How much sleep do you need? A comprehensive review of fatigue related impairment and the capacity to work or drive safely

In developed countries, deaths attributable to driving or working while intoxicated have steadily declined over recent decades. In part, this has been due to (a) public education programs about the risks and (b) the deterrence value associated with penalties and prosecutions based on an individual being 'deemed impaired' if they exceed a proscribed level of blood alcohol or drug concentration while driving/working. In contrast, the relative proportion of fatigue-related accidents have remained stubbornly high despite significant public and workplace education. As such, it may be useful to introduce the legal principle of 'deemed impaired' with respect to fatigue and/or sleep loss. A comprehensive review of the impairment and accident literature was performed, including 44 relevant publications. Findings from this review suggests that a driver or worker might reasonably be 'deemed impaired' once the amount of sleep falls below five hours in the prior 24. Building on the legal principles first outlined in recent New Jersey legislation (Maggie's Law), this review argues that an individual can reasonably be 'deemed impaired' based on prior sleep wake behaviour. In Maggie's Law, a driver can be indirectly 'deemed impaired' if they have not slept in the prior 24 h. Based on the extant literature, we argue that, relative to drug and alcohol intoxication, this may be overly conservative. While roadside measurement of fatigue and prior sleep-wake behavior is not yet possible, we suggest that public education programs should provide specific guidance on the amount of sleep required and that post-accident forensic examination of prior sleep wake behaviours may help the community to determine unsafe behaviours and liability more objectively than is currently the case.

Co-occurrence of Aicardi-Goutières syndrome type 6 and dyschromatosis symmetrica hereditaria due to compound heterozygous pathogenic variants in ADAR1: a case series from India

Aicardi-Goutières syndrome type 6 (AGS6) and dyschromatosis symmetrica hereditaria (DSH) are allelic disorders caused respectively by biallelic and heterozygous pathogenic variants in ADAR1. We report three unrelated children presenting with features of both AGS6 and DSH, two of whom had compound heterozygous pathogenic variants in ADAR1. We also describe the novel genetic variants in our cases and review the literature on association of ADAR1-related AGS6 and DSH with these phenotypes.

Optimizing the Handling of Invasive Fungal Sinusitis Surgical Specimens

Introduction/Objective

Invasive fungal sinusitis (IFS) is an aggressive disease characterized by invasion of fungal hyphae into tissue/neurovascular bundles. This project assessed the handling of IFS specimens and implemented protocols to improve turnaround time (TAT).

Methods

A retrospective review of cases accessioned with a clinical concern for IFS from 2014-2019 was performed. TAT for each step in the specimen processing was recorded. A flowchart was created using stakeholder interviews and a revised protocol was developed after assessing critical needs. Assessment of interventions was performed following implementation of the new protocol. The protocol will be evaluated by prospective direct case-by-case feedback and after a 6-month interval (projected August/2020). At 6-months, goals are a 24 hours median time between frozen section and sign-out and elimination of outliers (greater than 2 working days).

Results

We identified 53 specimens from 32 patients in the pre-intervention period (36 cases positive for IFS). Median time from frozen section to final sign-out was 28 (5-312) hours. Four areas for improvements were identified:

(1) triaging specimens to different protocols according to arrival time, (2) optimized triaging for available histology processors, (3) standardized GMS ordering, and (4) standardized case delivery/communication with sign-out staff. Interventions include: protocol for processing specimens based on time of day, new histology protocols to expedite GMS performance, an email group for rapid communication with staff pathologists and histology, and a worksheet/checklist to track each case. After implementation of the protocol, 8 cases from 7 patients were received. Median time from frozen section to final sign-out was reduced to 20 (2 – 50) hours.

Conclusion

The protocol for handling IFS specimens became live on 2/1/2020. It has reduced TAT of suspected IFS cases, from a median of 28 hours to 20 hours. The longest interval to sign-out went from312 hours to 50 hours.

Healthy choices in New South Wales health facilities for staff and visitors: a policy evaluation

Issue

Obesity and its determinants are risk factors for most leading causes of chronic diseases. In New South Wales (NSW), Australia, 1 in 2 adults and more than 1 in 5 children are above a healthy weight. As a key symbolic part of a suite of health eating policies, the NSW Ministry of Health implemented a Healthy Food and Drink in NSW Health facilities for Staff and Visitors Framework (Framework) across 18 Local Health Districts (LHDs). Many countries are grappling to understand the effectiveness of obesity prevention policies. Description 2: This policy evaluation synthesised evaluation study findings and internal records to assess the effectiveness of the Framework in achieving implementation targets: a) the removal of sugar-sweetened drinks (SSDs) from sale (Dec 2017), b) implementation of 12 food-based practices (Dec 2018).

Results

The overall implementation package was appropriate for the large, geographically dispersed, decentralised health system (160 health facilities; 927 food outlets;76 retailers) and variable retail arrangements. The Ministry provided LHDs with overall direction, phasing, and monitoring; the LHDs had local leadership, governance, cross-functional support and autonomy to implement in a way to suit them. Accountability and pace of implementation was driven most notably by monitoring and reporting using an electronic tool (PHIMS-N), and a 'network of practice' that was pivotal to problem solving. SSDs were removed from 96% (n = 606) of applicable food outlets; overall average achievement of all practices was high at 82% (22.4 SD). Nine in 10 (92%) consumers support the Framework, and retailers are accepting of its targets. Lessons: This was the right policy at the right time, with well-orchestrated implementation. Annual monitoring and reporting enabled by PHIMS-N is unique in this type of policy implementation and essential for tracking progress, informing decision making, and ensuring accountability.

Key messages

Implementation of the Framework has resulted in the removal of SSDs from sale, increased availability of healthier foods and decreased unhealthy foods as measured by 12 food-based practices. The Framework is feasible and effective in influencing retail practices in health facilities, has high consumer support for its goals, and overall acceptability and adoption amongst retailers.

GW190521: A Binary Black Hole Merger with a Total Mass of 150 M_{⊙}

On May 21, 2019 at 03:02:29 UTC Advanced LIGO and Advanced Virgo observed a short duration gravitational-wave signal, GW190521, with a three-detector network signal-to-noise ratio of 14.7, and an estimated false-alarm rate of 1 in 4900 yr using a search sensitive to generic transients. If GW190521 is from a quasicircular binary inspiral, then the detected signal is consistent with the merger of two black holes with masses of 85_{-14}^{+21}  M_{⊙} and 66_{-18}^{+17}  M_{⊙} (90% credible intervals). We infer that the primary black hole mass lies within the gap produced by (pulsational) pair-instability supernova processes, with only a 0.32% probability of being below 65  M_{⊙}. We calculate the mass of the remnant to be 142_{-16}^{+28}  M_{⊙}, which can be considered an intermediate mass black hole (IMBH). The luminosity distance of the source is 5.3_{-2.6}^{+2.4}  Gpc, corresponding to a redshift of 0.82_{-0.34}^{+0.28}. The inferred rate of mergers similar to GW190521 is 0.13_{-0.11}^{+0.30}  Gpc^{-3} yr^{-1}.