Transition Off Research Articles

Relationship between sleep and exercise as colorectal cancer survivors transition off treatment.

The primary objective of this study was to evaluate the relationship between exercise and sleep disturbance in a sample of individuals diagnosed with stage I, II, and III colorectal cancer (CRC) as patients transitioned off first-line treatment. We also sought to identify heterogeneity in the relationship between sleep disturbance and exercise. Data were obtained from the MY-Health study, a community-based observational study of adults diagnosed with cancer. Patient-Reported Outcomes Measurement Information System® (PROMIS) measures (e.g., PROMIS Sleep) were administered, and participants self-reported demographics, comorbidities, cancer treatment, and exercise. Regression mixture and multiple regression models were used to evaluate the relationship between sleep disturbance and exercise cross-sectionally at an average of 10months after diagnosis, and the change in sleep disturbance over a 7-month period, from approximately 10 to 17months post-diagnosis. Patients whose exercise was categorized as likely at or above American College of Sports Medicine's guidelines did not report statistically better sleep quality compared to patients who were classified as not active. However, retirement (B = - 2.4), anxiety (B = 0.21), and fatigue (B = 0.24) had statistically significant relationships with sleep disturbance (p < 0.05). Increase in exercise was not significantly associated with a decrease in sleep disturbance. No statistical heterogeneity was revealed in the relationship between sleep and exercise. Further prospective research using an objective measure of exercise is warranted to confirm or refute the nature of the relationship between exercise and sleep disturbance in individuals diagnosed with CRC transitioning off first-line treatment.

Young children's internalizing and externalizing behaviors after mothers exit welfare: Comparisons with children of non-welfare mothers

Although not part of its stated aims, current welfare legislation is assumed to benefit children through increased parental employment and self-sufficiency. Research findings on the extent to which parental welfare participation improves child well-being are inconclusive. This study investigates the behavioral outcomes of young children whose mothers have received TANF using data from the Fragile Families and Child Wellbeing Study (N = 2169). Controlling for maternal demographic characteristics, current financial status, and health risks, we found that the difference between children's externalizing behaviors in families of former TANF recipients relative to children of mothers who had never been on welfare decreased the longer mothers had been off welfare. However, overall, externalizing behaviors were significantly higher among children of former TANF recipients relative to children whose mothers had never received welfare. The findings suggest that ensuring healthy development for children requires long-term supports to help mothers as they transition off welfare.

Relationship between sleep and exercise as colorectal cancer survivors transition off treatment

Relationship between sleep and exercise as colorectal cancer survivors transition off treatment

Sleep quality in individuals diagnosed with colorectal cancer: Factors associated with sleep disturbance as patients transition off treatment

Sleep quality in individuals diagnosed with colorectal cancer: Factors associated with sleep disturbance as patients transition off treatment

Sleep quality in individuals diagnosed with colorectal cancer: Factors associated with sleep disturbance as patients transition off treatment.

To identify patient characteristics associated with sleep disturbance and worsening of sleep in individuals diagnosed with localized colorectal cancer and assess heterogeneity in these relationships. Data were from the MY-Health study, a community-based observational study of adults diagnosed with cancer. Patient-Reported Outcomes Measurement Information System® Sleep Disturbance, Anxiety, Depression, Fatigue, and Pain Interference measures were administered. Participants self-reported demographics, comorbidities, and treatment information. Regression mixture and multiple regression models were used to evaluate the relationship between sleep disturbance and patient characteristics cross-sectionally at an average of 10months after diagnosis (n=613) as well as change in sleep disturbance over a 6-month period (n=361). Pain, anxiety, fatigue, and the existence of multiple comorbid conditions had statistically significant relationships with sleep disturbance (B=0.09, 0.22, 0.29, and 1.53, respectively; P<0.05). Retirement (B=-2.49) was associated with sleep quality in the cross-sectional model. Worsening anxiety (B=0.14) and fatigue (B=0.20) were associated with worsening sleep disturbance, and more severe sleep disturbance 10months after diagnosis (B=-0.21) was associated with improvement in sleep quality after diagnosis (P<0.05). No evidence of latent subgroups of patients (heterogeneity) was present. Pain, anxiety, fatigue, employment, and comorbid conditions were associated with sleep disturbance, but regression coefficients were small (< |2.5|). Results suggest that screening for anxiety, depression, fatigue, or pain is not sufficient for identifying sleep disturbance. Given the negative consequences of sleep disturbance, sleep disturbance screening may be warranted.

How expensive is an energy transition? A lesson from the German Energiewende

The Paris climate agreement of December 2015 is generally considered a breakthrough on the way to a sustainable future for mankind. In particular, the agreement calls for fundamental transitions in the energy systems worldwide, since more than 80% of CO2 emissions stem from the use of fossil fuels in the energy supply. Considering such energy transitions, in any country there will certainly be technical issues, there will be debates as to which political instruments are most suitable, and others; but there is no doubt that the question of cost is one of the most crucial issues in the course of such a long-term project. After all, the expected financial burden on the national economy and its stakeholders is the most convincing argument for putting in energy transition off or for slowing it down.There is also no doubt that the German Energiewende, at first sight, does not serve as an encouraging example in this respect: The cost bill - in the sense of the direct, perceptible financial effects - has already run up to almost € 500 billion, and the German private households as well as many businesses pay significantly more for electricity than in most other OECD-countries. As a consequence, in Germany there is a growing opposition against going forward with the Energiewende as planned, and also in the international media, the initially positive image of the German project has suffered.A closer look at the costs of the German energy transition, however, reveals that around 75% of them are due to two particularities of the Energiewende that do not hold true for other energy transitions: the politically enforced nuclear phase-out and the fact that Germany massively expanded renewable energies at a time when they were still very expensive.Therefore, the real lesson of the German example is the opposite of what it may seem: The transition to renewable energies in the electricity sector in a highly industrialized country can be quite affordable.

Why People Who Inject Drugs Voluntarily Transition Off Methadone in Ukraine.

Methadone maintenance therapy (MMT) treats opioid use disorder among people who inject drugs (PWID). To understand why PWID may voluntarily discontinue MMT, we analyzed data from 25 focus groups conducted in five Ukrainian cities from February to April 2013 with 199 participants who were currently, previously, or never on MMT. Using constant comparison method, we uncovered three themes explaining why PWID transition off MMT: (a) purposeful resistance to rigid social control associated with how MMT is delivered and to power asymmetries in provider-patient relationships, (b) self-management of a PWID's "wounded identity" that is common in socially stigmatized and physically sick persons-MMT serves as a reminder of their illness, and (c) the quest for a "normal life" uninterrupted by daily MMT site visits, harassment, and time inefficiencies, resources, and social capital. Focusing on holistic principles of recovery would improve addiction treatment and HIV prevention in Ukraine and globally.

Chemistry of the oldest white dwarf planetary systems

AbstractAlmost all stars in the Milky Way, including the Sun, will end their lives as white dwarfs. Their relatively peaceful transition off of the main sequence implies that most of their planetary systems will survive engulfment during the deaths of their host stars. These remnant planetary systems remain detectable for many Gyr through the occasional metal-contamination of the white dwarf photospheres by tidally disrupted planetesimals. Spectral analysis of these “metal-polluted” white dwarfs therefore provides a direct method for measuring the chemical compositions of extrasolar material. Here we present our sample of 230 cool white dwarfs with metal-rich photospheres, explore the diverse range of compositions of the accreted matter, and discuss two extreme systems which have respectively accreted planetesimals consistent with crust-like and core-like planetary material.

Within-person analysis of welfare transitions in a longitudinal panel survey reveals change in mental health service use.

While international research shows that receipt of welfare benefits is associated with poor mental health, less is known about the relationship between welfare receipt and mental health service use. We investigate whether within-person change in welfare recipient status is associated with change in mental health service use. Analysis of two waves of data from an Australian national household survey. Random- and fixed-effect models considered the effect of change in welfare receipt status, and assessed whether change in mental health service use differed by type of welfare benefit or the direction of welfare transition. Individuals were more likely to report greater mental health service use at times of welfare receipt. These associations were attenuated, but remained significant, after adjusting for mental health. Increased health service use was not tied to specific types of welfare benefits. The increase in mental health service use associated with a transition onto welfare benefits was much greater than the decline in service use associated with the transition off benefits. Within individuals, welfare receipt is associated with greater mental health service use. While this does reflect poorer mental health at the time of welfare receipt, other factors seem to facilitate health service use.

Perioperative Glycemic Control in Post-Cardiac Surgery Patients

Background: Tight glycemic control (GC) via insulin infusion protocols (IIP) improves outcomes in postoperative cardiac surgery patients. Upon transition off of insulin infusion, glycemic control becomes compromised, increasing risk of postoperative infection and length of stay.

A New Family of Non-Isolated Zero-Current Transition PWM Converters

A new auxiliary circuit for boost, buck, buck-boost, Cuk, SEPIC, and zeta converters is introduced to provide soft switching for pulse-width modulation converters. In the aforementioned family of DC-DC converters, the main and auxiliary switches turn on under zero current transition (ZCT) and turn off with zero voltage and current transition (ZVZCT). All diodes commutate under soft switching conditions. On the basis of the proposed converter family, the boost topology is analyzed, and its operating modes are presented. The validity of the theoretical analysis is justified by the experimental results of a 100W, 100 kHz prototype. The conducted electromagnetic emissions of the proposed boost converter are measured and found to be lower than those of another ZCT boost converter.

Effects of a Breast Milk Diet on Enteral Feeding Outcomes of Neonates with Gastrointestinal Disorders.

The objective of this study was to assess whether a diet of ≥50% breast milk (BM) was associated with earlier transition off parenteral nutrition (PN) in neonates with gastrointestinal (GI) disorders. This retrospective study assessed enteral feeding outcomes of neonates with surgical GI disorders admitted within the first week of life to a single center between January 1, 2012 and August 10, 2015. Outcomes were assessed according to diet from the point of first enteral intake through 7 days of full enteral feeds. Diets were classified as 100%, ≥50%, or <50% BM. One hundred sixty-three patients with an average gestational age of 36 weeks (range 28-40) and birthweight of 2570 g (range 1250-4900) were included. Significant differences in days to full enteral feeds between the 100% and <50% BM groups were found (median 21 versus 32 days; p = 0.023). There were no significant differences between the 100% and ≥50% BM (p = 0.05) or ≥50% versus <50% BM groups (p = 0.74). The 100% BM group had significantly fewer days on PN compared to the ≥50% BM group (median 21 versus 28.5 days, p = 0.034). Hospital length of stay was significantly shorter in the 100% BM group, which was discharged an average of 10 and 13.5 days sooner than the ≥50% and <50% BM groups (p < 0.05). Neonates with specific GI disorders who received a 100% BM diet were found to achieve earlier full enteral feeds, have shorter PN courses, and be discharged from the hospital significantly sooner than those who received diets that included formula.

Advances in the management of relapsing-remitting multiple sclerosis: role of oral dimethyl fumarate (BG-12).

Multiple sclerosis is a complex and chronic inflammatory disease of the central nervous system which affects an estimated 2.3 million individuals worldwide. Genetic research has uncovered over 100 immune-related genes associated with the disease and has provided a multitude of potential therapeutic targets. To date, 13 US Food and Drug Administration-approved disease-modifying therapies designed to influence the aberrant immune system are available for the indication of relapsing forms of the disease. BG-12 is a novel oral multiple sclerosis therapeutic with a unique putative mechanism of action that activates the Nrf2 anti-oxidant pathway. Despite the enthusiasm for multiple therapeutic options, including oral options, the practitioner is faced with the difficult task of providing guidance for patients regarding optimal sequencing of therapeutics without sensitive clinical biomarkers to match a particular therapy’s putative mechanism of action to the patient’s specific pathophysiology. Moreover, while BG-12 has a preferred route of administration, there is limited safety data with which to guide counseling in the clinic. Dimethyl fumarate (DMF or BG-12) is one of three available oral therapies which will be discussed in this review in terms of its pharmacokinetic profile, putative mechanism of action, clinical effectiveness, safety, tolerance, and patient-reported experience. BG-12’s potential as a first-line therapy and as a sequencing therapeutic to aid in transition off natalizumab will be discussed.

Hydrodynamic and geomorphological controls on surface sedimentation at the Subtropical Shelf Front / Brazil–Malvinas Confluence transition off Uruguay (Southwestern Atlantic Continental Margin)

Abstract The hydrology of the Southwestern Atlantic margin is dominated by the confluence of water masses with contrasting thermohaline properties, generating a frontal zone that extends from the Brazil-Malvinas Confluence zone (BMC) in the open ocean to the Subtropical Shelf Front (STSF) on the continental shelf. However, the hydrodynamics of the transition between these hydrographic features is still not fully understood. High-resolution morphological (multibeam) and hydrological (CTD) data were integrated with sedimentological data (textural and productivity proxies) in order to develop a sound framework to understand surface sedimentation of the slope extension of the STSF (subsurface, outer shelf and upper slope) and of the BMC (intermediate level, middle slope) on the Uruguayan continental margin (34° to 36°S). Since the detailed morphology of the study area is presented for the first time, related geological processes are briefly discussed. On the outer shelf and upper slope, and north of the STSF, the current direction of erosive mound scarps indicates the dominance of the southward-flowing Brazil Current (BC). This suggests a northernmost boundary for the distribution of the STSF. A strong flux of the BC favored by a steeper slope as well as by the occurrence of canyons incised on the upper slope is evidenced by the occurrence of coarser sediments and low values of productivity proxies, but also by the presence of deep sea coral reefs. Southwards, the effect of a less energetic Malvinas Current (MC) and the highly productive STSF is indicated by the deposition of fine sediments with high organic matter content, as well as by the absence of deep sea coral reefs. This depositional scenario is enhanced by a smooth slope and the occurrence of canyons incised deeper in the middle slope. Off-shelf sediment transport along the STSF is inferred by the similar texture registered between the outer shelf and shallow upper slope, the occurrence of biogenic shelly reworked sands and gravel, and by the observed decrease in grain size with depth. Glacial iceberg transport northwards and/or gravity processes are suggested by the occurrence of igneous/metamorphic gravel in lag deposits on the upper slope. On the middle slope, the northernmost influence of the erosive Antarctic Intermediate Water is evidenced by the vanishing of morphologic contouritic structures. This is also imprinted in a pronounced northward fining in grain size. This contribution increase our understanding of this highly dynamic and complex area, providing the first detailed analysis of the regional sediment patterns and oceanographic and morphological controls on surface sedimentation.

The effect of welfare sanctions on TANF exits and employment

Abstract Using longitudinal administrative data for Wisconsin, this article accounts for the length of time on welfare and the length of sanctioning to better understand the effect of work-related financial sanctions on cash welfare (TANF) participants' program exits and subsequent employment. Temporary Assistance for Needy Families (TANF) remains an important, if less generous, part of the safety net for families with children. Our findings highlight the importance of considering the time on welfare, duration of sanctions, and post-welfare employment and earnings outcomes. The results indicate that being sanctioned increases the likelihood of transition off TANF cash assistance and this effect increases with the duration of the sanction. In addition to measuring the effects of welfare sanctions on individual participants, the article also estimates the effects of agency sanction policies, using measures of the risk of sanctions at the agency level. Agency policy effects were of interest both because they addressed the potential effects of changes in the threat of sanctions—even on those not directly subject to them—and because the agency effects were not subject to the same concerns about unobserved individual heterogeneity between sanctioned and non-sanctioned participants. We found that an increase in an agency's use of sanctions resulted in increased exits to no job, to jobs paying less than cash benefits, and to jobs paying more than available cash benefits. Our results have important implications for understanding the consequences of financial sanctions for public program participants.

Slow V̇o2 off-kinetics in skeletal muscle is associated with fast PCr off-kinetics—and inversely

The computer model of the bioenergetic system in skeletal muscle, developed previously, was used to study the effect of the characteristic decay time of the parallel activation of oxidative phosphorylation [τ(OFF)] during muscle recovery on the muscle oxygen consumption rate (Vo2) and phosphocreatine (PCr) work-to-rest transition (off)-kinetics and on the relationship between the Vo2 and PCr rest-to-work transition (on)- and off-kinetics in moderate and heavy exercise. An increase in τ(OFF) slows down the initial phase of the muscle Vo2 off-kinetics and accelerates the PCr off-kinetics. As a result, the relationship between the initial phase of the Vo2 off-kinetics (lasting approximately 3-60 s in computer simulations) and the PCr off-kinetics is inverse: the slower the former, the faster the latter. A faster initial phase of the Vo2 off-kinetics is associated with a slower late phase of the Vo2 off-kinetics, and as a result, the integral of Vo2 above baseline during recovery, representing the oxygen debt, is identical in all cases [values of τ(OFF)] for a given PCr decrease. Depending on τ(OFF), the muscle Vo2 on-kinetics was either equally fast or slower than the Vo2 off-kinetics in moderate exercise and always slower in heavy exercise. PCr on-kinetics was always faster than PCr off-kinetics. This study clearly demonstrates that τ(OFF) has a pronounced impact on the mutual relations between the muscle Vo2 and PCr on- and off-kinetics.

Effect of the approach to insulin therapy on glycaemic fluctuations and autonomic tone in hospitalized patients with diabetes

Glycaemic variability (GV) is associated with mortality in acutely ill patients, but the mechanism is unknown. The objective of this study is to determine whether common approaches to insulin therapy have distinct effects on GV and autonomic tone. Hospitalized patients with diabetes were randomized to short-term intravenous (IV) or physiologic subcutaneous (SQ) insulin. Heart rate variability (HRV) and cardiac impedance (pre-ejection period, PEP) were used to estimate parasympathetic and sympathetic tone, respectively. GV was measured using a continuous glucose monitor. Mean glucose tended to be lower initially in the SQ group (N = 16) compared with the IV group (N = 17) on day 1 (10.5 vs. 8.6 mmol/l, p = 0.05), but became non-significant during the transition off of the infusion. There was no difference in glycaemic lability index (GLI), continuous overlapping net glycaemic action (CONGA) or coefficient of variation (CV) on day 1, but by day 2, these measures were higher in the IV group (p < 0.05 for all). PEP was higher in the SQ group during (110 vs. 123 ms, p = 0.02) and after the intervention (104 vs. 126 ms, p = 0.004). Hypoglycaemia was similar in both groups. There were only small differences in HRV. Post-treatment PEP was inversely correlated with log GLI (r = -0.41, p = 0.03) but not other measures. Short-term IV insulin is associated with an increase in multiple GV measures compared with optimal SQ insulin. However, GLI was the only predictor of PEP. Further research is needed to determine if interventions that minimize GV improve outcomes in the hospital.

Observation of incretin effects during enteral feed transitions of critically ill patients

Summary Background & aims Critically ill patients are regularly feed via constant enteral (EN) nutrition infusions. However, the incretin effect or its impact on endogenous insulin concentration remains unclear. This study determines whether there is an EN-driven incretin effect in critically ill patients requiring glycaemic control. Methods Clinically validated, model-based time-variant insulin sensitivity (SI) profiles were identified for 52 non-diabetic patients on Specialized Relative Insulin Nutrition Titration (SPRINT) glycaemic control during transitions off EN (ON/OFF), and back on to EN (OFF/ON). Incretin effects were observable via increased modelled SI after the OFF/ON transition or a decreased SI after the ON/OFF transition. Results Patients exhibited a median −36% (IQR −82% to 24% p = 0.001) reduction after the ON/OFF feed transition, and a median of +32% (IQR −5% to 53%, p = 0.05) rise in measured SI after the OFF/ON transition. However, 32% of patients exhibited increased SI at the OFF/ON transition, and 37% exhibited reduced SI at the ON/OFF transition. The results are likely due to changes in patient condition over the 5–8 h considered outweighing this effect. Blood glucose was the same during both transitions with median shifts of −2% and −3% after the ON/OFF, and OFF/ON transitions (p > 0.5), respectively. Conclusions Results imply a significant incretin effect is observed at a cohort level. The impact was stronger for the OFF/ON transition indicating that this effect may be blunted by long-term continuous EN infusions. These results provide the data to design conclusive studies, and to inform glycaemic control protocol development and implementation.

Natalizumab Discontinuation: Observational Study of University of Colorado Patients with Relapsing-Remitting Multiple Sclerosis (P06.170)

Objective: Evaluate disease activity among relapsing remitting multiple sclerosis patients during transition off natalizumab therapy. Background Natalizumab (NTZ) is an effective disease modifying drug (DMD) for treatment of relapsing-remitting multiple sclerosis (RRMS)¹. Patients discontinue NTZ for many reasons, including increased risk of progressive multifocal leukoencephalopathy (PML)². Many studies have demonstrated marked increases in gadolinium enhancing (Gd+) lesions and clinical activity among a subset of patients after NTZ withdrawal³. In our retrospective study, we characterized disease activity among patients with RRMS who transitioned off of NTZ. Design/Methods: Seventy-six patients were followed clinically and radiographically over 6 months following NTZ withdrawal. Decision to discontinue NTZ included increased or continued disease activity, adverse events, JCV seropositive status, and the decision to become pregnant. Alternative treatments were initiated after NTZ discontinuation (interferon-β 1a or -β 1b, glatiramer acetate, fingolimod, rituximab, pulsed steroids, or none). Intervals between NTZ discontinuation and start of alternative therapies were documented. Results: Thirty-seven subjects had return of clinical activity (relapse) following NTZ withdrawal. Median time to relapse after NTZ discontinuation was 3 months. Among relapses, the median time between NTZ discontinuation and initiation of an alternative DMD was 0.5 months. Nine severe relapses, defined as disease activity more than 2-fold higher than pre-NTZ were observed (MRI: average pre-NTZ = 0.5 Gd+ lesions; average post-NTZ withdrawal = 7.6 Dd+ lesions). Conclusions: Return of disease activity was noted clinically and radiographically. Disease activity increases within the first 3 months after NTZ discontinuation and is associated with increased time to alternative therapy. More studies are needed to identify patients at risk for increased disease activity in order to develop protocols that minimize disease burden following NTZ discontinuation. We will continue to evaluate the association of disease activity and choice of alternative DMD, duration of NTZ therapy, and interval between discontinuation of NTZ and initiation of alternative therapy. Disclosure: Dr. Nnunukwe has nothing to disclose. Dr. Schreiner has nothing to disclose.

Advanced Pulmonary Hypertension: Considerations for Care Planning at End of Life (427)

Objectives 1. Explain the pathophysiology of and symptoms associated with advanced pulmonary hypertension including the mechanisms of action of medications commonly used for advanced pulmonary hypertension and their impact on symptoms. 2. Discuss the current literature on managing patients with advanced pulmonary hypertension at the end-of-life. 3. Propose a guideline for providing end-of-life care for patients with advanced pulmonary hypertension. The survival of patientswithWorldHealthOrganization functional class IV pulmonary hypertension is less than one year if untreated. Although initiation of prostacyclin analogues improves functional status and survival, class IV pulmonary hypertension remains a terminal illness. Unfortunately, there is little evidence on how best to manage these patients at the end-oflife. This session will use case studies of patients admitted to our MICU on continous IV prostacyclin analogues to discuss the challenges and considerations inherent in providing care to patients dying with advanced pulmonary hypertension. Briefly, we will describe the pathophysiology of advanced pulmonary hypertension including a review of associated symptoms. Next, we will outline the pharmacokinetics of intravenous prostacyclin analogues (epoprostenol and trepostinil) used for patients with class IV pulmonary hypertension, including the impact of these medications on patient symptoms. Given the dearth of literature on end-oflife care for patients with class IV pulmonary hypertension, we will propose general guidelines for medical management by extrapolating from studies examining discontinuation or transitions off of other medications with similar mechanisms (eg, nitric oxide, sildenafil, and prostacyclin) as well as from our own experiences. Finally, we will use these cases to examine various psychosocial challenges associated with patients dying from pulmonary hypertension, including considerations for place of death (eg, hospital setting, home hospice, inpatient hospice). A detailed handout will be provided that outlines our proposed medical management guidelines for care of patients dying from advanced pulmonary hypertension.