11 It is impossible to dissect out the differences between religion and culture as many religions were found in a specific geographical area, such as more Catholic physicians in the Southern countries. This effect has

also been seen in America where one study showed that Jewish physicians in Pennsylvania were less likely to withdraw support31 as compared to North American Jewish Inhibitors,research,lifescience,medical health care providers who were more willing to limit therapy.32 RELIGIOSITY Bulow et al.22 investigated the significant differences in end-of-life decisions between doctors, nurses, patients, and families who consider themselves actively religious and those who identify themselves as only affiliated to a religion. Physicians and nurses wanted less treatment (ICU admission, Inhibitors,research,lifescience,medical CPR, ventilation) than check details patients and family members.22 Religious respondents requested more treatment and were more in favor of prolonging life.22 Religious respondents were less likely to want euthanasia than those only affiliated

to a religion.22 Fervent belief in religion usually provides support for families and staff but may lead to significant conflict between staff and parents regarding Inhibitors,research,lifescience,medical end-of-life decisions. Brierley et al.33 reviewed end-of-life decisions in a pediatric intensive care unit. Of 203 cases in which withdrawal or limitation of treatment was recommended, agreement with family was achieved in 186 Inhibitors,research,lifescience,medical (92%). In 17 cases (8%), despite extensive discussions with medical teams and local support mechanisms, no agreement could be obtained. In 11 of these cases (65%), the family expressed explicit religious belief that divine intervention would provide a miracle cure and the medical predictions were wrong.33 OTHER FACTORS Azoulay et al.34 investigated end-of-life practices in 282 intensive care units in seven geographic areas around the world. Of 14,488 patients with available data, 92% did not have decisions to forgo life-saving treatments, Inhibitors,research,lifescience,medical and 8% did. Of the 1,239 patients with decisions

to limit therapies, 677 (55%) had treatment withheld, and 562 (45%) had treatment Bay 11-7085 withdrawn. As expected, limitations were made in the sickest ICU patients.34 Organizational factors seemed to play a role in limitations. For example, patients admitted from another hospital were more likely to have limitations. The presence of a full-time intensivist and availability of doctors on weekends decreased the limitations. Other factors influencing decisions were personal physician characteristics, experience, and gender, case-mix in the ICU, and co-morbidities of patients.34 SUMMARY End-of-life decisions occur daily in ICUs around the world. There are numerous factors affecting these decisions including geographical location,6,7,10 religion,11,12 and attitudes of caregivers, patients, and families.

We expect that 20 enrolled patients will have clinically important cervical spine injury. For clinical impact, we anticipate that as much as 40% of all patients assessed could be transported without

full cervical spine immobilization. Discussion We can expect paramedic use of the CCR to ultimately lead to improved efficiency for EMS systems, Inhibitors,research,lifescience,medical hospital EDs, and the Canadian health care system. Approximately 40% of all very low-risk trauma patients could be transported safely, without c-spine immobilization devices, decreasing the time spent in the field immobilizing patients before transport, and increasing paramedic field availability for the next patient from faster transfer of care to the ED personnel. While 1.3 million injury patients Inhibitors,research,lifescience,medical are transported each year by paramedics, the vast majority are low-risk and do not need cervical immobilization. This study is an essential step extending the responsibility of effective triage of trauma patients to paramedics across Canada. Most Canadian paramedics currently do not evaluate Inhibitors,research,lifescience,medical patients for potential c-spine injury, a task that is exclusively done by physicians. Our previous PR-171 molecular weight studies have determined the safety and effectiveness of the rule when used by physicians and nurses,

but what remains unknown is safety and efficiency of patient care that would follow evaluation of the c-spine by paramedics. We believe that use of the CCR has Inhibitors,research,lifescience,medical the potential to increase the autonomy of the paramedic profession in managing the very common low-risk trauma patients. We expect the results of this efficacy study to be valuable and applicable to paramedics throughout all of Canada. We hope to plan a future implementation trial study that would focus on effectiveness in widespread Canadian locations. Our partners have not only expressed their support for this study, they have clearly indicated their intent to Inhibitors,research,lifescience,medical use the findings to change policies and guidelines

within their organizations. These changes will eventually impact paramedic practice in all EMS services across Canada as well as in other countries. Competing interests The authors declare that they have no competing interests. Authors’ contributions CV conceived the study and obtained funding. MC helped draft and edit the manuscript. AK obtained ethics approval. JM drafted Linifanib (ABT-869) and edited the medical directive and revised the methodology critically for important intellectual content. GW assisted with the methodology and revised it critically for important intellectual content. IS contributed significantly to the conception of the study and to the application for funding. All authors read and approved the final manuscript. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-227X/11/1/prepub Acknowledgements This study is funded by the Canadian Institutes for Health Research (grant #102597).

Radical Cystectomy Although there is a this website paucity of studies evaluating the incidence and treatment of VTE in patients undergoing cystectomy, the available data are impressive. As described previously,

White’s review of the California Patient Discharge Data Set revealed a postoperative VTE rate of 3.7%, the highest reported of any surgery in the database.36 Similarly, in a review of 101 patients undergoing radical cystectomy for cancer, Rosario and colleagues found a symptomatic VTE rate of 6%. There were 4 incidences of DVT and 2 of PE; none were fatal. No comment was made regarding what thromboprophylaxis modality, if any, was used.79 No prospective, randomized, controlled trials regarding the Inhibitors,research,lifescience,medical use of pharmacologic thromboprophylaxis have been performed. However, these 2 studies reveal radical cystectomy to be an Inhibitors,research,lifescience,medical extremely highrisk procedure

for VTE. This association is likely related to patient age, comorbid cardiopulmonary pathology, malignancy, smoking history, extensive pelvic dissection including lymphadenectomy, increasing use of adjuvant and neoadjuvant Inhibitors,research,lifescience,medical chemotherapy, central venous catheterization, and prolonged postoperative immobility/ institutionalization. In light of the high risk for and significant consequences of VTE, surgeons should strongly consider the use of perioperative pharmacologic thromboprophylaxis in patients undergoing radical cystectomy. Nephrectomy Several large-scale retrospective studies have demonstrated an increased risk of VTE in patients with renal malignancies Inhibitors,research,lifescience,medical relative to other cancers. However, incidence varies drastically from study to study and is likely a result of significant differences in disease stage depending on mode of retrospective examination. For example, in a retrospective study of incidence of VTE in patients with solid tumors, Sallah and associates reported a 22.6% incidence of VTE in patients with renal

cell carcinoma. Inhibitors,research,lifescience,medical This was higher than that reported for pancreatic and brain tumors in the same study. The authors reviewed only patients referred to hematology/oncology services at 3 tertiary medical centers. In most cases, only patients who are not surgically cured of renal cell carcinoma (those with metastatic disease, vascular invasion, or local not invasion) are referred to oncology. Thus, this extremely high incidence of VTE results from a selection bias for patients with stage III–IV disease.49 In a dated review of Medicare data from 1988–1990, Levitan and colleagues found a 0.8% incidence of VTE among patients admitted with an International Statistical Classification of Diseases and Related Health Problems, version 9, diagnosis of renal cancer. This finding placed renal cancer among the top 6 malignancies with regard to incidence of VTE. Once again, data regarding the nature of admission, stage of disease, and surgical treatment were not reported.

A1-LC is a local closer interE3 Ligase inhibitor neuron in the A1 neuromere of the metathoracic ganglion (Fig. 8A). Its dorsal cell body was located near the ganglion midline and its primary neurite projected toward the contralateral ganglion side. An anterior and a posterior dendritic main branch arose from the primary neurite at the midline of the ganglion and ramified along the dorsal midline of A1 and A2 where they spatially overlapped with the posterior dendrite of T3-DO and axonal branches of A3-AO and T3-DO. During fictive singing, A1-LC was depolarized and generated 2–4 action potentials in each wing-closer phase

and was inhibited during the wing-opener phase (Fig. 8B). For each syllable, the Inhibitors,research,lifescience,medical neuron fired its Inhibitors,research,lifescience,medical first spike 11.4 ± 1.5 msec (mean ± SD; N = 1, n = 20) after the first wing-opener motoneuron spike and 10.2 ± 1.1 msec (mean ± SD; N = 1, n = 20) before the first spike of the wing-closer burst. During the chirp intervals, the membrane potential of A1-LC was up to 3 mV below the resting potential, which drastically reduced its spontaneous spike activity from 23 Inhibitors,research,lifescience,medical Hz before and after singing episodes to a mean spike activity of 8 Hz during chirp intervals. Figure 8 Structure and activity of the local closer-interneuron A1-LC. (A) Morphology of A1-LC

in the fused abdominal neuromeres of the metathoracic ganglion (ventral view). (B) and (C) Singing motor activity (top trace) and intracellular recordings of Inhibitors,research,lifescience,medical A1-LC (lower … In the A2 neuromere, we recorded a morphologically unidentified closer interneuron that received conspicuous inhibition at the beginning of each chirp and indicated postinhibitory rebound as a presumable mechanism contributing to singing pattern Inhibitors,research,lifescience,medical generation. During fictive singing, this closer neuron was inhibited in each opener phase and depolarized by 20–25 mV in the closer phase (Fig. 9A). Every depolarization gave rise to a burst of 5–6 action potentials with a spike frequency of 250–300

Hz. During each syllable, the neuron fired its first spike 12.0 ± 2.3 msec (mean ± SD; N = 1, n = 50) after the start of the wing-opener Nature Reviews Microbiology motoneuron burst and 8.0 ± 0.4 msec (mean ± SD; N = 1, n = 50) before the first spike of the wing-closer burst. Injection of depolarizing current pulses (+5 nA; 100 msec) reset the ongoing chirp rhythm similar to A3-AO and T3-DO, but in contrast to the reset effect of the opener interneurons, electrical stimulation of this closer neuron did not elicit additional singing motor activity (Fig. 9B). Interestingly, during the chirp intervals following the current pulses (arrows in Fig. 9B), the membrane potential was about 3 mV lower as during the preceding and following chirp intervals. Before the start of each singing episode, this closer interneuron received several volleys of 4–6 individual IPSPs at a time (Fig. 9C).

Fig. 1 The electrocardiogram showed complete right bundle branch block with posterior fascicular block. Fig. 2 The transthoracic echocardiography (A) and transesophageal echocardiography (B) showed prolapse of the septal (arrows) and anterior (arrow heads) tricuspid valve leaflet with large portions of the valve and the subvalvular appratus protruding into the … Fig. 3 The color-flow Doppler transthoracic echocardiography showed

severe tricuspid regurgitation (A). Peak velocity of tricuspid valve was 1.62 m/sec and right ventricular systolic pressure was 20.5 mmHg (B). Fig. 4 Inhibitors,research,lifescience,medical The transthoracic echocardiography after tricuspid valve repair showed satisfactory leaflet coaptation (A) and repaired papillary muscle (B). Discussion The incidence of blunt chest wall trauma and reported traumatic tricuspid regurgitation has been increasing during

the last Stem Cell Compound Library decade.5) However, the diagnosis is difficult because this pathology slowly Inhibitors,research,lifescience,medical progress and its presentation can be atypical or asymptomatic, so its incidence rates may be underestimated.2),5),6) The most common mechanism of acute or subacute tricuspid regurgitation is an anteroposterior compression of the chest Inhibitors,research,lifescience,medical with a sudden increase in the right ventricular pressure during the end diastolic phase, when the main pulmonary vessels are compressed. This Inhibitors,research,lifescience,medical generates a marked traction on both valvular and subvalvular apparatus.5-8) The usual lesion observed at surgery is subvalvular rupture of the anterior papillary muscle.9) Alternatively, delayed tricuspid regurgitation may be due to papillary

muscle contusion with hemorrhage, inflammation, and late necrosis, leading to disruption over time.10) The timing of surgical intervention after traumatic tricuspid regurgitation is a subject Inhibitors,research,lifescience,medical of debate. The traditional indication for operation is symptomatic heart failure. But, severe tricuspid regurgitation can result in right ventricular myocardial ANNUAL REVIEWS dysfunction and ventricular dilatation so that operation should be performed before development of myocardial dysfunction and symptom onset.11-13) Another factor to be considered in the optimal operation timing is contusion induced pulmonary hypertension in the acute event. In the treatment of tricuspid regurgitation with contusion induced pulmonary hypertension, postponing surgery to resolve pulmonary hypertension provides successful and durable repair.10) If valve is intact, tricuspid regurgitation is effectively correctable with reparative techniques in an early operation. Also it prevents right ventricular dysfunction.

Chronic health conditions that are common among the homeless include chronic lung diseases [5], circulatory diseases [6], and diabetes [7]. Homeless persons also experience higher incidences of substance use [8,9], severe mental illness [10,11], and infectious diseases such as HIV/AIDS [12,13] and Hepatitis C [14]. Daily challenges associated with homelessness (e.g. food insufficiency, exposure, etc.) [4,15,16] and barriers to accessing health care services (e.g. discrimination, lack of insurance, etc.) [4,17,18] make it difficult to manage

medical needs, leading to further deteriorations in overall health. Homeless populations subsequently have among the highest all-cause mortality rates of any population in Inhibitors,research,lifescience,medical Inhibitors,research,lifescience,medical North selleck compound America [19-23]. Homeless persons have a high level of need for end-of-life care services [24,25] and these needs may be increasing due to the steady growth in the number of homeless older adults [26,27]. It is estimated that more than 58,000 seniors (i.e. 62years or older) will experience homelessness annually in the US by 2020 [26] and, while estimates are not available for Canada, researchers in various cities have observed upward trends [27]. High levels of morbidity among homeless older adults [28], in combination with the natural progression of

health challenges common among this population (e.g., HIV/AIDS, HCV, etc.), suggest that the end-of-life care system will likely see an increased Inhibitors,research,lifescience,medical demand for its services among the homeless in the immediate future. While the demand for end-of-life

care services may be growing among the homeless in North America, this population faces many barriers to accessing end-of-life care services [24,25,29,30]. In North America, the end-of-life care system is largely Inhibitors,research,lifescience,medical premised on a series of assumptions that do not reflect the experiences and circumstances of homeless populations. Specifically, the end-of-life care system generally assumes that prospective clients are housed, supported by family Inhibitors,research,lifescience,medical and friends, and able to pay for supplementary care. In Canada, where our research was conducted, hospice and palliative care services are underdeveloped [31] and are structured in ways that limit access for TCL homeless populations. For example, existing service structures emphasize family caregivers and dying-in-place (i.e., the home) [31,32]. Accordingly, in many regions, end-of-life care services are oriented toward providing home care support and potentially limit access for homeless or precariously housed persons. Hospice and hospital-based end-of-life care services are also available to provide an additional source of care in many communities, especially in urban centres [31]. However, homeless populations are often unable to access hospice or hospital-based end-of-life care due to rules and regulations (e.g. anti-drug policies, codes of behaviour, etc.) that exclude substance-using populations [29,30].

Complaints of poor sleep are common in older populations. Insomnia reduces quality of

life and is often a factor in decisions to seek health care. Sleep complaints often lead to overmedication and sedation of the elderly, with the numerous potential attendant problems, including increased morbidity and mortality. Finally, cognition also declines with advancing age, particularly those cognitive functions that involve novel problem solving and psychomotor processing speed, with its own related impact on the older individual’s ability to function independently. Interventions that could at least stabilize or possibly improve functional capacity, sleep quality, and cognitive function theoretically Inhibitors,research,lifescience,medical have the potential to prolong an older individual’s ability to live independently, and interest in their possible utility is growing rapidly. There is increasing evidence that the functioning of many of these systems may be improved through stimulation Inhibitors,research,lifescience,medical of the “somatotrophic” or growth hormone (GH)-insulinlike growth factor-I (IGF-I) axis. Levels

of GH and IGF-I Inhibitors,research,lifescience,medical rise rapidly at puberty, remain high during early adulthood, and then decline progressively with aging. It has been suggested that with age there is a “somatopause” of GH-IGF-I anabolic status in both sexes, which is reversible by GH restoration or stimulation therapies. Because the aging pituitary remains capable of synthesizing and secreting increased amounts of GH if appropriately stimulated, several recent studies have examined the effects of

VEGFR assay administering GH secretagogues (GHSs) – factors that stimulate Inhibitors,research,lifescience,medical GH secretion – as an alternative to GH treatment. These secretagogues include analogs of the endogenous hypothalamic GHS, growth hormone-releasing hormone (GHRH). Here we briefly review the evidence for such somatotrophic interventions. We also report preliminary findings on the effects of chronic GHRH treatment on the somatotrophic hormones, body composition, functional status, sleep, and cognitive function of healthy older men and women from two major GHRH intervention studies, one recently completed and the other ongoing. Aging, Inhibitors,research,lifescience,medical somatotrophic hormones, and body composition GH is secreted by the pituitary under the hypothalamic control of at least Nature Reviews Genetics three peptide systems: somatostatin (somatotropin-rcleasc inhibiting factor [SRIF]), which inhibits GH secretion; GHRH; and a second recently characterized secretogogue, ghrelin.1 The combined influences of these systems yield a pulsatile pattern of GH secretion in peripheral blood. GH exerts its effects by binding to its own receptor as well as by stimulating the synthesis of IGF-I. The liver is the primary contributor to levels of IGF-I in the systemic circulation, but IGF-I is generated in many GH target tissues, and local effects may be more important than those of circulating IGF-I of hepatic origin.1 With aging, there are declines in the GH-IGF-I axis2 and in lean body mass.

2011). More importantly, ASL directly assesses CBF through the use of a magnetically labeled arterial blood water endogenous tracer (Aslop et al. 2010; Austin et al. 2011). The technological and also economic benefits of ASL may be advantageous over other imaging modalities that assess cerebral perfusion (e.g., PET, single-photon emission computed tomography (SPECT)), though future studies should examine ASL versus PET versus

SPECT measured blood flow in older adult CVD patients as they relate to cognition Inhibitors,research,lifescience,medical and adverse brain changes. The generalizability of the current findings is limited in several ways. First, the current study consisted of cross-sectional analyses and prospective studies are needed to determine whether cerebral hypoperfusion leads to cognitive decline and accelerated brain atrophy and cortical thinning in older adults. However, the suggested direction of these effects over time is supported by past work (Kitagawa et al. 2009). In addition, the current study found Inhibitors,research,lifescience,medical no association between brain volume or cortical thickness and cognitive function, and additional work is needed to clarify this pattern. Indeed, range restriction may

have limited the current findings, as this sample exhibited relatively intact cognition and future studies with larger more diverse samples would Inhibitors,research,lifescience,medical increase the external validity. Consistent with this notion, the current study attempted to Pemetrexed cell line control for key medical covariates that influence neurocognitive outcomes, though larger sample sizes are needed to confirm our findings through increased statistical power and subsequent Inhibitors,research,lifescience,medical adjustment of other important possible confounds (e.g., white matter lesions, medication side effects). Similarly, prospective studies should examine the role of CBF in the development of white matter lesions, Inhibitors,research,lifescience,medical as recent work in CVD patients shows that WMH may be a key contributor to cognitive

impairment (Alosco et al. 2013). Likewise, it is also possible that WMH leads to reduced CBF to exacerbate brain injury and cognitive impairment, as suggested by past work using ASL imaging in elderly subjects with diffuse confluent WMH (Bastos-Leite et al. 2008). Consistent with this notion, future work should also quantify and examine the contribution of silent infarcts and brain microbleeds to neurocognitive outcomes Nature Reviews Microbiology in aging CVD populations, particularly as they affect cerebral perfusion and subsequent neurocognitive outcomes. Lastly, cerebral perfusion may also be a more sensitive marker of early cognitive impairment relative to subclinical cerebral atrophy in the context of the normal aging process. In brief summary, the current study found that reduced cerebral perfusion as measured by ASL is associated with poorer neurocognitive function in older adults, including reduced cognitive function, smaller TBV, and reduced cortical thickness.

Efficacy measures were total score on the rating scales, their change from baseline, or the response rate. Responders were generally defined as patients with a decrease in the HAMD or MADRS total score of at least 50% after at least 3 weeks of therapy (or time not given), or a score of 1 or 2 on the CGI. Parallel-group dose comparison studies VEGFR inhibitor citalopram The short-term studies with citalopram did not show significant differences In terms of clinical efficacy across a dose range of 20 to 60 mg/day Even a dose of 10 mg/day was effective compared with placebo.10 The results of the maintenance

Inhibitors,research,lifescience,medical study by Montgomery et al11 and the meta-analysis by the same authors12 support these findings. Therefore, for the majority of patients, there Is no advantage of increasing the dose of citalopram above 20 mg/day. The study by Montgomery et al11 Is particularly Interesting, because, In the acute double-blind phase of one of the two Initial studies (Table I),13 citalopram 20 mg/day was no more effective Inhibitors,research,lifescience,medical than placebo. However, in the long-term phase, the relapse rate was similar In the group of responders Inhibitors,research,lifescience,medical on citalopram 20 mg/day who were randomized to placebo and In the group of those who were responders and continued In double-blind on placebo, but higher than in the group of those who were randomized to continue on citalopram

20 mg/day. These results Inhibitors,research,lifescience,medical tend to show that citalopram 20 mg/day was effective in the acute phase despite the observation that it was not significantly different from placebo. Table I Selective and serotonin reuptake inhibitors (SSRls) and dose-efficacy relationship in parallel-group dose comparison studies ranked in order of increased efficacy. HAMD, Hamilton Rating Scale for Depression; MADRS, Montgomery and Åsberg Depression … The study by Montgomery et al13 failed Inhibitors,research,lifescience,medical to show a benefit of citalopram 20 mg/day on the HAMD 17 Items and MADRS total scores In a group

of 56 évaluable patients, ie, those who remained at least 3 weeks In the study; only citalopram 40 mg/day, In a group of 49 évaluable patients, was superior to placebo and to citalopram 20 mg/day. When using change on the HAMD and MADRS total score, citalopram 20 and 40 mg/day were no different from placebo. Using the 50% reduction on the HAMD and MADRS total score, there were no differences between citalopram 20 and 40 mg/day and placebo at the end of 6 weeks. In other words, there Behavioral and Brain Sciences were no more responders In the two citalopram groups than In the placebo group. All analyses were carried out on a LOCF. In a large study by Felghner and Overo (Table I), 14 citalopram 40 and 60 mg/day, but not 10 and 20 mg/day, were more effective than placebo on change on the HAMD 21 Items total score on ITT-LOCF at the end of 6 weeks. However, there was no statistical analysis comparing the different doses of citalopram.

Only 20% (2/10) of the patients on SSRIs developed IFN-MDD, while 47.6% (10/21) not on antidepressants did. These results are numerically similar to the RCTs reviewed above. This very limited analysis suggests a more targeted use of SSRIs to prevent recurrence, limiting prophylactic SSRI to those patients who are known to have past MDD histories. However, all of these studies have been very limited in size, and therefore power. Assessing all of the six published prevention studies and our open-label data combined – in a very exploratory type of meta-analysis

– 15/97 (15%) patients receiving SSRIs prior to starting IFN-α developed IFN-MDD, compared with 36/99 (36%). This is a Inhibitors,research,lifescience,medical significant difference, χ2=8.2;P<0.001. However, limiting the meta-analysis to the three RCTs, 10/55 (18%) subjects randomized to pretreatment paroxetine developed IFN-MDD while 21/68 Inhibitors,research,lifescience,medical (31%) randomized to placebo did. The trend is numerically similar to the larger meta-analysis, but does not have the power to be significant in a chi-square test (χ2=1.98). At this point, only tentative conclusions are possible: (i) Prophylactic SSRIs may plausibly cut in half the incidence of IFN-MDD. To conclusively determine this, however,

will require a larger-size trial than those performed to date; (ii) SSRIs Inhibitors,research,lifescience,medical may specifically benefit subjects with Belinostat buy either pre-existing depressive symptoms (ie, subthreshold depression) and/or a history of prior MDD. This is consistent either with studies of “indicated prevention” in which patients with subthreshold depression are prevented from worsening to full categorical MDD by about Inhibitors,research,lifescience,medical 30%,108-110 or with studies preventing recurrence of MDD.116-119 A more targeted prevention RCT would be valuable to examine these two possibilities; (iii) Even if Inhibitors,research,lifescience,medical SSRIs are found to be effective prophylactics for some people, about 15% to 20% of patients still developed IFN-MDD even when prescribed SSRIs, there fore antidepressants may not be universally effective. Other targets and approaches for prevention

are needed; (iv) Most importantly, about half of the patients with a history of MDD remain resilient even during IFN-α treatment. Identifying the source of this resilience for potential replication in other patients Dacomitinib would be beneficial. Modifiable risk factors for IFN-MDD The goal for this work is preventative treatments that can be targeted towards specifically mitigating those mechanisms underlying vulnerability. Poor sleep quality prior to IFN-α treatment may be one such risk factor.121,122 Patients with scores greater than 10 on the Pittsburgh Sleep Quality Index, a validated self-report assessment of sleep quality,123 were ten times more like to subsequently develop IFN-MDD than patients sleeping better than this.122 This large effect size was evident even when controlling for other depression symptoms.