A clinical approach to circadian rhythm sleep disorders

Prevention and control of jet lag symptoms and temporary impairment of cognitive function with Pycnogenol® in healthy individuals and in hypertensives

BACKGROUND

The aim of this registry study was to evaluate the efficacy of Pycnogenol® in controlling signs/symptoms and temporary impairment of cognitive function (COFU) associated with jet lag. Previous flight studies have shown a decrease in the level of jet lag symptoms with Pycnogenol®. The control of jet lag signs/symptoms appeared to be correlated with flight-related microangiopathy and peripheral edema. Pycnogenol® - a standardized extract from the bark of French maritime pine - has significant antiedema, anti-inflammatory and antioxidant properties.

METHODS

A group of subjects flying east in economy class for 10-12 hours used Pycnogenol® 150 mg/day and a similar group without supplementation served as controls. A subgroup of mild hypertensive subjects using a single ACE inhibitor was also included.

RESULTS

One hundred twenty-seven subjects completed the study. Of the participants, 48 were aviation professionals like pilots, flight attendants or air company staff - 24 of them took Pycnogenol® and 24 served as controls. Forty-seven study participants were frequent flyers and non-staff professionals, 25 of which took Pycnogenol® and 22 served as controls. In addition, a group of 32 subjects with mild hypertension was included, 16 took Pycnogenol® and 16 served as controls. No side effects and a good tolerability were observed. The registry groups were comparable for baseline characteristics. Eastbound flights' duration was 11.22±0.4 hours in supplemented subjects and 11.14±0.32 in controls. Dropouts were due to logistical problems. Post flight Visual Analogue Scale (VAS) scores were significantly lower in all Pycnogenol® groups, including hypertensives for all signs and symptoms of jet lag compared to controls, showing prevention and improvement of jet lag symptoms. The duration of any sign/symptom of jet lag with Pycnogenol® intake was significantly shorter (P<0.05) post-flight compared to controls (P<0.05). The number of nights of altered/disturbed sleep was also lower in the Pycnogenol® groups compared to controls. Leg edema was present in almost all subjects with different degrees especially in the hypertensive group. The increase in ankle circumference before and after flight was significantly lower with Pycnogenol® compared to controls (P<0.05). After the flight, average scores of the single COFU tasks were significantly higher in the Pycnogenol® groups compared to controls, showing preserved cognitive function.

CONCLUSIONS

In conclusion, in this registry study Pycnogenol® was effective in preventing jet lag-related symptoms and preserving cognitive functions without tolerability problems. These observations should be tested in a larger group of subjects including complex individuals prone to edema (i.e. diabetics, hypertensive or older patients).

Sleep Problems in Autism Spectrum Disorder

Sleep problems are common in children with autism spectrum disorder (ASD), with 40% to 80% prevalence. Common disorders include insomnia, parasomnias, and circadian rhythm sleep-wake disorders. These problems have a multifactorial etiology and can both exacerbate and be exacerbated by core ASD symptoms. Sleep problems also impact the health and quality of life of both patients and their caregivers. All children with autism should be regularly screened for sleep problems and evaluated for co-occurring medical contributors. Behavioral interventions with caregiver training remain first-line treatment for sleep disorders in both neurotypical and neurodiverse youth.

Delayed sleep wake phase disorder in adolescents: an updated review

PURPOSE OF REVIEW

This review examines the most common circadian rhythm disorder in adolescents, delayed sleep phase disorder. It explores the etiology, prevalence, clinical features, diagnostic tools and criteria, and treatment options to identify sleep disorders early in the course. This is important to help improve youths in terms of education and quality of life.

RECENT FINDINGS

Recent studies indicate that delayed sleep wake phase disorder has a range of prevalence between 1% and 16%. It is often associated with neurodevelopmental disorders (i.e. attention deficit hyperactivity disorder and autism spectrum disorder) as well as psychopathology (i.e. substance use, anxiety, and depression). It can present with a myriad of symptoms, such as insomnia, restless sleep, and poor daytime cognitive function, often seen in pediatric practice. Important diagnostic measures incorporate history-taking, sleep logs, actigraphy (i.e. Apple watches) and measurement of dim light melatonin onset. Treatments include improved sleep hygiene, chronotherapy, exogenous melatonin administration, and bright light therapy.

SUMMARY

There are many environmental and genetic factors that can predispose an individual to circadian rhythm disorders. Delayed sleep phase disorder has detrimental effects on overall health, cognition, and behavior. It is important to screen for this disorder in routine pediatric clinic visits. The goal of early intervention is to prevent health and behavioral complications and treat adolescents using a multimodal approach, especially those with affective/neurodevelopmental conditions, who are prone to having delayed sleep wake phase disorder.

Acupuncture in circadian rhythm sleep-wake disorders and its potential neurochemical mechanisms

Circadian rhythm sleep-wake disorders (CRSWDs) are becoming increasingly common in modern societies due to lifestyle changes. The detrimental effects of CRSWDs on sleep and psychological health have attracted considerable attention recently. Alternative remedies for the treatment of CRSWDs have also gained attention in recent years owing to the limitations of medications. Several in vivo and clinical investigations have shown that acupuncture, one of the most important components of traditional Chinese medicine (TCM), has been shown to modulate sleep-related circadian rhythms. Owing to the lack of research on the mechanism and effectiveness of acupuncture in treating CRSWDs, clinical applications of acupuncture have not gained popularity. This paper reviews the acupuncture methods, acupoint selection, and biochemical indicators supplied by in vivo and clinical studies to explore the effectiveness of acupuncture, and summarizes the circadian rhythm mechanisms and the acupuncture characteristics on circadian rhythm. The neurochemical mechanisms linked to acupuncture in treating CRSWDs are also outlined from the perspective of the central and peripheral biological clocks. Lastly, the inadequacy of previous studies on CRSWDs and conflicting results regarding acupuncture are explored and future research directions are envisioned.

Case report: Diagnosis and intervention of a non-24-h sleep-wake disorder in a sighted child with a psychiatric disorder

Circadian rhythm sleep-wake disorders (CRSWD) are sleep dysfunctions related to circadian functioning. They are characterized by symptoms of insomnia or excessive sleepiness that occur because the intrinsic circadian pacemaker is not entrained to a 24-h light/dark cycle. Affected individuals with a free-running disorder or hypernycthemeral syndrome (N24SWD) have a longer sleep-wake cycle that produces a sleep pattern that typically delays each day. The disorder is seen in 70% of blind people, and among people with healthy vision, it is a rare pathology. Among sighted cases, 80% are young men and 28% have a psychiatric disorder. The patient was a 14-year-old boy with a psychiatric pathology diagnosed with a PANDAS syndrome (pediatric autoimmune neuropsychiatric disorders associated with streptococci), a sudden acute and debilitating onset of intense anxiety and mood lability accompanied by obsessive compulsive-like issues and/or tics, in association with a streptococcal A infection that occurs immediately prior to the symptoms. As a comorbidity, he exhibited severe insomnia due to an irregular sleep pattern that strongly delayed his sleep schedule day to day. It affected his daily routines, as he was not going to school, and aggravated, furthermore, the psychiatric symptoms. He was referred for sleep consultation, where the case was explored by ambulatory circadian monitoring (ACM) using the novel system Kronowise® (Chronolab, University of Murcia) and diagnosed with a non-24-h sleep-wake disorder (N24SWD). The first treatment approach for the patient was focused on improving symptoms during the acute infection and psychiatric symptoms. Additionally, sleep pathology was treated by light therapy and melatonin. After 8 months and different trials, it was possible to establish a treatment to normalize the symptoms and fix his sleep rhythm in a normal schedule as well as to reduce anxious symptoms during the day. The association of PANDAS and N24SWD has not previously been reported in the literature.

Maternal Circadian Disruption from Shift Work and the Impact on the Concentration of Melatonin in Breast Milk

Background and Objective: Melatonin in breast milk exhibits a 24-hour circadian rhythm, present in nighttime breast milk but nearly undetectable in daytime breast milk. Shift work can disrupt the circadian timing of individuals, evident in changes in melatonin in saliva and urine samples. However, it is unknown whether these changes are also reflected in breast milk from a shift working mother. The aim of this study was to investigate whether maternal circadian rhythm disturbance from shift work impacts the melatonin concentration in breast milk. Materials and Methods: Breast milk and saliva samples were collected from 11 shift working mothers at four timepoints across five consecutive days. This included during their day shift or nonworkdays to act as a control, night shift, subsequent night shifts and postnight shift. Where possible, pre- and postfeed collections were also undertaken. Samples were grouped into four-time intervals: 12-6:30 am, 7-11:30 am, 12-6:30 pm, 7-11:30 pm, and melatonin levels (picogram per milliliter) in the breast milk and saliva samples were analyzed. Results: There was a significant decrease in breast milk melatonin (p = 0.026) at the 12-6:30 am time interval on subsequent night shifts, compared with control days. However, there was no overall time and shift type interaction effect (p = 0.70). In addition, no observed difference in melatonin levels was found in saliva samples, or when comparing pre- and postfeed breast milk. Breast milk melatonin however was found to be significantly higher compared with saliva (p > 0.001), at all but one time interval. Conclusion: The findings suggest that there is a potential effect of maternal circadian rhythm disruption from shift work on breast milk melatonin levels. This is an important step in exploring the role of maternal circadian timing and the effect on breast milk composition. Expansion of this research and exploration of other circadian rhythm misalignment sleep disorders on breast milk is highly recommended.

Sleep and fatigue management strategies: How nurses, midwives and paramedics cope with their shift work schedules-a qualitative study

AIMS

To understand the benefits and challenges of shift work, and the coping strategies used by nurses, midwives and paramedics to manage the impact of shift work on sleep and fatigue from shift work.

DESIGN

A single case study with embedded units.

METHODS

Twenty-seven participants were interviewed exploring their shift work experiences, coping strategies used to improve sleep, and what their recommendations are for improving shift work management. Interviews were completed between November and December 2022.

RESULTS

Participants enjoyed the lifestyle, flexibility and financial rewards offered by working shift work. However, fatigue and sleep deprivation undermined these benefits, as it impacted their ability to enjoy social and family events. There were also concerns of long-term health consequences of shift work and delivery of care. Changes to rostering practices and sleep and shift work education were common recommendations.

CONCLUSION

This study provides insights on how healthcare professionals manage sleep and fatigue due to shift work and the inadequate support. There is absence of adequate policies, processes and training at an organizational, academic and personal level on how to best manage sleep and fatigue when working shift work. Future research is needed to explore how to equip healthcare shift workers with the skills to successfully manage their schedules to mitigate the negative impact that poor sleep and fatigue has on the health and safety of themselves and their patients.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Understanding the specific challenges of shift work and how workers manage their shift work schedules is critical for improving the health and safety of themselves and their patients. This study identified that there is insufficient training regarding sleep and shift work management strategies, potentially leading to occupational health and safety concerns. Further education and training to equip staff with the necessary information, training and guidance to staff on how to reduce fatigue risk is required.

PATIENT OR PUBLIC CONTRIBUTION

This study involved healthcare shift workers in semi-structured interviews. Data gathered from a previous survey that participants were involved in helped shape the interview topics and the study design.

Pharmacists' perspectives and attitudes towards the 2021 down-scheduling of melatonin in Australia using the Theoretical Domains Framework: a mixed-methods study

BACKGROUND

In Australia, prescription melatonin became a 'Pharmacist Only Medicine' for people over 55 with insomnia from June 2021. However, little is known about pharmacists' views on melatonin down-scheduling and perceived impacts on practice.

AIM

To explore Australian community pharmacists' views on and attitudes towards the down-scheduling of melatonin.

METHOD

A convenience sample of community pharmacists and pharmacy interns were recruited. Participants completed a survey capturing demographic and professional practice details, and rated their knowledge, beliefs and attitudes towards melatonin. This was followed by an online semi-structured interview. Interviews were guided by a schedule of questions developed using the Theoretical Domains Framework and explored the perceived role of melatonin, preparation/response to down-scheduling, practice changes and patient interactions. Interviews continued until data saturation and were digitally recorded, transcribed verbatim and analysed using the Framework Approach.

RESULTS

Twenty-four interviews were conducted with community pharmacists (n = 19) and intern pharmacists (n = 5), all practicing in metropolitan areas. Pharmacists/intern pharmacists welcomed the increased accessibility of melatonin for patients. However, pharmacists perceived a disconnect between the guidelines, supply protocols and pack sizes with practice, making it difficult to monitor patient use of melatonin. The miscommunication of eligibility also contributed to patient-pharmacist tension when supply was denied. Importantly, most participants indicated their interest in upskilling their knowledge in melatonin use in sleep, specifically formulation differences and dosage titration.

CONCLUSION

While pharmacists welcomed the down-scheduling of melatonin, several challenges were noted, contributing to pharmacist-patient tensions in practice. Findings highlight the need to refine and unify melatonin supply protocols and amend pack sizes to reflect guideline recommendations as well as better educating the public about the risk-benefits of melatonin.

Application and limitation of a biological clock-based method for estimating time of death in forensic practices

Estimating time of death is one of the most important problems in forensics. Here, we evaluated the applicability, limitations and reliability of the developed biological clock-based method. We analyzed the expression of the clock genes, BMAL1 and NR1D1, in 318 dead hearts with defined time of death by real-time RT-PCR. For estimating the time of death, we chose two parameters, the NR1D1/BMAL1 ratio and BMAL1/NR1D1 ratio for morning and evening deaths, respectively. The NR1D1/BMAL1 ratio was significantly higher in morning deaths and the BMAL1/NR1D1 ratio was significantly higher in evening deaths. Sex, age, postmortem interval, and most causes of death had no significant effect on the two parameters, except for infants and the elderly, and severe brain injury. Although our method may not work in all cases, our method is useful for forensic practice in that it complements classical methods that are strongly influenced by the environment in which the corpse is placed. However, this method should be applied with caution in infants, the elderly, and patients with severe brain injury.

Sleep Disorders during Adolescence

Sleep disorders during adolescence period increase each year and adversely affect the physical and mental health of adolescents. After-school social activities and various work outside the school may cause delays in bedtime. In addition, there can be shifts in the circadian rhythm due to a number of biological changes seen in the transition to adolescence, which can result in a wide range of sleep problems, such as not being able to fall asleep at night, difficulty waking up in the morning, daytime sleepiness, sleep deprivation and deterioration in sleep quality. It is important to know the causes of sleep disorders, possible effects on physical health and mental health, and protective and risk-forming factors seen in adolescent period; to intervene in these disorders and to develop preventive measures. Preventive measures, such as increasing awareness about sleep disorders in adolescents, informing families and adolescents about the issue, and organizing school start-up times for this age group, may contribute significantly to solving this important issue, which has increased year-to-year.

Use of Caffeine-Containing Energy Drinks by Japanese Middle School Students: A Cross-Sectional Study of Related Factors

Excessive consumption of caffeine negatively affects individuals' health. Therefore, we studied the use of energy drinks and the conditions associated with it among Japanese secondary school students. Participants were 236 students in grades 7-9 who completed anonymous questionnaires at home in July 2018. We measured the basic attributes and dietary, sleeping, and exercise habits. We used Chi-squared tests to compare differences between users and non-users of energy drinks. Logistic regression analyses were used to elucidate the complex association between the variables. The results showed that boys were more willing to consume energy drinks than girls. The reasons were 'feeling fatigued', 'needing to stay awake', 'for curiosity', and 'to quench one's thirst'. Among boys, the following were associated with the use of EDs. Buying their own snacks , not understanding nutritional labels on foods, high caffeinated beverage intake, late bed-times on weekdays, always waking up at about the same time, and weight. Health guidance is needed to prevent overconsumption and dependence on energy drinks. The cooperation of parents and teachers is needed to achieve these goals.

Potential of Polyphenols for Improving Sleep: A Preliminary Results from Review of Human Clinical Trials and Mechanistic Insights

Global epidemiologic evidence supports an interrelationship between sleep disorders and fruits and vegetable ingestion. Polyphenols, a broad group of plant substances, are associated with several biologic processes, including oxidative stress and signaling pathways that regulate the expression of genes promoting an anti-inflammatory environment. Understanding whether and how polyphenol intake is related to sleep may provide avenues to improve sleep and contribute to delaying or preventing the development of chronic disease. This review aims to assess the public health implications of the association between polyphenol intake and sleep and to inform future research. The effects of polyphenol intake, including chlorogenic acid, resveratrol, rosmarinic acid, and catechins, on sleep quality and quantity are discussed to identify polyphenol molecules that may improve sleep. Although some animal studies have investigated the mechanisms underlying the effects of polyphenols on sleep, the paucity of trials, especially randomized controlled trials, does not allow for conducting a meta-analysis to reach clear conclusions about the relationships among these studies to support the sleep-improving effects of polyphenols.

Management of Sleep and Fatigue in Gastrointestinal Patients

Sleep is an essential physiologic process, and unfortunately, people with gastrointestinal (GI) conditions are more likely than people in the general population to experience poor sleep quality, sleep disorders, and fatigue. Herein, we present information on common sleep disorders, fatigue, and data on these problems in various GI populations. We also discuss several treatments for sleep concerns and emerging research on the use of these treatments in GI populations. Cases that illustrate the GI/sleep relationship are presented, in addition to guidance for your own practice and cultural considerations.

The relationship between social anxiety and academic engagement among Chinese college students: A serial mediation model

BACKGROUND

Few studies have elucidated the mechanisms linking social anxiety and academic engagement. This study aimed to explore the link between social anxiety and academic engagement through a series of mediating effects of social media addiction and sleep quality among college students.

METHODS

2661 college students completed the Liebowitz Social Anxiety Scale, the Bergen Social Media Addiction Scale, the Pittsburgh Sleep Quality Index, and the Utrecht Work Engagement Scale for Student. The serial mediation analysis was conducted using Hayes' PROCESS macro (Model 6).

RESULTS

Social anxiety had a significantly direct effect on academic engagement (c = -0.162, p < 0.001) and through three significantly indirect pathways: (1) through social media addiction (B = -0.019, 95% CI: -0.027 to -0.011), accounting for 11.7% of the total effect; (2) through poor sleep quality (B = -0.043, 95% CI: -0.052 to-0.034), accounting for 26.5% of the total effect; and (3) through the serial mediators involving in social media addiction and poor sleep quality (B = -0.007, 95% CI: -0.009 to -0.005), accounting for 4.3% of the total effect. The total mediating effect was 42.6%.

LIMITATIONS

This cross-sectional study prevented us from establishing causality.

CONCLUSIONS

This study highlights the serial mediating role of social media addiction and sleep quality, the behavior and lifestyle factors, in the relationship between social anxiety and academic engagement. Therefore, social media addiction and sleep quality interventions for college students with social anxiety have the potential to improve their academic engagement.

Circadian Rhythm Sleep-Wake Disorders in Older Adults

The timing, duration, and consolidation of sleep result from the interaction of the circadian timing system with a sleep-wake homeostatic process. When aligned and functioning optimally, this allows for wakefulness throughout the day and a long consolidated sleep episode at night. Changes to either the sleep regulatory process or how they interact can result in an inability to fall asleep at the desired time, difficulty remaining asleep, waking too early, and/or difficulty remaining awake throughout the day. This mismatch between the desired timing of sleep and the ability to fall asleep and remain asleep is a hallmark of a class of sleep disorders called the circadian rhythm sleep-wake disorders. In this updated article, we discuss typical changes in the circadian regulation of sleep with aging; how age influences the prevalence, diagnosis, and treatment of circadian rhythm sleep disorders; and how neurologic diseases in older patient impact circadian rhythms and sleep.

The association between Internet addiction and sleep quality among Sohag University medical students

Background

Internet addiction (IA) is a growing issue with multiple impacts on psychological functions, including sleep. Consequently, the present study aimed to assess the correlation between IA as well as the quality of sleep among medical students. A total of 525 students from Sohag University were included in the study. Young Internet Addiction Test (YIAT) was utilized in order to evaluate IA. Demographic information, university-related factors, and Internet usage patterns of the participants were documented. Pittsburgh Sleep Quality Index was utilized so as to evaluate the quality of sleep.

Results

The prevalence of IA was 4.95% for severe addiction and 39.62% for moderate addiction. About 81.62% of subjects who suffer from IA significantly had poor quality of sleep. Young age, male gender, low academic performance, computer presence at home, Internet presence at home, using the Internet for chatting and gaming, and poor sleep quality are strong predictors of Internet addiction.

Conclusions

The prevalence of IA and its impact on the quality of sleep have been found to be substantial among medical students. There is a need for programs to raise awareness towards IA as well as its impact on sleep among university medical students.

The neurophysiologic basis of the human sleep–wake cycle and the physiopathology of the circadian clock: a narrative review

The objectives of this review were to explain the neurologic processes that control the human sleep–wake cycle as well as the pathophysiology of the human circadian clock. Non-rapid eye movement and rapid eye movement sleep are the two main phases of sleep. When triggered by circadian input from the anterior hypothalamus and sleep–wake homeostatic information from endogenous chemical signals (example, adenosine), the ventrolateral preoptic nucleus initiates the onset of sleep. Arousal in which there is a conscious monitoring of the surroundings and the ability to respond to external stimuli is known as wakefulness. It contrasts the state of sleep, in which receptivity to external stimuli is reduced. The higher the synchronous firing rates of cerebral cortex neurons, the longer the brain has been awake. Sleep–wake disturbances induced by endogenous circadian system disruptions or desynchronization between internal and external sleep–wake cycles are known as circadian rhythm sleep–wake disorder (CRSWD). Patients with CRSWD usually report chronic daytime drowsiness and/or insomnia, which interferes with their activities. CRSWD is diagnosed based on the results of some functional evaluations, which include measuring the circadian phase using core body temperature, melatonin secretion timing, sleep diaries, actigraphy, and subjective experiences (example, using the Morningness–Eveningness Questionnaire). CRSWD is classified as a dyssomnia in the second edition of the International Classification of Sleep Disorders, with six subtypes: advanced sleep phase, delayed sleep phase, irregular sleep–wake, free running, jet lag, and shift work types. CRSWD can be temporary (due to jet lag, shift work, or illness) or chronic (due to delayed sleep–wake phase disorder, advanced sleep–wake phase disorder, non-24-h sleep–wake disorder, or irregular sleep–wake rhythm disorder). The inability to fall asleep and wake up at the desired time is a common symptom of all CRSWDs.

Cystic Fibrosis and Sleep Circadian Rhythms

Cystic fibrosis (CF) is due to a mutation in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which leads to unusual water and chloride secretion across epithelial surfaces. The lungs are responsible for most morbidity, though other organs are frequently affected. Sleep abnormalities have long been recognized in CF. Abnormal ventilation and oxygenation, sinus disease, deconditioning due to muscle weakness and recurrent infections, and inflammation have been thought to play a role in sleep disorders in CF. However, there is evidence that CFTR gene dysregulation can affect circadian rhythms in CF. Early recognition and treatment of circadian rhythms may improve outcomes in CF.

Longitudinal Associations Between Sleep Habits, Screen Time and Overweight, Obesity in Preschool Children

INTRODUCTION

Decreased sleep duration and increased screen time as early as preschool age may contribute to overweight and obesity. The effects of bedtime together with nocturnal sleep duration remain unclear with a paucity of data evaluating these associations longitudinally. We aim to evaluate the independent and joint effects of sleep duration, sleep bedtime, and screen time at 3 years of age on BMI status, particularly overweight and obesity by age 5 years.

METHODS

Data from 2185 participants of the CHILD Cohort Study were analyzed longitudinally using generalized estimating equations (GEE). Models included changes in overweight/obesity status from 3 to 5 years of age as outcome, and nocturnal sleep duration, bedtime, and daily screen time at 3 years of age as explanatory variables. The joint effects of nocturnal sleep time and excess screen time, late bedtime on overweight/obesity were subsequently analyzed.

RESULTS

The median nocturnal sleep time at 3 and 5 years of age was 11.0 hours/night [IQR 10.5, 11.5]. A total of 14.5% children went to bed after 9PM at 3 years and 7.2% at 5 years. Median screen time was 1.0 hr/day [IQR 1.0, 2.0] at both ages. Longitudinal analyses showed that sleeping less than 10.5 hours at age 3 years was associated with 46% greater odds of overweight/obesity by age 5 years (OR 1.46, 95% CI 1.07, 2.00). The risk was higher when coupled with late bedtime after 9pm (OR 1.60, 95% CI 1.12, 2.31). Children with both short nocturnal sleep duration and excess screen time (>1hr/day) had twice the associated risk of overweight/obesity by age 5 years (OR 1.96, 95% CI 1.34, 2.88).

CONCLUSION

Nocturnal sleep duration and screen time are modifiable risk factors in young children, which may have important implications for obesity prevention as early as infancy.

The effectiveness of an individualized sleep and shift work education and coaching program to manage shift work disorder in nurses: a randomized controlled trial

STUDY OBJECTIVES

While insomnia and sleepiness symptoms are common in shift workers, 20-30% experience more severe symptoms and meet the criteria for shift work disorder (SWD). SWD can lead to impairments in cognitive function, physical and mental health, and reduced productivity and increased risk of workplace injury. The aim of this study was to deliver and evaluate a shift work individual management coaching program, focusing on sleep education, promoting good sleep hygiene, and providing individualized behavioral strategies to cope with shift schedules.

METHODS

A clustered randomized controlled trial of sleep education and sleep disorders screening was undertaken, based on hospital wards at a tertiary hospital in Melbourne, Australia. Participants identified as high risk for SWD underwent one of two 8-week programs; a shift work individualized management program (S.W.I.M.) or an active control. The primary outcome was ward-based sick leave. Secondary outcomes were SWD risk, sleep hygiene, insomnia, depression, and anxiety. A total of 149 nurses, across 16 wards (96% female, 34.66 ± 11.99 years) completed both baseline and follow-up questionnaires (23.9% were high risk SWD).

RESULTS

There was no significant reduction in sick leave between intervention and control wards (mean difference=1.2 days, p=.063). Improvements were seen in insomnia (p<.0001*), and depression (intervention, p=<.0001*, control, p=.023) in both groups, but were not significantly different between programs. Anxiety (p=.001. control p=.079) and FOSQ (p=.001 control p=.056) improved only for the intervention.

CONCLUSIONS

This SWD intervention trial did not reduce sick leave compared to the active control but there was an improvement. Improvements in sleep hygiene, insomnia, depression, and anxiety severity were seen for both groups. Future intervention trials should consider including both sleep and mental health interventions, strategies to avoid between group contamination and the duration of programs for optimal behavioral modification.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Identifier: ACTRN12616000369426.

Approach to Common Sleep Disorders

Sleep disorders are highly relevant in clinical practice given their prevalence as well as their impact on health outcomes and quality of life. The most common concerns are excessive daytime sleepiness, insomnia, disordered breathing, and abnormal movements or behaviors during sleep. A detailed but targeted history is vital, particularly from the sleep partner/witness. In-laboratory sleep testing (polysomnography and multiple sleep latency test) remains vital in the diagnosis of certain sleep disorders (such as sleep-disordered breathing and central hypersomnia) and in specific populations (such as in children and individuals with comorbid medical disorders). Advances in technology have allowed for a variety of methods in assessing a patient's sleep, from compact devices to evaluate for sleep apnea, wrist actigraphy, and mobile device-based applications. As the pathophysiology of various sleep disorders becomes better elucidated, disease-specific medications have been developed for these conditions. Nonetheless, a multidisciplinary approach to management is necessary, including improving sleep hygiene and cognitive behavioral therapy.

The role of sleep hygiene in the risk of Shift Work Disorder in nurses

A high proportion (20%-30%) of shift workers experience Shift Work Disorder (SWD), characterized by chronic sleepiness and/or insomnia associated with work schedules. The reasons for individual variation in shift work tolerance are not well understood, however. The aim of this study was to identify individual factors that contribute to the risk of SWD. Nurses (n = 202) were categorized as low or high risk of SWD based on the Shift Work Disorder Questionnaire. Participants provided demographic and lifestyle information and completed the Sleep Hygiene Index (SHI) and Morningness-Eveningness Questionnaire (MEQ). High risk of SWD was associated with poorer sleep hygiene (SHI, 35.41 ± 6.19 vs. 31.49 ± 7.08, p < .0001) and greater eveningness (MEQ, 34.73 ± 6.13 vs. 37.49 ± 6.45, p = .005) compared to low risk. No other factors, including body mass index, marital status, having children, or caffeine or alcohol intake were significant. Logistic regression showed that SHI was the most significant contributing factor to SWD risk (odds ratio [OR] = 1.09, 95% confidence interval [CI] = 1.04 to 1.14). Standardized odds ratio further revealed that with every unit increase on the SHI score, the odds of being at high risk of SWD increased by 80% (OR = 1.84). Most individuals at high risk of SWD reported "always" or "frequently" going to bed at different times (79%) and waking at different times (83%; compared to 58%, p = .017, and 61%, p = .002, respectively for the low-risk group), as well as going to bed stressed/angry (67% vs. 41%, p < .0001) and/or planning/worrying in bed (54% vs. 22%, p < .0001). Interventions aimed at improving sleep hygiene practices and psychological health of shift workers may help reduce the risk of SWD.

High social jetlag is correlated with nocturnal inhibition of melatonin production among night workers

Night work can lead to social jetlag (SJL), which can be briefly defined as the difference between social and biological time. In this sense, SJL has been viewed as a proxy for circadian misalignment. Studies have suggested that SJL may modify physiological processes, such as blood pressure, glucose metabolism, cortisol, and melatonin production. Therefore, we aimed to verify the correlation between SJL and nocturnal inhibition of melatonin production estimated by the concentration of its urinary metabolite (6-sulfatoximelatonin). The study included day workers (n = 9) and night workers (n = 13) from a public maternity hospital in the city of São Paulo. A questionnaire was used to obtain sociodemographic data, life habits, working conditions, and the Munich Chronotype Questionnaire (MCTQ_shift) was used to assess chronotype. Urine was collected on workdays and days off to estimate the concentration of 6-sulfatoximelatonin (aMT6s), quantified by the ELISA method. We found SJL 13 times higher for night workers (10.6 h) than day workers (0.8 h). The excretion of aMT6s in night workers was statistically different on workdays as opposed to days off, with the lowest excretion on workdays, as expected. SJL was correlated with the aMT6s's delta between the night off and night on among night workers, indicating that the higher is the SJL, the lower is the melatonin production. As expected, social jetlag was higher among night workers, compared to day workers. Moreover, our findings showed that melatonin concentration is directly correlated with SJL.

Advances in the pharmacological management of non-24-h sleep-wake disorder

Introduction: Melatonin, a hormone that regulates circadian rhythms and the sleep-wake cycle, is produced mainly during the dark period in the pineal gland and is suppressed by light exposure. Patients with non-24-h sleep-wake disorder (non-24) fail to entrain the master clock with the 24-h light-dark cycle due to the lack of light perception to the suprachiasmatic nucleus typically in totally blind individuals or other organic disorders in sighted individuals, causing a progressive delay in the sleep-wake cycle and periodic insomnia and daytime sleepiness.Areas covered: Herein, the authors review the pharmacological therapies including exogenous melatonin and melatonin receptor agonists for the management of non-24. They introduce a historical report about the effects of melatonin on the phase shift and entrainment for blind individuals with the free-running circadian rhythm.Expert opinion: Orally administered melatonin entrains the endogenous circadian rhythm and improves nighttime sleep and daytime alertness for non-24. Currently, tasimelteon is the only approved medication for non-24 by the US Food and Drug Administration and the European Medicines Agency. Treatments that focus only on sleep problems are insufficient for the treatment of non-24, and aids to entrain the free-running rhythm with the light-dark cycle are needed.

Circadian rhythm as a therapeutic target

The circadian clock evolved in diverse organisms to integrate external environmental changes and internal physiology. The clock endows the host with temporal precision and robust adaptation to the surrounding environment. When circadian rhythms are perturbed or misaligned, as a result of jet lag, shiftwork or other lifestyle factors, adverse health consequences arise, and the risks of diseases such as cancer, cardiovascular diseases or metabolic disorders increase. Although the negative impact of circadian rhythm disruption is now well established, it remains underappreciated how to take advantage of biological timing, or correct it, for health benefits. In this Review, we provide an updated account of the circadian system and highlight several key disease areas with altered circadian signalling. We discuss environmental and lifestyle modifications of circadian rhythm and clock-based therapeutic strategies, including chronotherapy, in which dosing time is deliberately optimized for maximum therapeutic index, and pharmacological agents that target core clock components and proximal regulators. Promising progress in research, disease models and clinical applications should encourage a concerted effort towards a new era of circadian medicine.

Managing Travel Fatigue and Jet Lag in Athletes: A Review and Consensus Statement

Athletes are increasingly required to travel domestically and internationally, often resulting in travel fatigue and jet lag. Despite considerable agreement that travel fatigue and jet lag can be a real and impactful issue for athletes regarding performance and risk of illness and injury, evidence on optimal assessment and management is lacking. Therefore 26 researchers and/or clinicians with knowledge in travel fatigue, jet lag and sleep in the sports setting, formed an expert panel to formalise a review and consensus document. This manuscript includes definitions of terminology commonly used in the field of circadian physiology, outlines basic information on the human circadian system and how it is affected by time-givers, discusses the causes and consequences of travel fatigue and jet lag, and provides consensus on recommendations for managing travel fatigue and jet lag in athletes. The lack of evidence restricts the strength of recommendations that are possible but the consensus group identified the fundamental principles and interventions to consider for both the assessment and management of travel fatigue and jet lag. These are summarised in travel toolboxes including strategies for pre-flight, during flight and post-flight. The consensus group also outlined specific steps to advance theory and practice in these areas.

The circadian machinery links metabolic disorders and depression: A review of pathways, proteins and potential pharmacological interventions

Circadian rhythms are responsible for regulating a number of physiological processes. The central oscillator is located within the suprachiasmatic nucleus (SCN) of the hypothalamus and the SCN synchronises the circadian clocks that are found in our peripheral organs through neural and humoral signalling. At the molecular level, biological clocks consist of transcription-translation feedback loops (TTFLs) and these pathways are influenced by transcription factors, post-translational modifications, signalling pathways and epigenetic modifiers. When disruptions occur in the circadian machinery, the activities of the proteins implicated in this network and the expression of core clock or clock-controlled genes (CCGs) can be altered. Circadian misalignment can also arise when there is desychronisation between our internal clocks and environmental stimuli. There is evidence in the literature demonstrating that disturbances in the circadian rhythm contribute to the pathophysiology of several diseases and disorders. This includes the metabolic syndrome and recently, it has been suggested that the 'circadian syndrome' may be a more appropriate term to use to not only describe the cardio-metabolic risk factors but also the associated comorbidities. Here we overview the molecular architecture of circadian clocks in mammals and provide insight into the effects of shift work, exposure to artificial light, food intake and stress on the circadian rhythm. The relationship between circadian rhythms, metabolic disorders and depression is reviewed and this is a topic that requires further investigation. We also describe how particular proteins involved in the TTFLs can be potentially modulated by small molecules, including pharmacological interventions and dietary compounds.

A detection method for latent circadian rhythm sleep-wake disorder

BACKGROUND

Individuals with typical circadian rhythm sleep-wake disorders (CRSWDs) have a habitual sleep timing that is desynchronized from social time schedules. However, it is possible to willfully force synchronisation against circadian-driven sleepiness, which causes other sleep problems. This pathology is distinguishable from typical CRSWDs and is referred to here as latent CRSWD (LCRSWD). Conventional diagnostic methods for typical CRSWDs are insufficient for detecting LCRSWD because sufferers have an apparently normal habitual sleep timing.

METHODS

We first evaluated the reliability of circadian phase estimation based on clock gene expression using hair follicles collected at three time points without sleep interruption. Next, to identify detection criteria for LCRSWD, we compared circadian and sleep parameters according to estimated circadian phases, at the group and individual level, between subjects with low and high Pittsburgh Sleep Quality Index (PSQI) scores. To validate the reliability of identified detection criteria, we investigated whether the same subjects could be reproducibly identified at a later date and whether circadian amelioration resulted in sleep improvement.

FINDINGS

We successfully validated the reliability of circadian phase estimation at three time points and identified potential detection criteria for individuals with LCRSWD attributed to delayed circadian-driven sleepiness. In particular, a criterion based on the interval between the times of the estimated circadian phase of clock gene expression and getting out of bed on work or school days was promising. We also successfully confirmed the reproducibility of candidate screening and sleep improvement by circadian amelioration, supporting the reliability of the detection criteria.

INTERPRETATION

Although several limitations remain, our present study demonstrates a promising prototype of a detection method for LCRSWD attributed to delayed circadian-driven sleepiness. More extensive trials are needed to further validate this method.

FUNDING

This study was supported mainly by JSPS, Japan.

Assessment of relationship between the use of cell phone and social networks and sleep quality in students of medical sciences: A cross-sectional study

Introduction

Sleep quality is an essential aspect in human health and function. Considering high prevalence of using smartphones and social networks among students and their impact on sleep quality, this study was conducted to determine the relationship between the overuse of cell phone and addiction to social networks and students’ sleep quality.

Materials and methods

This cross-sectional study was conducted in Kermanshah University of Medical Sciences, Kermanshah, Iran in 2018. Using cluster sampling, 321 students from different disciplines were selected. Data gathering tools consisted of the questionnaire of Pittsburgh Sleep Quality Index (PSQI). Cell phone use and addiction to social networks were assessed using Cell Phone Overuse Scale and a researcher-made questionnaire, respectively. Data were analyzed using SPSS software (version 19) and Pearson’s correlation test.

Results

The mean total score of sleep quality in students was 6.58 ± 1.05. There was a positive and significant correlation between sleep quality and social networks addiction score (p < 0.05, r = 0.5) and cell phone overuse (p < 0.05, r = 0.44); this is an inverse correlation, because higher scores of the total PSQI denote a lower sleep quality and, in Cell Phone Overuse Scale, higher scores shows overuse.

Conclusions

According to the findings of this study, there was a significant statistical relationship between the overuse of cell phone and social networks and students’ sleep quality. In other words, students who have had overuse of cell phones had poorer sleep quality. Therefore, providing effective educational programs to improve the sleep quality in this group is essential.

Clarifying the role of sleep in depression: A narrative review

It has been established that 4.4 to 20% of the general population suffers from a major depressive disorder (MDD), which is frequently associated with a dysregulation of normal sleep-wake mechanisms. Disturbances of circadian rhythms are a cardinal feature of psychiatric dysfunctions, including MDD, which tends to indicate that biological clocks may play a role in their pathophysiology. Thus, episodes of depression and mania or hypomania can arise as a consequence of the disruption of zeitgebers (time cues). In addition, the habit of sleeping at a time that is out of phase with the body's other biological rhythms is a common finding in depressed patients. In this review, we have covered a vast area, emerging from human and animal studies, which supports the link between sleep and depression. In doing so, this paper covers a broad range of distinct mechanisms that may underlie the link between sleep and depression. This review further highlights the mechanisms that may underlie such link (e.g. circadian rhythm alterations, melatonin, and neuroinflammatory dysregulation), as well as evidence for a link between sleep and depression (e.g. objective findings of sleep during depressive episodes, effects of pharmacotherapy, chronotherapy, comorbidity of obstructive sleep apnea and depression), are presented.

Efficacy and safety of supplemental melatonin for delayed sleep-wake phase disorder in children: an overview

Delayed sleep–wake phase disorder (DSPD) is the most frequently occurring intrinsic circadian rhythm sleep–wake disorder, with the highest prevalence in adolescence. Melatonin is the first-choice drug treatment. However, to date melatonin (in a controlled-release formulation) is only authorised for the treatment of insomnia in children with autism or Smiths-Magenis syndrome. Concerns have been raised with respect to the safety and efficacy of melatonin for more general use in children, as melatonin has not undergone the formal safety testing required for a new drug, especially long-term safety in children. Melatonin is known to have profound effects on the reproductive systems of rodents, sheep and primates, as well as effects on the cardiovascular, immune and metabolic systems.

The objective of the present article was therefore to establish the efficacy and safety of exogenous melatonin for use in children with DSPD, based on in vitro, animal model and clinical studies by reviewing the relevant literature in the Medline database using PubMed.

Acute toxicity studies in rats and mice showed toxic effects only at extremely high melatonin doses (>400 mg/kg), some tens of thousands of times more than the recommended dose of 3–6 mg in a person weighing 70 kg. Longer-term administration of melatonin improved the general health and survival of ageing rats or mice. A full range of in vitro/in vivo genotoxicity tests consistently found no evidence that melatonin is genotoxic. Similarly long term administration of melatonin in rats or mice did not have carcinogenic effects, or negative effects on cardiovascular, endocrine and reproductive systems.

With regard to clinical studies, in 19 randomised controlled trials comprising 841 children and adolescents with DSPD, melatonin treatment (usually of 4 weeks duration) consistently improved sleep latency by 22–60 min, without any serious adverse effects. Similarly, 17 randomised controlled trials, comprising 1374 children and adolescents, supplementing melatonin for indications other than DSPD, reported no relevant adverse effects. In addition, 4 long-term safety studies (1.0–10.8 yr) supplementing exogenous melatonin found no substantial deviation of the development of children with respect to sleep quality, puberty development and mental health scores. Finally, post-marketing data for an immediate-release melatonin formulation (Bio-melatonin), used in the UK since 2008 as an unlicensed medicine for sleep disturbance in children, recorded no adverse events to date on sales of approximately 600,000 packs, equivalent to some 35 million individual 3 mg tablet doses (MHRA yellow card adverse event recording scheme).

In conclusion, evidence has been provided that melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in children, provided that it is administered at the correct time (3–5 h before endogenous melatonin starts to rise in dim light (DLMO)), and in the correct (minimal effective) dose. As the status of circadian rhythmicity may change during long-time treatment, it is recommended to stop melatonin treatment at least once a year (preferably during the summer holidays).

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Melatonin improves sleep onset without serious adverse effects in youths with DSPD. Change th text after the fourth bullet into: Melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in youths.

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Melatonin for indications other than DSPD, dose not cause relevant adverse effects.

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Long term melatonin treatment does not impair sleep, puberty, and mental health.

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Melatonin is an efficacious and safe chronobiotic drug for the treatment of DSPD in youths.

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Melatonin should be administered at the correct time and in the minimal effective dose.

Shift Workers at Risk for Metabolic Syndrome

In this highly digitalized era, sleep disorders are becoming more common and are associated with an increased burden of chronic disease. Shift workers are at an increased risk for both sleep disorders and metabolic syndrome. In this article, the authors outline the connection between circadian discordance, hormonal imbalance, and the development of metabolic syndrome in shift workers. Based on a literature review of animal model studies, observational studies, and clinical trials conducted between August and October of 2018, the authors offer several clinical interventions, including work schedules, light therapy, medications, and dietary habits to improve the circadian synchronicity of shift workers and reduce their risk of morbidity and mortality. It is important for physicians to be familiar with the consequences of shift work and ways to mitigate the risks for this patient population.

Sleep Improvement Effect on Sexual Life Quality Among Rotating Female Shift Workers: A Randomized Controlled Trial

BACKGROUND

Poor sleep quality consequences among shift working nurses are well recognized.

AIM

To investigate the impact of sleep improvement on sexual quality of life.

METHODS

The study was a parallel randomized controlled trial, conducted among 120 female nurses in 2 educational hospitals in the Northeast of Iran, Shahroud. Using random blocks of four, 120 eligible participants were randomly assigned to study groups. Data collecting tools included a demographic data questionnaire, Pittsburgh Sleep Quality Index to assess sleep quality, and the survey of sexual quality of life-female and Sexual Self-Efficacy Questionnaire to evaluate level of sexual quality of life and sexual self-efficacy, respectively. The intervention consisted of 3 weekly sleep intervention sessions that lasted from 90 to 120 minutes.

OUTCOMES

The study's primary and secondary outcomes were sleep quality, and the level of sexual self-efficacy and sexual quality of life, respectively.

RESULTS

By 3-month follow-up, the loss to follow-up rate was 5.9%. The mean sleep quality score was 7.61 ± 2.26 in the recruited participants. Following the intervention, the sleep quality score showed statistically significant differences compared to the control group [mean difference (CI 99.98%), -1.89 (-2.40, -1.38)]. Participants in the intervention group showed modest increases in both measures; sexual self-efficacy [mean difference (CI 99.98%), 8.82 (6.83, 10.81)] and sexual quality of life [mean difference (CI 99.98%), 19.64 (18.08, 21.20)].

CLINICAL IMPLICATIONS

These findings suggest that sleep improvement could promote the sexual quality of life among shift working nurses.

STRENGTHS & LIMITATIONS

Strengths of this study include the use of a validated outcome measure. Focusing the study on female nurses and the small size of the study population are the limitations.

CONCLUSION

Improved sleep showed an impact on sexual quality of life among rotating female shift workers. Khastar H, Mirrezaie SM, Chashmi NA, et al. Sleep Improvement Effect on Sexual Life Quality Among Rotating Female Shift Workers: A Randomized Controlled Trial. J Sex Med 2020;17:1467-1475.

A Guide to Management of Sleepiness in ESKD

Daytime sleepiness, also known as hypersomnolence, is common among patients receiving maintenance dialysis and following successful kidney transplantation. Sleepiness may be secondary to medical comorbid conditions, medication side effect, insufficient sleep syndrome, and sleep-disordered breathing or the result of a primary central disorder of hypersomnolence, such as narcolepsy. Unrecognized and untreated sleep disorders are associated with substantial morbidity and mortality among patients with end-stage kidney disease. Effective management of hypersomnolence can improve quality of life in patients with kidney disease. This review focuses on the principal causes of sleepiness in patients with end-stage kidney disease. Awareness of these disorders by treating nephrologists is crucial. This review provides a systematic approach to guide providers through the recognition, early diagnosis, and treatment of hypersomnolence, which is commonly encountered in this patient population. Areas of future research are also suggested.

Understanding Quantitative Circadian Regulations Are Crucial Towards Advancing Chronotherapy

Circadian rhythms have a deep impact on most aspects of physiology. In most organisms, especially mammals, the biological rhythms are maintained by the indigenous circadian clockwork around geophysical time (~24-h). These rhythms originate inside cells. Several core components are interconnected through transcriptional/translational feedback loops to generate molecular oscillations. They are tightly controlled over time. Also, they exert temporal controls over many fundamental physiological activities. This helps in coordinating the body’s internal time with the external environments. The mammalian circadian clockwork is composed of a hierarchy of oscillators, which play roles at molecular, cellular, and higher levels. The master oscillation has been found to be developed at the hypothalamic suprachiasmatic nucleus in the brain. It acts as the core pacemaker and drives the transmission of the oscillation signals. These signals are distributed across different peripheral tissues through humoral and neural connections. The synchronization among the master oscillator and tissue-specific oscillators offer overall temporal stability to mammals. Recent technological advancements help us to study the circadian rhythms at dynamic scale and systems level. Here, we outline the current understanding of circadian clockwork in terms of molecular mechanisms and interdisciplinary concepts. We have also focused on the importance of the integrative approach to decode several crucial intricacies. This review indicates the emergence of such a comprehensive approach. It will essentially accelerate the circadian research with more innovative strategies, such as developing evidence-based chronotherapeutics to restore de-synchronized circadian rhythms.

Effects of Bright Light with Reduced Blue Light on Sleepiness on Rising: A Small Exploratory Study

Bright light therapy is a treatment modality for seasonal affective disorder and circadian rhythm disorders in which artificial light of 2,500 lux or higher at the eye is effective. Although short-wavelength visible light is more effective than long-wavelength visible light, it may be hazardous to the retina. Recently, light-emitting diodes (LEDs) have been used as the light source in bright light therapy apparatuses. We developed goggles for bright light therapy equipped with LEDs as the light source. The aim of this study was to examine the efficacy and safety of our goggles when emitting 10,000-lux light with its short-wavelength light content reduced by 30% or 50% (denoted as 30%-cut and 50%-cut light, respectively, henceforth). Six healthy young males participated in this study. They were administered no light, 50%-cut light, and 30%-cut light for 30 min early in the morning for 4 days each. Subjective sleepiness and sleep quality were evaluated by the Stanford Sleepiness Scale (SSS) and the Oguri–Shirakawa–Azumi sleep inventory MA version (OSA-MA), respectively. Subjective sleepiness evaluated by the SSS and the subscale of the OSA-MA significantly decreased with 30%-cut light compared with no light. Psychomotor performance evaluated by a calculation task improved with the 30%-cut light, although not significant after multiple comparisons were considered. No abnormality was found by ophthalmoscopy and the vision test. In conclusion, our goggles with 30%-cut light may be safe and have an awakening effect.

Universal method for robust detection of circadian state from gene expression

Circadian clocks play a key role in regulating a vast array of biological processes, with significant implications for human health. Accurate assessment of physiological time using transcriptional biomarkers found in human blood can significantly improve diagnosis of circadian disorders and optimize the delivery time of therapeutic treatments. To be useful, such a test must be accurate, minimally burdensome to the patient, and readily generalizable to new data. A major obstacle in development of gene expression biomarker tests is the diversity of measurement platforms and the inherent variability of the data, often resulting in predictors that perform well in the original datasets but cannot be universally applied to new samples collected in other settings. Here, we introduce TimeSignature, an algorithm that robustly infers circadian time from gene expression. We demonstrate its application in data from three independent studies using distinct microarrays and further validate it against a new set of samples profiled by RNA-sequencing. Our results show that TimeSignature is more accurate and efficient than competing methods, estimating circadian time to within 2 h for the majority of samples. Importantly, we demonstrate that once trained on data from a single study, the resulting predictor can be universally applied to yield highly accurate results in new data from other studies independent of differences in study population, patient protocol, or assay platform without renormalizing the data or retraining. This feature is unique among expression-based predictors and addresses a major challenge in the development of generalizable, clinically useful tests.

Light Therapy With Scheduled Rise Times in Young Adults With Delayed Sleep Phase Disorder: Therapeutic Outcomes and Possible Predictors

Clinical trials with light therapy (LT) for delayed sleep phase disorder (DSPD) are sparse and little is known about factors that are favorable for improvements. In this study, LT with scheduled rise times was conducted at home for 14 days by 44 participants with DSPD aged 16-26 years. Primary outcomes were sleep onset and sleep offset. Potential predictors were demographic characteristics, chronotype, dim light melatonin onset, the number of days the LT lamp was used, the daily duration of LT, daytime sleepiness, anxiety, depression, worry, and rumination. Significant advances were observed in sleep onset and sleep offset from baseline to the end of treatment. The number of days of LT predicted earlier sleep onset and sleep offset.

NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients

Background

Non-REM parasomnias are not uncommon conditions in the general population. Current treatment options are based on small case series and reports. In this study, we aimed to present the clinical experience from a large cohort of patients.

Patients

Five hundred and twelve patients with Non-REM parasomnia or parasomnia overlap disorder (POD), who had undergone a video polysomnography and were exposed to treatment, were retrospectively identified. Treatment outcome was assessed based on patients’ reports, and treatment approach on a locally accepted hierarchy of interventions.

Results

Forty percent of patients were diagnosed with sleepwalking, 23.8% with mixed-phenotype and 10% with POD. Ultimately, 97.2% reported adequate control of their symptoms. Moreover, 60.1% were treated with pharmacotherapy and 32.0% without, consistent across all phenotypes (p = 0.09). Benzodiazepines were the most common drugs prescribed (47.1%, p < 0.05). In the end, 37.7% of our patients were receiving a benzodiazepine as part of their successful treatment, 11.7% an antidepressant, 9.2% a z-drug, and 10.7% melatonin. Finally, 13.2%, 12.1%, and 5.8% of our patients reported good control of their symptoms with sleep hygiene, management of sleep-disordered breathing, and psychological interventions (cognitive behavioral therapy [CBT] or mindfulness-based stress reduction [MBSR]), as monotherapy, respectively.

Conclusion

The treatment approach to effective treatment of the patients with Non-REM parasomnias or POD offering first sleep hygiene advice, next treatment of concurrent sleep disorders and management of other priming factors like stress and anxiety, and lastly pharmacotherapy for Non-REM parasomnia is supported by our results. Non pharmacological interventions were effective in one third of our patients, and CBT/MBSR and melatonin appeared promising new treatments.

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This study supports a standardised treatment approach in NREM-parasomnias.

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Pharmacotherapy alone effectively treated two thirds of the patients.

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One third of the patients were effectively treated without pharmacotherapy.

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Treatment of sleep apnea and periodic limb movements in sleep is recommended.

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Melatonin and psychological therapies are promising treatment options.

Direct Midbrain Dopamine Input to the Suprachiasmatic Nucleus Accelerates Circadian Entrainment

Dopamine (DA) neurotransmission controls behaviors important for survival, including voluntary movement, reward processing, and detection of salient events, such as food or mate availability. Dopaminergic tone also influences circadian physiology and behavior. Although the evolutionary significance of this input is appreciated, its precise neurophysiological architecture remains unknown. Here, we identify a novel, direct connection between the DA neurons of the ventral tegmental area (VTA) and the suprachiasmatic nucleus (SCN). We demonstrate that D1 dopamine receptor (Drd1) signaling within the SCN is necessary for properly timed resynchronization of activity rhythms to phase-shifted light:dark cycles and that elevation of DA tone through selective activation of VTA DA neurons accelerates photoentrainment. Our findings demonstrate a previously unappreciated role for direct DA input to the master circadian clock and highlight the importance of an evolutionarily significant relationship between the circadian system and the neuromodulatory circuits that govern motivational behaviors.

Evaluation of circadian phenotypes utilizing fibroblasts from patients with circadian rhythm sleep disorders

We evaluated the circadian phenotypes of patients with delayed sleep-wake phase disorder (DSWPD) and non-24-hour sleep-wake rhythm disorder (N24SWD), two different circadian rhythm sleep disorders (CRSDs) by measuring clock gene expression rhythms in fibroblast cells derived from individual patients. Bmal1-luciferase (Bmal1-luc) expression rhythms were measured in the primary fibroblast cells derived from skin biopsy samples of patients with DSWPD and N24SWD, as well as control subjects. The period length of the Bmal1-luc rhythm (in vitro period) was distributed normally and was 22.80±0.47 (mean±s.d.) h in control-derived fibroblasts. The in vitro periods in DSWPD-derived fibroblasts and N24SWD-derived fibroblasts were 22.67±0.67 h and 23.18±0.70 h, respectively. The N24SWD group showed a significantly longer in vitro period than did the control or DSWPD group. Furthermore, in vitro period was associated with response to chronotherapy in the N24SWD group. Longer in vitro periods were observed in the non-responders (mean±s.d.: 23.59±0.89 h) compared with the responders (mean±s.d.: 22.97±0.47 h) in the N24SWD group. Our results indicate that prolonged circadian periods contribute to the onset and poor treatment outcome of N24SWD. In vitro rhythm assays could be useful for predicting circadian phenotypes and clinical prognosis in patients with CRSDs.

Study of insomnia in rotating shift-workers

BACKGROUND

Shift-workers commonly suffer from insomnia. This study evaluates different domains of insomnia.

AIM

This study was aimed to study sleep and insomnia in rotating shift-workers and compare with day-workers.

MATERIALS AND METHODS

This was case-control study. The sleep of rotating shift-workers is compared with day workers using Athens Insomnia Scale.

RESULTS

Rotating shift-workers had significantly higher scores on Athens insomnia scale on domains of initial, intermediate and terminal insomnia than day workers. Duration and quality of sleep and sense of well-being are lower in rotating shift-workers. Rotating shift-workers also experienced more day-time sleepiness than day workers. However, there was no difference in perceived physical and mental functioning between the two groups.

CONCLUSION

Individuals working in rotating shifts for more than 15 days have significantly higher prevalence of insomnia than day-workers.