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1.  Morbidity in nocturnal asthma: sleep quality and daytime cognitive performance. 
Thorax  1991;46(8):569-573.
Most patients with asthma waken with nocturnal asthma from time to time. To assess morbidity in patients with nocturnal asthma nocturnal sleep quality, daytime sleepiness, and daytime cognitive performance were measured prospectively in 12 patients with nocturnal asthma (median age 43 years) and 12 age and intellect matched normal subjects. The median (range) percentage overnight fall in peak expiratory flow rate (PEF) was 22 (15 to 50) in the patients with nocturnal asthma and 4 (-4 to 7) in the normal subjects. The patients with asthma had poorer average scores for subjective sleep quality than the normal subjects (median paired difference 1.1 (95% confidence limits 0.1, 2.3)). Objective overnight sleep quality was also worse in the asthmatic patients, who spent more time awake at night (median difference 51 (95% CL 8.1, 74) minutes), had a longer sleep onset latency (12 (10, 30) minutes), and tended to have less stage 4 (deep) sleep (-33 (-58, 4) minutes). Daytime cognitive performance was worse in the patients with nocturnal asthma, who took a longer time to complete the trail making tests (median difference 62 (22, 75) seconds) and achieved a lower score on the paced serial addition tests (-10 (-24, -3)). Mean daytime sleep latency did not differ significantly between the two groups (2 (-3, 7) minutes). It is concluded that hospital outpatients with stable nocturnal asthma have impaired sleep quality and daytime cognitive performance even when having their usual maintenance asthma treatment.
PMCID: PMC463276  PMID: 1926025
2.  Availability and use of hepatitis B vaccine in laboratory and nursing schools in the United States. 
Public Health Reports  1991;106(5):529-535.
Hepatitis B is a well-documented occupational hazard for health care workers, including both laboratory and nursing personnel. Since the development of effective hepatitis B vaccines, the Immunization Practices Advisory Committee (ACIP) has recommended that health care workers receive the vaccine. In this study, 78 laboratory training programs and 83 nursing training programs were surveyed regarding availability and usage of hepatitis B vaccine. The hepatitis B vaccine was made available to students in 81 percent of the laboratory programs and 23 percent of the nursing programs. In those programs making the vaccine available, only 59 percent of the laboratory programs and 5 percent of the nursing programs reported a high (greater than 75 percent) use by students. Concern about cost and payment for the vaccine was the most common reason (80 percent) noted by laboratory schools that did not have hepatitis B vaccination programs for students. Of the nursing schools that did not have vaccine programs, 58 percent had not yet considered a program. At laboratory schools with vaccination programs, who paid for the vaccine (hospital or school versus student) was among the most important determinants for vaccine usage by students. These findings point out that some laboratory schools and many nursing schools have not applied the ACIP recommendations to their own programs. Educational efforts and creative payment plans for the vaccine are needed to increase the availability and use of hepatitis B vaccine among laboratory and nursing students.
PMCID: PMC1580298  PMID: 1832779
3.  Twenty four hour heart rate variability: effects of posture, sleep, and time of day in healthy controls and comparison with bedside tests of autonomic function in diabetic patients. 
British Heart Journal  1991;65(5):239-244.
Heart rate variability was measured in 77 healthy controls and 343 diabetic patients by a count of the number of beat-to-beat differences greater than 50 ms in the RR interval during a 24 hour ambulatory electrocardiogram. In the healthy controls the lower 95% tolerance limits for total 24 hour RR interval counts were approximately 2000 at age 25, 1000 at 45, and 500 at 65 years. Six controls confined to bed after injury had normal 24 hour patterns of RR counts, while eight other controls showed loss of diurnal variation in both heart rate and RR counts during a period of sleep deprivation. RR counts in ten controls on and off night duty increased during sleep whenever it occurred. Nearly half (146) the 343 diabetic patients had abnormal 24 hour RR counts. The percentage of abnormal RR counts increased with increasing autonomic abnormality assessed by a standard battery of tests of cardiovascular autonomic function. A quarter of those with normal cardiovascular reflex tests had abnormal 24 hour RR counts. There were close correlations between 24 hour RR count results and the individual heart rate tests (r = 0.6). The assessment of cardiac parasympathetic activity by 24 hour RR counts was reliable. The diurnal variations in RR counts seen in the controls were probably related to sleep rather than either posture or time of day. The method was more sensitive than conventional tests of cardiovascular reflexes.
PMCID: PMC1024623  PMID: 2039667

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