA status was assessed at baseline RFA. Clinical follow up occurred at 3-6 month intervals.OSA had been previously diagnosed in 94/247 (38%). Among 153 patients without prior diagnosis of OSA, 121 (79%) had high risk STOP-BANG scores for OSA. Probability of maintaining sinus rhythm after RFA was similar among patients with known OSA (66/94, 70%) and high risk OSA scores (95/124, 77%) and higher than among patients with low risk OSA scores (29/32, 91%, P=0.03). Among patients without prior OSA, a high risk STOP-BANG score did predict recurrent AF (OR = 3.7, 95 % CI 1.4-11.4, P = 0.0005). Multivariate analysis showed a higher risk of atrial arrhythmia recurrence for non-paroxysmal AF patients (OR = 3.1, ± 95 % CI 1.4-7.1, P = 0.005).The majority of AF patients undergoing RFA have high risk OSA scores, suggesting that OSA is vastly underdiagnosed in this population. STOP-BANG independently predicted recurrent AF in patients without a prior diagnosis of OSA.

© 2015 Taylor & Francis. Background: Sexually transmitted infections (STIs) are prevalent throughout the world with the rate of these infections increasing on a daily basis. STI acquisition has the ability to cause personal adversity and elicit feelings of stigma and shame. Aim: The aim of this paper is to report on the sources of support young women who acquired STIs drew on to overcome their associated adversity. Methods: This study utilised a feminist qualitative methodology. Findings: Findings revealed that the women drew on both personal and anonymous sources of support. Conclusion: Nurses and other health-care professionals need to be equipped with knowledge and strategies to promote personal wellbeing and minimise the adversity felt among people having acquired these infections.

Evidence suggests that while the high prevalence of obstructive sleep apnea (OSA) in children with Down syndrome (DS) likely contributes to sleep fragmentation, their poor sleep is only partly attributable to the presence of OSA. We hypothesized that a sleep phenotype exists for DS, which would be independent of OSA and evident across childhood. This is a retrospective study of sleep architecture in children with DS together with matched controls. All subjects underwent baseline polysomnography between January 1985 and January 2013. Case-control pairs were compared according to age group. Sleep characteristics were compared in 130 DS subjects aged 0–17.8 years (median 5.8 years) and 130 matched controls. Body mass index z-scores were similar between cases and controls. Compared to controls, children with DS had a lower sleep efficiency and higher percentage of slow-wave sleep at 2–6.9, 7–11.9, and 12–17.9 years (p

Background Stillbirth after 28 weeks gestation affects between 1.3–8.8 per 1000 births in high-income countries. The majority of stillbirths in this setting occur in women without established risk factors. Identification of risk factors which could be identified and managed in pregnancy is a priority in stillbirth prevention research. This study aimed to evaluate women’s experiences of fetal movements and how these relate to stillbirth. Methods An international internet-based case–control study of women who had a stillbirth ≥28 weeks’ gestation within 30 days prior to completing the survey (n = 153) and women with an ongoing pregnancy or a live born child (n = 480). The online questionnaire was developed with parent stakeholder organizations using a mixture of categorical and open–ended responses and Likert scales. Univariate and multiple logistic regression was used to determine crude (unadjusted) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). Summative content analysis was used to analyse free text responses. Results Women whose pregnancy ended in stillbirth were less likely to check fetal movements (aOR 0.54, 95% CI 0.35–0.83) and were less likely to be told to do so by a health professional (aOR 0.55, 95% CI 0.36–0.86). Pregnancies ending in stillbirth were more frequently associated with significant abnormalities in fetal movements in the preceding two weeks; this included a significant reduction in fetal activity (aOR 14.1, 95% CI 7.27–27.45) or sudden single episode of excessive fetal activity (aOR 4.30, 95% CI 2.25–8.24). Cases described their perception of changes in fetal activity differently to healthy controls e.g. vigorous activity was described as “frantic”, “wild” or “crazy” compared to “powerful” or “strong”. Conclusions Alterations in fetal activity are associated with increased risk of stillbirth. Pregnant women should be educated about awareness of fetal activity and reporting abnormal activity to health professionals. Electronic supplementary material The online version of this article (10.1186/s12884-017-1555-6) contains supplementary material, which is available to authorized users.

This article reviews three new and emerging risk factors for stillbirth that may be modifiable or might identify a compromised fetus. We focus on fetal movements, maternal sleep, and maternal diet. Recent studies have suggested than a sudden increase in vigorous fetal activity may be associated with increased risk of stillbirth. We review the papers that have reported this finding and discuss the implications as well as potential future directions for research. There is emerging literature to suggest that maternal sleep position may be a risk for stillbirth, especially if the woman settles to sleep supine. This risk is biologically plausible. How this knowledge may be utilized to assist stillbirth reduction strategies is discussed. Finally, we examine the somewhat limited literature regarding maternal diet and pregnancy outcome. Introducing probiotics into the diet may prove useful, but further work is required. The possible next steps for research are considered, as well as some potential intervention strategies that may ultimately lead to stillbirth reduction. Refereed/Peer-reviewed

Sleep-disordered breathing (SDB) and speech difficulties are common problems in children with craniofacial malformations (CFM). The present study was designed to investigate whether resonance issues identified during speech assessment are associated with parental report of SDB symptoms in children with CFM.Children aged 2-18 years with congenital CFM attending at the Craniofacial Anomalies Program from March 2007 to April 2011 were screened for SDB symptoms using the Sleep-Related Breathing Disturbance Scale of the Pediatric Sleep Questionnaire. Speech evaluation, based on the Pittsburgh Weighted Speech Scale score, was the tool used to investigate velopharyngeal dysfunction (VPD) based on speech perceptual assessment.A total of 488 children with congenital CFM were included. Overall 81% were Caucasian and 24% were overweight/obese. Twenty-four percent of children screened positive for SDB and 35% had VPD. Children with VPD were no more likely to screen positive for SDB than children without VPD (26% vs. 23%, p = 0.38). However, children with previous sphincter pharyngoplasty (SP) were more likely to have hyponasality (51% vs. 12%, p = 0.0001) and reduced or absent nasal emission (33% vs. 16%, p = 0.008). In a logistic regression, the adjusted odds ratio for SDB for those with hyponasality was 2.10 (95%CI 1.21-3.61, p = 0.008) and for those with reduced or absent nasal emission was 1.75 (95%CI 1.06-2.88, p = 0.028).Symptoms of sleep disordered breathing are common in children with craniofacial malformations especially if they have undergone sphincter pharyngoplasty; many of these children can be identified by measures of resonance on routine speech evaluation.

To investigate the influence of sleep position and sleep state on obstructive sleep apnea (OSA) severity in in children with Down syndrome (DS).Retrospective review.Sleep disorders laboratory of a tertiary medical center.Children with Down syndrome and typically developing children matched for age, gender, apneahypopnea index (AHI), and year of polysomnogram.Sleep variables from baseline polysomnography. Sensor-recorded position (supine, prone, lateral) was expressed as the percentage of total sleep time. The AHI was calculated in each sleep state (NREM, REM), position, and position-sleep state combination. Of 76 DS subjects (55% male) the median age and AHI were 4.6 years (range 0.2-17.8 years) and 7.4 events/h (range 0-133). In all subjects, AHI was higher in REM than NREM (p0.05); however, the NREM AHI was higher in DS subjects than controls (p0.05). Compared to controls, the percentage of prone sleep was greater in DS subjects (p0.05), but the percentage of supine or non-supine (prone plus lateral) sleep was no different. For DS subjects alone, NREM AHI was higher in supine than non-supine sleep (p0.05).In DS and non-DS children alike, respiratory events are predominantly REM related. However, when matched for OSA severity, children with DS have a higher NREM AHI, which is worse in the supine position, perhaps indicating a positional effect compounded by underlying hypotonia inherent to DS. These findings illustrate the clinical importance of NREM respiratory events in the DS population and implications for treatment options.

Introduction Mistimed sleep/wake and eating patterns put adult shift workers at increased risk for chronic disease, and epigenetic modification of core clock genes has been proposed as a mechanism. Although not as extreme as shift workers, adolescents often have delayed sleep timing. Our aim was to assess whether sleep midpoints in adolescents are associated with DNA methylation of circadian genes. A secondary aim was to examine associations between dietary patterns and circadian gene methylation. Methods The study population included 142 Mexican youth (average age 14.0 (SD=2.0) years, 49% male) enrolled in a cohort study. Average sleep midpoint (between bed time and wake time) over 7 days was estimated with actigraphy. Diet was assessed with a semi-quantitative food frequency questionnaire, and three dietary patterns were derived from principal components analysis (a vegetable-based pattern, a meat and starch-based pattern, and a breakfast pattern). DNA methylation was quantified in blood leukocytes with the Infinium MethylatinEPIC BeadChip. We selected 166 loci (CpG sites) within CpG islands of core ‘clock’ genes known to regulate circadian rhythms (CLOCK, BMAL, PER1, PER2, PER3, CRY1, CRYI2, RORA, RORB, REV-VERBA, REV-VERBB). Linear regression was used to analyze associations between sleep midpoint or dietary patterns and logit-transformed percent methylation at the 166 CpG sites. All models were adjusted for sex and age. Results The average midpoint was 3:41 AM (SD=1 hr 15 min); average bed time was 11:29 PM (SD=68 min) and average wake time was 7:53 AM (SD=97 min). Sleep midpoint was positively associated with DNA methylation of CpG sites from the genes REV-VERBA and RORB at the Bonferroni-corrected significance level of p Conclusion Sleep timing and dietary habits are associated with DNA methylation of core clock genes in adolescents. Epigenetic modification of clock genes could in part underlie relationships between sleep, diet, and metabolic health among adolescents. Support (If Any) Dr. Jansen is supported by the NIH/NHLBI grant 5T32HL110952-05.

The prevalence of pediatric obesity and short sleep duration has simultaneously increased in recent decades. Sleep plays a critical role in metabolic and endocrine regulation and insufficient sleep has been shown to be associated with changes in metabolism. Obesity, a major risk factor for obstructive sleep apnea (OSA), has been also associated with metabolic dysregulation. Despite this, no study investigating short sleep and obesity has addressed the potential confounder of OSA. The aim of this study was to investigate the association between short sleep duration and obesity in children with and without OSA. In this retrospective study, 306 children who underwent polysomnography between January and December 2010 were included. A diagnosis of OSA was made if the apnea/hypopnea index on polysomnography is ≥1. Typical sleep times were obtained by parental report. Short sleep duration was defined as a reduction of >1 h from the minimum total sleep time (TST) recommended for age from the National Sleep Foundation (NSF). Overall, 32 % were obese, 39.5 % had short sleep duration, and 78 % had OSA. Children with OSA had a similar frequency of short sleep duration than those without (39.6 vs. 42.4 %, p = 0.950). In children with short sleep duration, the odds ratio for obesity was 2.5 (95 % CI 1.3–4.9; p = 0.009) compared to children with TST within normal limits even after accounting for the presence of OSA. A parental history of total sleep duration of only 1 h less than recommended per age by the NSF is associated with a higher risk for obesity in children independently of the presence of OSA.

STUDY OBJECTIVE This cohort study examined the impact of maternal snoring on key delivery outcomes such as mode of delivery, infant birth centile, and small-for-gestational age. DESIGN Cohort study. SETTING A large tertiary medical center. PATIENTS OR PARTICIPANTS Pregnant women in their third trimester were recruited between March 2007 and December 2010. MEASUREMENTS AND RESULTS Women were screened for habitual snoring, as a known marker for sleep disordered breathing. Outcome data were obtained from medical records following delivery and birth centiles were calculated. Of 1,673 women, a total of 35% reported habitual snoring (26% with pregnancy-onset snoring and 9% with chronic snoring). After adjusting for confounders, chronic snoring was associated with small-forgestational age (OR 1.65, 95%CI 1.02-2.66, P = 0.041) and elective cesarean delivery (OR 2.25, 95%CI 1.22-4.18, P = 0.008). Pregnancy-onset snoring was associated with emergency cesarean delivery (OR 1.68, 95%CI 1.22-2.30, P = 0.001). CONCLUSION Maternal snoring during pregnancy is a risk factor for adverse delivery outcomes including cesarean delivery and small-for-gestational age. Screening pregnant women for symptoms of SDB may provide an early opportunity to identify women at risk of poor delivery outcomes. CLINICAL TRIALS REGISTRATION IDENTIFIER: NCT01030003.

Background Children and adolescents who have experienced trauma are at high risk of developing post-traumatic stress disorder (PTSD) and other negative emotional, behavioural and mental health outcomes, all of which are associated with high personal and health costs. A wide range of psychological treatments are used to prevent negative outcomes associated with trauma in children and adolescents. Objectives To assess the effects of psychological therapies in preventing PTSD and associated negative emotional, behavioural and mental health outcomes in children and adolescents who have undergone a traumatic event. Search methods We searched the Cochrane Common Mental Disorders Group's Specialised Register to 29 May 2015. This register contains reports of relevant randomised controlled trials from The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). We also checked reference lists of relevant studies and reviews. We did not restrict the searches by date, language or publication status. Selection criteria All randomised controlled trials of psychological therapies compared with a control such as treatment as usual, waiting list or no treatment, pharmacological therapy or other treatments in children or adolescents who had undergone a traumatic event. Data collection and analysis Two members of the review group independently extracted data. We calculated odds ratios for binary outcomes and standardised mean differences for continuous outcomes using a random-effects model. We analysed data as short-term (up to and including one month after therapy), medium-term (one month to one year after therapy) and long-term (one year or longer). Main results Investigators included 6201 participants in the 51 included trials. Twenty studies included only children, two included only preschool children and ten only adolescents; all others included both children and adolescents. Participants were exposed to sexual abuse in 12 trials, to war or community violence in ten, to physical trauma and natural disaster in six each and to interpersonal violence in three; participants had suffered a life-threatening illness and had been physically abused or maltreated in one trial each. Participants in remaining trials were exposed to a range of traumas. Most trials compared a psychological therapy with a control such as treatment as usual, wait list or no treatment. Seventeen trials used cognitive-behavioural therapy (CBT); four used family therapy; three required debriefing; two trials each used eye movement desensitisation and reprocessing (EMDR), narrative therapy, psychoeducation and supportive therapy; and one trial each provided exposure and CBT plus narrative therapy. Eight trials compared CBT with supportive therapy, two compared CBT with EMDR and one trial each compared CBT with psychodynamic therapy, exposure plus supportive therapy with supportive therapy alone and narrative therapy plus CBT versus CBT alone. Four trials compared individual delivery of psychological therapy to a group model of the same therapy, and one compared CBT for children versus CBT for both mothers and children. The likelihood of being diagnosed with PTSD in children and adolescents who received a psychological therapy was significantly reduced compared to those who received no treatment, treatment as usual or were on a waiting list for up to a month following treatment (odds ratio (OR) 0.51, 95% confidence interval (CI) 0.34 to 0.77; number needed to treat for an additional beneficial outcome (NNTB) 6.25, 95% CI 3.70 to 16.67; five studies; 874 participants). However the overall quality of evidence for the diagnosis of PTSD was rated as very low. PTSD symptoms were also significantly reduced for a month after therapy (standardised mean difference (SMD) -0.42, 95% CI -0.61 to -0.24; 15 studies; 2051 participants) and the quality of evidence was rated as low. These effects of psychological therapies were not apparent over the longer term. CBT was found to be no more or less effective than EMDR and supportive therapy in reducing diagnosis of PTSD in the short term (OR 0.74, 95% CI 0.29 to 1.91; 2 studies; 160 participants), however this was considered very low quality evidence. For reduction of PTSD symptoms in the short term, there was a small effect favouring CBT over EMDR, play therapy and supportive therapies (SMD -0.24, 95% CI -0.42 to -0.05; 7 studies; 466 participants). The quality of evidence for this outcome was rated as moderate. We did not identify any studies that compared pharmacological therapies with psychological therapies. Authors' conclusions The meta-analyses in this review provide some evidence for the effectiveness of psychological therapies in prevention of PTSD and reduction of symptoms in children and adolescents exposed to trauma for up to a month. However, our confidence in these findings is limited by the quality of the included studies and by substantial heterogeneity between studies. Much more evidence is needed to demonstrate the relative effectiveness of different psychological therapies for children exposed to trauma, particularly over the longer term. High-quality studies should be conducted to compare these therapies.

Obstructive sleep apnea (OSA) is common after stroke and predicts poor outcomes. Continuous positive airway pressure (CPAP) treats OSA but is generally poorly tolerated by stroke patients. We assessed whether nasal expiratory positive airway pressure (EPAP), an alternative to CPAP, may be an effective option after acute stroke.We conducted a randomized, controlled, two-period crossover study in which each acute ischemic stroke patient received 1 night of EPAP and 1 night without EPAP while OSA was monitored with a validated device, the Watch-PAT 200. Linear repeated- measures analyses were conducted. Sample size calculations indicated that 18 subjects would be required to detect a 10-point or larger average reduction in the apnea-hypopnea index (AHI, the primary outcome), with use of EPAP, with power ≥ 80% and α = 0.05.Among the 19 subjects who completed the protocol, nasal EPAP treatment was associated with a nonsignificant absolute difference in AHI of -5.73 events/h in the primary analysis (p = 0.183, 95% confidence interval -14.4, 2.97) and a nonsignificant absolute difference in AHI of -5.43 events/h in the subgroup of patients who used nasal EPAP for ≥ 3 h (p = 0.314, 95% confidence interval -16.6, 5.76).This study suggests that EPAP is not an effective alternative to CPAP in acute stroke patients with OSA. Further work is needed to identify other more effective alternatives.ClinicalTrials.gov, ID: NCT01703663.

Objective Sleep disturbances are thought to be frequent in women undergoing IVF despite minimal research of this hypothesis. Our goal was to longitudinally assess sleep duration and disturbances in women undergoing IVF and assess impact of habitual sleep duration on oocytes retrieved, an important outcome in IVF. Methods Actigraphy and questionnaire batteries containing sleep and psychometric instruments were performed prior to and throughout 24 IVF cycles. Results TST 10 was noted in 24%, 33%, and 36% of cycles during baseline, stimulation, and post-embryo transfer. PSQI >5 was noted in 57%, 43%, and 29% of cycles during baseline, stimulation, and post-embryo transfer. TST (F = 2.95, p = 0.04) and ESS (F = 4.36, p = 0.02) were the only sleep metrics in which a significant main effect of time was found by mixed models analysis. The final linear regression model chosen by stepwise selection to best explain the variability in oocytes retrieved included anti-mullerian hormone, day three follicle stimulating hormone, and baseline TST and explained 40% of the variance in oocytes retrieved (adjusted R 2 = 0.40, p = 0.03). Although not statistically significant, a trend towards a linear association between baseline TST and oocytes retrieved was seen with an increase of oocytes retrieved by 1.5 for every hour increase in TST (p = 0.09). Conclusions This is the first study to describe, with subjective and objective measures, sleep disturbances present throughout the IVF cycle. Importantly, a trend towards a linear relationship between TST and oocytes retrieved was found in this pilot study. Sleep may be a modifiable target to improve outcomes in women undergoing IVF and further investigations are needed.

Police are a major source of referral to psychiatric hospitals in industrialized countries with mental health legislation. However, little attention has been paid to nurses' experience of caring for police-referred patients to psychiatric hospitals. This study utilized a Heideggerian phenomeno- logical framework to explore the experiences of nine nurses caring for patients referred by the police, through semistructured interviews. Two major themes emerged from the hermeneutic analyses of interviews conducted with nurse participants: (i) 'expecting "the worst" '; and (ii) 'balancing thera- peutic care and forced treatment'. Expecting 'the worst' related to the perceptions nurse participants had about patients referred by the police. This included two sub-themes: (i) 'we are here to care for whoever they bring in'; and (ii) 'but who deserves care?' The second theme balancing therapeutic care and forced treatment included the sub-themes: (i) 'taking control, taking care'; and (ii) 'managing power'. The study raises ethical and skill challenges for nursing including struggling with the notion of who deserves care, and balancing the imperatives of legislation with the need to work within a therapeutic framework.

The issue of potential conflict of interest and its risk to professional integrity in journal article publication has been strongly debated in medical circles. Most medical journals adhere to international requirements for disclosure of potential conflict of interest. The debate on this issue in nursing, and specifically mental health nursing, has been neither prolific nor strong, despite nursing's potential to influence particular viewpoints about treatment and indeed to prescribe particular treatments; and nursing being a target for pharmaceutical industry marketing. The purpose of this paper is to raise debate about potential conflict of interest in journal article publication and to make recommendations for the management of such potential for this journal.

Aim To identify the reasons why nurses continue migrating across international borders. Background International nurse recruitment and migration have been increasing in the last decade and recent trends show an increase in the movement of nurses between developing and developed countries, resulting in a worldwide shortage of nurses. Methods A manual and electronic database literature search was conducted from January 2004 to May 2010. Qualitative content analysis was completed for the final 17 articles that satisfied the inclusion criteria. Results Motivators to nurse migration were linked to financial, professional, political, social and personal factors. Although economic factors were the most commonly reported, they were not the only reason for migration. This was especially evident among nurses migrating between developed countries. Conclusion Nurses migrate for a wide variety of reasons as they respond to push and pull factors. Implications for nursing management It is important for nurse managers in the source countries to advocate incentives to retain nurses. In the recipient countries the number of international nurses continues to increase implying the need for more innovative ways to mentor and orientate these nurses.

This article aims to present a new theoretical approach for examining paramedic clinical decision-making in relation to mental health care. Recent theorizing has begun exploring key clinical decision-making approaches that are particularly relevant to paramedic practice. These approaches have also revealed some important factors that influence clinical decision-making behaviours among paramedics such as prior experience and clinical and tacit knowledge. The literature, however, provides very little insight into the clinical decision-making strategies paramedics draw on and use when dealing with mental health patients, in particular, those patients who are dealt with under involuntary provisions of mental health legislation. In addition, the literature provides limited coverage to account for how paramedics deal with and mitigate risk factors relating to patients experiencing a mental health emergency. Following these shortcomings, this article will propose the use of hermeneutic phenomenological methods as a suitable and innovative interpretive research approach for examining paramedic clinical decision-making in relation to prehospital mental health care. It is argued that this approach is well suited for exploring how paramedics make sense of their experience providing emergency mental health care, how they perceive their role within the clinician-patient relationship, and the particular circumstances in which paramedics exercise their legislative responsibilities under mental health legislation.

For emergency health professionals, the response to a mental health emergency in the community is often brief in nature and centred on quickly ascertaining whether a patient is psychiatrically or physically unwell. For paramedics, mental health emergencies are often challenging because of the ambiguous nature of clinical presentations, lack of collaborative information such as a patient's medical history and back up assistance. Mental health emergencies require paramedics to possess advanced interpersonal skills and patient assessment competencies. With the introduction of new emergency powers across Australian state and territory-based mental health legislation, the roles and responsibilities of paramedics across some jurisdictions has changed significantly. In response to these changes, a number of ambulance services have introduced specific mental health training programmes in an attempt to prepare their workforce to meet and fulfil their legislative responsibilities. In spite of this, the role of paramedics in the care and management of the mentally ill has attracted limited attention in the research literature. This article examines the role of the paramedic with respect to mental illness, what is known about paramedics' clinical decision-making practices, and the opportunities for future development of their scope of practice. It identifies the need for further research to explore the clinical decision-making processes are used by paramedics when fulfilling their mental health legislative responsibilities.

There is substantial evidence supporting the need for effective intervention for children and families living with parental mental illness. However, translation of this knowledge into mental health workforce practice remains variable, with a range of clinical practices and models of care evident. Nurses, who constitute the majority of the mental health workforce, are in prime positions to support children and families and provide preventative measures, identify those at risk, and intervene early. In this paper, we provide a framework for practice for nurses working with consumer parents. We contend that traditional models of nursing practice concentrating on the consumer are insufficient in meeting the needs of children and families living with parental mental illness. A focus on families needs to be core business for mental health nurses. A family-focused approach can be used to prevent problems for children and their families, and identify their strengths as well as vulnerabilities. Family-focused care is a useful framework from which to support families and address the challenges that might arise from parental mental illness, and to build individual and family resilience.

A significant number of clients utilizing mental health services will also be parents. Being a child of a parent with mental illness increases health risks for the child, and hospitalization of the parent has been identified as one of the most difficult times for children. However, few proactive measures have been taken to understand or provide for the needs of children visiting psychiatric inpatient facilities. The aim of this exploratory study was to identify the perspectives children, their parents, nominated carers, and clinicians from their experience of children visiting. The study used qualitative data gathered from interviews to develop an understanding of the issues. The purpose of this paper was to present the findings from parents, carers, and children. Children indicated that they wanted to visit and to remain involved with their parent, but that there was little support from staff. Families indicated that children visiting psychiatric inpatient facilities were not well managed, and they received little support about decisions around children visiting. The issue of children visiting psychiatric facilities when they have a parent who is an inpatient appears not to have been addressed in models of inpatient mental health care.

Aim. This paper reports the healthcare experiences of women who have been diagnosed with a sexually transmitted infection. Background. The incidence of sexually transmitted infections is increasing throughout the globe on an annual basis. To effectively curb this trend and reduce the spread of these infections, effective education and treatment is essential. Design. This study used a feminist approach. Methods. Ten women participated in this study. Interviews were conducted online and transcripts were thematically analysed. Results. Findings from this study revealed that the women generally characterised their healthcare experiences as negative. Some women perceived being negatively judged by healthcare professionals and felt they were not provided with sufficient information or support when diagnosed with a sexually transmitted infection. Conclusion. This paper reveals how healthcare professionals have the ability to exacerbate the adversity felt by women diagnosed with a sexually transmitted infection and how providing appropriate therapeutic care can assist young women who have been diagnosed with these types of infections. Relevance to clinical practice. Nurses and other healthcare professionals can better serve patients by providing emotional and therapeutic support and information about the possible effects and long-term sequelae of sexually transmitted infections. Further, by providing sufficient information and support, the negative effects of having a sexually transmitted infection can be reduced and women’s ability to cope with a sexually transmitted infection can be enhanced.

Adopting a collaborative approach within clinical relationships is illustrative of consumers' and nurses' positive beliefs, values, and attitudes towards each other and their partnership. However, for collaboration to be successful, how roles are determined, how each partner relates to the other, and how decisions are to be made need to be clearly defined and agreed upon. The research study described here utilized a mixed-method approach comprising focus groups and surveys to explore the subjective understandings, attitudes, and experiences of consumer-nurse collaboration within a mental health rehabilitation context in order to more clearly determine the conditions for successful nurse-consumer collaboration. The study found that although consumers and nurses conceptualized collaboration in similar ways, their lived experiences were disparate. A key finding of the study was that mutual recognition of each others' knowledge and expertise is needed for successful collaboration. The study reinforced the need for consumers and nurses to establish common ground on which to collaborate and to articulate the behaviours and expectations of working collaboratively. While collaboration was acknowledged as a significant and desirable basis for therapeutic relationships, it was challenged by determinants of power, such as knowledge, information, and expertise.

To identify any differences between patients referred by police compared with patients referred from other sources, to a psychiatric hospital in Australia, a retrospective audit of 200 patient files was undertaken. The two most common reasons for the involuntary referral of patients by police were bizarre ideas (33%) and threats of suicide (28%). When 101 patients referred by police were compared with 99 patients from other sources, police referrals were three times more likely to be diagnosed with a mental and behavioural disorder because of psychoactive substance use, less likely to be diagnosed with a mood disorder, and less likely to be diagnosed as psychotic. Police referrals were more likely to have worse functional scores; exhibit aggressive behaviour; spend fewer days in hospital; more likely to be admitted to the psychiatric intensive care unit, and to be secluded. The most important predictor for a police referral was drug or alcohol problems. The study indicates that patients referred by the police were more likely to demonstrate particular characteristics compared with patients referred by other sources.

Mentoring relationships are dynamic alliances that can be used as a supportive mechanism for growing nurse leaders and promoting the future of the nursing profession. This article explores imagination as one of the central meanings of being a mentor for nursing leadership. Findings from a hermeneutic-phenomenological study concerned with Australian nurse leaders' experiences and understandings of mentorship for leadership revealed that imagination was a key characteristic of being a nurse leader-mentor. Imagination that moved beyond fantasy to closely connect with reason was essential for nurse leader-mentors to recognize and activate the myriad possibilities available to mentees and the nursing profession more broadly. Copyright © 2010 Lippincott Williams & Wilkins.

AIM: This paper is a report of a study of sexually active young womens experiences of negotiating condom use both before and after diagnosis of a sexually transmitted infection. BACKGROUND: The male condom is the most efficient method in preventing and reducing the transmission of sexually transmitted infections. However condom use can be hindered by factors including societal norms and gender roles which can create difficulties for women in initiating and negotiating condom use in heterosexual partnerships. METHODOLOGY: A feminist narrative approach was used and ten womens stories were collected via online interviews in 2007. FINDINGS: None of the women initiated or negotiated use of the male condom for various reasons. Some relied on their male partners to initiate condom use some were unable to practise safer sex due to the abuse and unequal gender dynamics that existed in their sexual relationships and some thought that condom use was not necessary because of a belief that they were in safe and monogamous relationships. Even following diagnosis of a sexually transmitted infection some women said that they were not empowered enough to initiate condom use with subsequent sexual partners resulting in continued high-risk sexual behaviour. CONCLUSION: Successful condom promotion relies on the recognition of the gender factors that impede young womens condom negotiation and use. Strategies that overcome gender dynamics and empower women to negotiate condom use have the ability to promote condom use among this group. (c) 2010 Blackwell Publishing Ltd.

ObjectiveTo evaluate whether the percentage of time spent supine during sleep in the third trimester of pregnancy could be reduced using a positional therapy device (PrenaBelt) compared with a sham device.DesignA double-blind, randomised, sham-controlled, cross-over pilot trial.SettingConducted between March 2016 and January 2017, at a single, tertiary-level centre in Canada.Participants23 participants entered the study. 20 participants completed the study. Participants were low-risk, singleton, third-trimester pregnant women aged 18 years and older with body mass index 2at the first antenatal appointment for the index pregnancy and without known fetal abnormalities, pregnancy complications or medical conditions complicating sleep.InterventionsA two-night, polysomnography study in a sleep laboratory. Participants were randomised by computer-generated, one-to-one, simple randomisation to receive either a PrenaBelt or a sham-PrenaBelt on the first night and were crossed over to the alternate device on the second night. Allocation concealment was by unmarked, security-tinted, sealed envelopes. Participants, the recruiter and personnel involved in setting up, conducting, scoring and interpreting the polysomnogram were blinded to allocation.Primary and secondary outcome measuresThe primary outcome was the percentage of time spent supine during sleep. Secondary outcomes included maternal sleep architecture, respiration, self-reported sleep position and feedback.ResultsThe median percentage of sleep time supine was reduced from 16.4% on the sham night to 3.5% on the PrenaBelt night (pseudomedian=5.8, p=0.03). We were unable to demonstrate differences in sleep architecture or respiration. Participants underestimated the time they spent sleeping supine by 7.0%, and six (30%) participants indicated they would make changes to the PrenaBelt. There were no harms in this study.ConclusionsThis study demonstrates that the percentage of sleep time supine during late pregnancy can be significantly reduced via positional therapy.Trial registration numberNCT02377817; Results.

Stories convey values and emotions, and can reveal the differences and similarities between people's experiences. Elucidating personal stories involves sharing which can help form bonds and supportive networks. With reflection, these can help to develop resilience. While the literature recognises the potential cathartic and therapeutic benefits associated with storytelling in research, links between the development of personal resilience and storytelling for research purposes have not been drawn. This paper argues that storytelling aids the development of personal resilience and provides opportunities to celebrate the hardiness of research participants who contribute to knowledge by recounting their stories of difficulty and adversity.

Aims and objectives. To evaluate nurses’ knowledge of adolescent sleep and sleep disturbance and the strategies they employ to facilitate sleep in adolescent patients. Background. Sleep disturbance in adolescents is common and associated with potentially devastating outcomes and co-morbidities. Despite this, little literature exists that reports nursing interventions related to facilitating sleep, and no literature could be located that explored what Australian nurses know about adolescent sleep and sleep disturbance. Design. Qualitative. Method. Eight nurses routinely involved in the care of adolescent patients were interviewed via email and instant messaging over a five month period. Explored was the formation and extent of knowledge held by these nurses about adolescent sleep and sleep disturbance and the strategies they used to facilitate sleep in adolescent patients. Data were analysed thematically. Results. Three main themes were identified: ‘A patchwork of experiences’, ‘Traditional remedies, personal beliefs and commonsense’ and ‘Drugs, doctors and disempowerment’. Conclusions. Despite a lack of formal education about adolescent sleep and sleep disturbance, through life and professional experience the nurses in this study had formulated effective strategies to assist the sleep of adolescent patients. Relevance to clinical practice. There is a need for nursing education regarding adolescent sleep issues. Providing rationales for nursing strategies would afford nurses greater confidence to strongly advocate for a more non-pharmacological approach to managing certain types of sleep disturbance. Initiating routine assessment of adolescent sleep in both hospital and community settings could be beneficial to detecting a range of difficulties adolescent patients may be experiencing.

Obstructive sleep apnea (OSA) causes excessive daytime sleepiness in at least 3% of adults, affects many others without causing overt sleepiness, and accounts for the majority of patients seen at sleep disorders centers. Between one quarter and one half of patients evaluated by polysomnography for suspected OSA also prove to have periodic leg movements (PLMs) during sleep.1,2 The PLMs are prominent in most patients with restless legs syndrome (RLS)3 but are also common in other conditions besides OSA that share disturbances of both sleep and dopaminergic transmission. Such conditions include narcolepsy,4 rapid eye movement sleep (REM) behavior disorder,5 Parkinson disease,6 and attention-deficit/hyperactivity disorder.7 The pathophysiology of RLS, and perhaps PLMs as well, may involve iron,8 a rate-limiting cofactor in the synthesis of dopamine, strongly suspected to play key roles in RLS,9 PLMs,10 and normal maintenance of alertness.11 Severity of RLS symptoms is associated with low body iron stores, as reflected by serum ferritin levels.12,13 Whether PLMs are similarly associated with low ferritin levels is less clear. In a study of 39 children with PLMs, no significant association could be demonstrated between ferritin levels and the number of PLMs per hour of sleep (periodic leg movement index, or PLMI).14 A study of 27 adults with RLS similarly found no significant association between ferritin levels and PLMI, though the PLM-arousal index did show a significant relationship.13 In contrast, Earley et al. demonstrated that intravenous administration of iron dextran to patients with RLS substantially decreased PLMs in 5 of 6 subjects whose restless legs also showed prominent improvement.15 In another study, 10 dialysis patients who received oral iron, intravenous iron in some cases, and erythropoietin also showed reduced PLMs.16 Despite these observations, no one knows why PLMs are so common in patients with OSA, or what the clinical significance is (if any) of PLMs found to be comorbid with OSA. Also poorly understood is the common question of why some patients with OSA are severely sleepy, whereas others seem immune to this effect. One possibility not previously examined is that iron deficiency could play a role in sleep disorders other than RLS, and in OSA in particular. Sleep deprivation or other physiologic consequences of OSA could conceivably influence iron absorption, loss, or stores through effects on nutrition consumption,17 gastrointestinal function,18 key metabolic pathways,19 or endocrine function.19 We therefore explored, in an initial manner, several innovative hypotheses, summarized in Figure 1: that OSA could promote iron deficiency, that iron deficiency through a putative effect on dopaminergic transmission could explain PLMS in OSA, and that deficient iron again through effects on dopaminergic systems could help to explain the complaint of sleepiness in many patients with OSA. Figure 1 Novel hypotheses tested in this study were that obstructive sleep apnea promotes deficient body iron stores (Hypothesis 1, H1) and that deficient iron (via an unmeasured influence on dopamine synthesis) promotes both periodic limb movements during sleep ...

McCLOUGHEN A, O’BRIEN L and JACKSON D. Nursing Inquiry 2009; 16: 326–336 Esteemed connection: creating a mentoring relationship for nurse leadership Mentoring relationships occur across a range of nursing contexts and are shown to have multiple, favourable personal and professional outcomes. Specifically, mentoring has been associated with the development of nurse leaders. This study describes features that are integral to initiating mentoring relationships that focus on nursing leader development. These significant features are addressed in relation to the nursing literature. Thirteen nurse leaders from eastern states of Australia were interviewed during 2005 and 2006 about their understanding and experiences of mentoring for leadership. Their narratives were analysed using a hermeneutic phenomenological methodology. Mentoring relationships for nurse leadership were revealed as developing from esteemed connections between two people. Mentors were shown to unconditionally champion their mentee’s careers, and mentees were shown to possess a leadership vision for nursing. The findings of this study have implications for establishing mentoring relationships for nurse leader development. Consideration should be given to the specific focus and context of these relationships to ensure that the full potential of the mentoring process is realised. It is also important to better understand the key aspects that contribute to the phases of mentoring relationships for nurse leader development because they are shown to influence the dynamic and function of these relationships over time.

This paper reports on the results of a descriptive study that explored death and dying education in Australian undergraduate nursing curricula conducted as phase one of a two-phase, longitudinal mixed-method study. A descriptive study using survey method was selected. Thirty-nine Deans of Nursing (or their equivalent position title) were invited to participate. The study setting involved university schools of nursing (or equivalent title) in the six states and two territories of Australia. A mailed survey was self-administered by participants. Descriptive statistics were used to generate a description of the current curricula practices used by Australian undergraduate nursing programmes to provide death and dying education. A response rate of 76% (n = 26) was achieved. The results show death and dying education has a minimal and inconsistent presence in Australian undergraduate nursing programmes. The main conclusions include: (i) little evidence exists of significant change to the provision of death and dying education in undergraduate nursing curricula since the 1960s; (ii) the conceptualization of death and dying education in Australian undergraduate nursing curricula is poorly designed and underdeveloped; (iii) what constitutes the ‘best’ death and dying education experiences remains unclear with little evidence to support decision-making; and (iv) reform of undergraduate nursing curricula is required to enhance graduate preparation to deliver contemporary practice especially in the area of caring for dying patients and their families.

SummaryThis study found that CHC and combination therapy had asignificant physiological and psychological effect on qualityof life and the participants described their struggle tomaintain a meaningful relationship with their partners andchildren. Strategies for coping appeared in the narratives butmost obvious were their descriptions of the effects of stigmaon their lives. Participants also felt that many health careprofessionals held prejudiced views and lacked knowledgeabout CHC. Discussion CHC and combination therapy caused serious impairment ofthe participants’ physiological, mental and emotional wellbeing (Dolan 1997, Dusheiko 1997, Oon 1999, Hoofnagle &Seeff 2006). One of the most common side effects of IFNsuffered by the participants was depression and this com-pounded their situation. IFN is known to cause severeneuropsychiatric syndromes including depression, suicidalideation, paranoia and confusion (Rataj et al. 2005).Routine activities of daily living became burdensome andthe participants’ role shifted from independence to depen-dence. Family members became an important source ofphysical, emotional and financial support. The partners’workload increased as they took over most of the housework.The participants’ temporary inability to fulfil their rolecreated the opportunity for their partner to experience anew side to themselves (Altschuler 1997).However, frustration, irritation and anger were oftendirected at the partners. The pressures brought on by CHCand treatment, combined with the stresses of everyday life,became accumulative and led to conflicts between theparticipants and their partners. Poor communication wasanother source of anxiety and feelings that were withheld orwere not well communicated resulted in greater distancebetween spouses. Participants described a change in theirintimate and sexual relationships because the effects of CHCand treatment contributed to a loss of sexual desire andsatisfaction (Larsen et al. 1998).The participants decided it was better not to talk to othersoutside the family about hepatitis C given the stigma andprejudice attached to HCV. Not all the participants in thisstudy acquired HCV through injecting drug use but theydescribed how society associates HCV infection with inject-ing drug use and HIV. All are seen as conditions broughtupon oneself by behaviour for which society has littlesympathy or understanding (Morton & Johnson 1996).Participants described altered relationships with family,friends and relatives and reported a loss of social networksbecause of poor health and the stigma attached to HCV.These findings are consistent with a report by Richmondet al. (2004) that confirmed people with HCV infection feelthe impact of stigma and discrimination which affects theirsocial interactions, social networks, self-esteem and qualityof life.The participants felt that health care professionals pre-sented a negative attitude and lacked understanding of CHC.This study and several other studies revealed that discrimi-nation occurred in the health care setting (Zickmund et al.2003, Richmond et al.2004, Hopwood 2006a,b). A