What Are the Effects of Sleep Deprivation and Fatigue in Surgical Practice?

Advancing fatigue management in healthcare: risk-based approaches that enhance health service delivery

Given the need for 24/7 healthcare services, fatigue is an inevitable consequence of work in this industry. A significant body of regulatory advice and hospital services have focused primarily on restricting work hours as the primary method of mitigating fatigue-related risk. Given the inevitability of fatigue, and the limited capacity of labour agreements to control risk, this commentary explores how the principles of fatigue risk management might be applied in a healthcare setting.

Light at night exposure and risk of breast cancer: a meta-analysis of observational studies

Objective

The aim of this meta-analysis is to evaluate the impact of light at night (LAN) exposure on the risk of breast cancer across varying factors.

Method

We conducted a systematic search of literature up to July 15, 2023, including PubMed, Cochrane Library, and Embase databases, using keywords related to breast cancer and LAN exposure. Cohort study and case-control study literature on night light exposure and breast cancer risk were included. Statistical analyses were performed using Stata software version 17.0. To address heterogeneity among different studies, we employed a random-effects model for analysis and assessed publication bias using funnel plots and Egger's test.

Results

We included 13 case-control and 8 cohort studies with 734,372 participants worldwide. In the Newcastle-Ottawa Scale (NOS) assessments, the average score was 7.43 (ranging from 5 to 9). The overall meta-analysis demonstrated a significant association between exposure to LAN and risk of breast cancer (RR = 1.12; 95% CI: 1.06-1.17; I2 = 31.3%, p < 0.001). In the subgroup analysis, the results of the analysis for study types (case-control studies: RR = 1.16; 95% CI: 1.06-1.27; I2 = 40.4%, p = 0.001; cohort studies: RR = 1.08; 95% CI: 1.04-1.14; I2 = 0.0%, p < 0.001) and the results for light exposure types (outdoor LAN: RR = 1.07; 95% CI: 1.02-1.13; I2 = 30.9%, p = 0.004) are presented. In the analysis conducted for continents, the highest breast cancer risk was observed in the Asian population (Asian: RR = 1.24; 95% CI: 1.15-1.34; I2 = 0.0%, p < 0.001) and in the analysis of estrogen receptor status (ER+: RR = 1.10; 95% CI: 1.03-1.18; I2 = 17.0%, p = 0.005;). We also conducted an analysis on menopausal status and various lifestyles but did not find any statistically significant findings.

Conclusion

Our study demonstrates that LAN exposure is associated with an increased risk of breast cancer, particularly in the Asian population. Among the existing hypotheses, the idea that LAN exposure leads to a decrease in melatonin is widely accepted. However, until the mechanism of this effect is clearly elucidated, it is not recommended to take melatonin supplements for breast cancer prevention without medical advice. We hope to conduct more high-quality research, especially concerning the investigation of other environmental confounding factors, to further advance this field.

Elucidating regulatory processes of intense physical activity by multi-omics analysis

BACKGROUND

Physiological and biochemical processes across tissues of the body are regulated in response to the high demands of intense physical activity in several occupations, such as firefighting, law enforcement, military, and sports. A better understanding of such processes can ultimately help improve human performance and prevent illnesses in the work environment.

METHODS

To study regulatory processes in intense physical activity simulating real-life conditions, we performed a multi-omics analysis of three biofluids (blood plasma, urine, and saliva) collected from 11 wildland firefighters before and after a 45 min, intense exercise regimen. Omics profiles post- versus pre-exercise were compared by Student's t-test followed by pathway analysis and comparison between the different omics modalities.

RESULTS

Our multi-omics analysis identified and quantified 3835 proteins, 730 lipids and 182 metabolites combining the 3 different types of samples. The blood plasma analysis revealed signatures of tissue damage and acute repair response accompanied by enhanced carbon metabolism to meet energy demands. The urine analysis showed a strong, concomitant regulation of 6 out of 8 identified proteins from the renin-angiotensin system supporting increased excretion of catabolites, reabsorption of nutrients and maintenance of fluid balance. In saliva, we observed a decrease in 3 pro-inflammatory cytokines and an increase in 8 antimicrobial peptides. A systematic literature review identified 6 papers that support an altered susceptibility to respiratory infection.

CONCLUSION

This study shows simultaneous regulatory signatures in biofluids indicative of homeostatic maintenance during intense physical activity with possible effects on increased infection susceptibility, suggesting that caution against respiratory diseases could benefit workers on highly physical demanding jobs.

Impact of sleep deficiency on surgical performance: a prospective assessment

STUDY OBJECTIVES

Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear.

METHODS

Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call.

RESULTS

Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time.

CONCLUSIONS

Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency.

CITATION

Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Insomnia-A Systematic Review and Comparison of Medical Resident's Average Off-Call Sleep Times

Sleep deprivation is known to have serious consequences, including a decrease in performance, attention and neurocognitive function. It seems common knowledge that medical residents are routinely sleep deprived, yet there is little objective research recording their average sleep times. To discern whether residents may be suffering from the abovementioned side effects, this review aimed to analyze their average sleep times. Thirty papers recording the average sleep time of medical residents were found via a literature search using the key words "resident" and "sleep". An analysis of the mean sleep times cited therein revealed a range of sleep from 4.2 to 8.6 h per night, the median being 6.2 h. A sub-analysis of papers from the USA showed barely any significant differences in sleep time between the specialties, but the mean sleep times were below 7 h. The only significant difference (p = 0.039) was between the mean sleep times of pediatric and urology residents, with the former achieving less sleep. The comparison of methods for data collection showed no significant difference in the sleep times collected. The results of this analysis imply that residents are regularly sleep deprived and may therefore suffer from the abovementioned consequences.

Applying human factors to improve patient safety, morale and team working for oral pathology and medicine specialists

BACKGROUND

Human error is inevitable, and therefore can be considered as a 'normal' part of everyday life. Unfortunately, error can never be eliminated completely. However, learning from our mistakes can help reduce problems in future. Fifty years ago, most clinicians paid little or no attention to the human factors (HF) that can affect individual and team performance. It has only been in the last 20-25 years that colleagues in healthcare have truly begun recognizing the importance of HF and non-technical skills in medicine and dentistry and how their application can significantly improve patient safety and aid better team working and staff morale in the clinical setting and laboratory.

DISCUSSION

Personal factors such as stress, tiredness, hunger and dehydration all reduce human performance and can raise the risk of mistakes. In addition, how we work and interact with the wider team is important since many errors can occur because of ineffective communication, steep hierarchal (authority) gradients and loss of situational awareness.  This short HF overview in the 50th commemorative special of JOPM issue is timely. It provides a contemporary overview of human factors and performance that the authors consider important for oral medicine and pathology colleagues and which can affect individuals and teams This article also discuss ways to reduce the chances of medical and dental error and improve patient safety.

Tremor, finger and hand dexterity and force steadiness, do not change after mental fatigue in healthy humans

The effects of mental fatigue have been studied in relation to specific percentages of maximal aerobic or anaerobic efforts, maximal voluntary contractions or the performance of sport specific skills. However, its effects on tremor, dexterity and force steadiness have been only marginally explored. The present work aimed at filling this gap. In twenty-nine young individuals, measurement of postural, kinetic and isometric tremor, pinch force steadiness and finger and hand dexterity were performed before and after either 100 min of mental fatigue or control tasks. During the interventions blood pressure, oxygen saturation and heart rate and perceived effort in continuing the task were recorded every 10 minutes. Tremor was analysed in both time (standard deviation) and frequency domain (position, amplitude and area of the dominant peak) of the acceleration signal. Finger dexterity was assessed by Purdue pegboard test and hand dexterity in terms of contact time in a buzz wire exercise. Force steadiness was quantified as coefficient of variation of the force signal. Postural, kinetic and isometric tremors, force steadiness and dexterity were not affected. Higher oxygen saturation values and higher variability of heart rate and blood pressure were found in the intervention group during the mental fatigue protocol (p < .001). The results provide no evidence that mental fatigue affects the neuromuscular parameters that influence postural, kinetic or isometric tremor, force steadiness and dexterity when measured in single-task conditions. Increased variability in heart rate may suggest that the volunteers in the intervention group altered their alert/stress state. Therefore, it is possible that the alterations that are commonly observed during mental fatigue, and that could have affected tremor, steadiness and dexterity only last for the duration of the cognitive task and are not detectable anymore soon after the mental task is terminated.

Sleep patterns, fatigue, and working hours among veterinary house officers: a cross-sectional survey study

OBJECTIVE

To describe the sleep patterns, working hours, and perceptions of fatigue among veterinary house officers and to identify potential areas for targeted intervention to improve well-being.

SAMPLE

303 house officers.

PROCEDURES

A 62-item questionnaire was generated by use of an online platform and sent to veterinary house officers at participating institutions via email. Responses were analyzed for trends and associations between variables of interest.

RESULTS

The mean age of respondents was 30 ± 3.7 years. Participants included 239 residents and 64 interns. House officers slept significantly less during times when they had clinical responsibilities compared to off-clinic time (6.0 hours vs 7.5 hours, respectively; P < 0.01). The majority of house officers reported working 11 to 13 hours on a typical weekday (58% [174/302]), and 32% reported clinical responsibilities 7 d/wk. Working hours were negatively related to sleep quantity (Pearson correlation coefficient, −0.54; P < 0.01), and perceived sleep quality was worse when on call (P < 0.01). The majority of house officers felt that fatigue negatively interfered with their technical skills, clinical judgment, and ability to empathize to some extent in the previous 4 weeks.

CLINICAL RELEVANCE

Most house officers fail to obtain sufficient sleep for optimal cognitive function and physical and mental health. Working hours and on call may be important factors contributing to the sleep patterns of veterinary house officers, and training program structure should be critically evaluated to promote protected time for sleep.

Human factors application for healthcare teams in low- and medium-income countries (LMIC) to help improve patient safety and performance

Mistakes will always happen whether at work or in our personal lives. We can never completely eliminate error, but learning and disseminating lessons from these mistakes to others is essential. Human factors application for colleagues in healthcare, particularly in low- and medium-income countries (LMIC) can greatly improve patient safety and aid better team working and staff morale. Factors such as hunger, dehydration anger, and tiredness, all reduce personal performance and can raise the risk of personal error. It is vital that we understand and optimize interaction within the healthcare team members. As part of this, ineffective communication, steep hierarchy and loss of situational awareness can lead to compromised patient safety and potentially serious error. In this paper, we provide a brief overview of human factors for healthcare colleagues in LMIC. We highlight ways to reduce the chances of error and improve patient safety by recognizing and applying various human factors to our day to day practices.

European Association of Oral Medicine 2021 Conference - Crispian Scully Lecture: Applying Human Factors to Improve Patient Safety and Performance

BACKGROUND

This paper is a synopsis of the Crispian Scully Lecture, presented by one of the authors (PAB), at the 2021 European Association of Oral Medicine (EAOM) Conference in Lisbon, Portugal. It provides an overview of human factors that affect individuals and teams, highlighting ways to reduce the chances of error and improve patient safety.

DISCUSSION AND CONCLUSION

Error is an inevitable and 'normal' part of being human, and it can never be completely eliminated, though learning from mistakes is essential. Human factor application in health care can greatly improve patient safety and lead to better team working and staff morale. Personal factors including tiredness, hunger, dehydration and stress can all reduce performance and raise the risk of clinical error. It is also important to understand and optimise interaction within the clinical team. Poor communication, steep hierarchy and loss of situational awareness can all potentially compromise patient safety.

After hours surgery for elderly hip fracture patients: How safe is it?

INTRODUCTION

The recent focus on early surgery for hip fractures to reduce complications and improve morbidity, has led some resource-constrained institutions to perform after hours surgery in a bid to meet these timelines. However, there are concerns about the potential increase in complications and poorer outcomes in after hours surgery. This study aims to evaluate the safety of after hours hip fracture surgery and its related complications.

MATERIALS AND METHODS

This is a retrospective review of hip fracture patients admitted over a 2-year period to a tertiary centre with an established orthogeriatric co-managed hip fracture care pathway. Patients were divided into two groups based on their operating start time: (1) office hours surgery was defined as surgery conducted between 8 am to 5 pm on weekdays and 8 am to 12 noon on Saturdays; and (2) after hours surgery was defined as surgery conducted between 5 pm to 8 am on weekdays, and between Saturday 12 noon to Monday 8 am, as well as those that were conducted on public holidays. Demographic data, comorbidities, fracture details, operative details and outcome measures (complications, mortality and functional scores) were collated.

RESULTS

A total of 903 patients were surgically treated for per- and intertrochanteric or femoral neck fractures. 76.7% (n = 693) of the patients underwent operation during office hours while 23.3% (n = 210) of the patients underwent after hours operation. 12.4% (n = 26) of the after hours group underwent surgery within 24 h of admission, compared with 6.8% (n = 47) in the office hours group (p = 0.009). We did not find any significant difference between the two groups in terms of complications, mortality and functional outcomes (p > 0.05).

CONCLUSION

In conclusion, our study did not show that after hours surgery increases complication rates in hip fracture surgery and had equivalent functional outcomes.

Assessment of fitness to perform using a validated self-test in obstetric and gynecological night shifts in the Netherlands

BACKGROUND

The field of obstetrics and gynecology requires complex decision-making and skills because of unexpected high-risk situations. These skills are influenced by alertness, reaction time, and concentration. Night shifts result in sleep deprivation, which might impair these functions, although it is still unclear to what extent.

OBJECTIVE

This study aimed to investigate whether a night shift routinely impairs the obstetrics and gynecology consultants' and residents' fitness to perform and whether this reaches a critical limit compared with relevant frames of reference.

STUDY DESIGN

Residents (n=33) and consultants (n=46) in obstetrics and gynecology conducted multiple measurements (n=415) at precall, postcall, and noncall moments with the fitness to perform self-test. The self-test consists of an adaptive pursuit tracking task that is able to objectively measure alertness, reaction time, concentration, and hand-eye coordination and Visual Analog Scale tests to subjectively score alertness. The test is validated with a sociolegal reference of a 0.06% ethanol blood concentration (the peak level after 2 units of alcohol, the legal driving limit). This equals -1.37% on the objective score and -8.17 points on subjective alertness. Linear mixed models were used to analyze the difference within subjects over a night shift, integrating repeated measures over time.

RESULTS

The overnight objective difference between postcall and precall measurements was -0.62 (P<.05) for residents and 0.28 (P=NS) for consultants, both not exceeding the sociolegal reference as a group. Objective impairment exceeded the reference for 31% of the residents and 28% of the consultants. Subjective alertness decreased in residents (-18.26; P<.001) and consultants (-10.85; P<.001), both exceeding the reference. No residents had to continue work postcall versus 7.8% of the consultants. None of the consultants that had to continue work were in an objective critically impaired state.

CONCLUSION

This study provides insight and awareness of individual performance after night shifts with clear frames of reference. The performance of residents is negatively and significantly affected by night shifts; therefore, a scheduled day off after a night shift is justified. Consultants showed no overall impairment; however, a quarter did exceed the alcohol limit reference after their night shift. If not logistically feasible to schedule a protected day off after a night shift, our group recommends safe shift scheduling, including options to transfer care after a demanding night shift to prevent working in a compromised state.

Cross-Subject Zero Calibration Driver's Drowsiness Detection: Exploring Spatiotemporal Image Encoding of EEG Signals for Convolutional Neural Network Classification

This paper explores two methodologies for drowsiness detection using EEG signals in a sustained-attention driving task considering pre-event time windows, and focusing on cross-subject zero calibration. Driving accidents are a major cause of injuries and deaths on the road. A considerable portion of those are due to fatigue and drowsiness. Advanced driver assistance systems that could detect mental states which are associated with hazardous situations, such as drowsiness, are of critical importance. EEG signals are used widely for brain-computer interfaces, as well as mental state recognition. However, these systems are still difficult to design due to very low signal-to-noise ratios and cross-subject disparities, requiring individual calibration cycles. To tackle this research domain, here, we explore drowsiness detection based on EEG signals' spatiotemporal image encoding representations in the form of either recurrence plots or gramian angular fields for deep convolutional neural network (CNN) classification. Results comparing both techniques using a public dataset of 27 subjects show a superior balanced accuracy of up to 75.87% for leave-one-out cross-validation, using both techniques, against works in the literature, demonstrating the possibility to pursue cross-subject zero calibration design.

A model-based validation study of postoperative complications with considerations on operative timing

Background

Surgery is a highly technical procedure relying on high mental acuity and manual dexterity. The possibility that surgical outcomes and post-operative complications could be subject to influence by fatigue and/or circadian rhythms in surgeons has been investigated with inconsistent results.

Methods

We conducted a retrospective study to assess the significance of operative timing on classifying surgical complications using an interpretable machine learning approach. We trained various linear, generative as well as tree models on the surgical record data collected from a university-affiliated, tertiary teaching hospital in China by performing parameter tuning using grid search cross-validation for optimizing the F1 score.

Results

The results indicated that XGBoost was the best-performing model overall and its feature importance was shown to provide insight into possible timing-related associations with postoperative complications. We observed that the duration of surgery acted as the strongest indicator, and while surgery initiated at night (between 9 pm and 7 am) also ranked higher on the feature importance scale, it bore less significance than other factors such as the patient's age, gender, and type of surgery performed.

Conclusions

We showed that surgical records could be used to demonstrate that operative timing might affect the occurrence of postoperative complications, but only in a relatively mild way while potentially entangling with multiple factors.

Night shift work in resident physicians: does it affect mood states and cognitive levels?

BACKGROUND

The effects of night shift work on health status have been widely studied. Night workers seem to smoke more, eat badly and show a low propensity to physical activity. Night work can be associated with an increase in cardiovascular and gastrointestinal disorders, alterations in immune response, diabetes, aging, hormonal imbalance, and premature death; alteration of circadian rhythm is also regarded as a risk factor for breast cancer and neuropsychiatric disorders. Moreover, several studies have highlighted the effects of sleep deprivation on clinical performance, quality of care and personal safety of healthcare personnel. No studies have investigated the effects of night work on Italian resident physicians and compared its effect across specialties. This study aims to assess the prevalence of sleep disorders, possible cognitive impairment and mood states, in relation to night shift work among resident physicians.

METHODS

80 resident physicians, attending the postgraduate training into an Hospital located in the South of Italy, were divided into 4 areas (medical, surgical, services and anaesthesia). They were recruited from July 2017 to June 2018 and participated to a survey consisting of 4 questionnaires to investigate the presence of sleep deprivation and sleep quality (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index), their cognitive status (Mini Mental State examination) and mood profiles (Profile of Mood States, POMS). Analysis of variance was used for comparison of questionnaires scores across specialties.

RESULTS

Authors reported no sleep deprivation, no sleep disorders and their outcomes, no changes in intellectual efficiency and no cognitive impairment in this population, neither in the areas performing night shifts nor in those involving only day shifts. Mood states measured by POMS showed a borderline level of Anger-Hostility (A) value among the residents of the medical area and services, and an increase slightly beyond the physiological levels of the T-score 50 of Fatigue-Inertia (F) always in the same groups. An increase in the Vigour-Activity (V) value beyond T-score 50 levels was also observed among residents of all the areas considered.

CONCLUSIONS

Emotional involvement could be attributed to the gap between high professional demand and lack of experience and knowledge among trainees. Tutors should help their students in order to identify earlier changes in the mood. Improvement in the organization of the trainee's activity could reduce the emotional overload.

Objective Assessment of Fitness to Perform (FTOP) After Surgical Night Shifts in the Netherlands: An Observational Study Using the Validated FTOP Self-test in Daily Surgical Practice

BACKGROUND

Surgical skills and decision making are influenced by alertness, reaction time, eye-hand coordination, and concentration. Night shift might impair these functions but it is unclear to what extent. The aim of this study was to investigate whether a night shift routinely impairs the surgeon's fitness to perform and whether this reaches a critical limit as compared to relevant frames of reference.

METHODS

Consultants (n = 59) and residents (n = 103) conducted fitness to perform measurements at precall, postcall, and noncall moments. This validated self-test consists of an adaptive tracker that is able to objectively measure alertness, reaction time, concentration, and eye-hand coordination, and multiple visual analog scales to subjectively score alertness. Results are compared to sociolegal (ethanol) and professional (operative skills) frames of reference that refer to a decrease under the influence of 0.06% ethanol.

RESULTS

Residents spent 1.7 call hours asleep on average as compared to 5.4 for consultants. Subjective alertness decreased in residents after night shifts (-13, P < 0.001) but not in consultants (-1.2, P = NS). The overnight difference in tracker score was -1.17 (P < 0.001) for residents and 0.46 (P = NS) for surgeons. Postcall subjective alertness only correlated to objective alertness in consultants. For residents, hours slept on-call correlated to objective alertness. For consultants, subsequent night calls significantly correlated to objective alertness, with the third subsequent call related to performance below the reference.

CONCLUSIONS

Consultants remain fit to perform after night call, but subsequent calls may compromise clinical activities. This study provides insight and awareness of individual performance with clear frames of reference.

Association Between Surgical Trainee Daytime Sleepiness and Intraoperative Technical Skill When Performing Septoplasty

Importance

Daytime sleepiness in surgical trainees can impair intraoperative technical skill and thus affect their learning and pose a risk to patient safety.

Objective

To determine the association between daytime sleepiness of surgeons in residency and fellowship training and their intraoperative technical skill during septoplasty.

Design, Setting, and Participants

This prospective cohort study included 19 surgical trainees in otolaryngology-head and neck surgery programs at 2 academic institutions (Johns Hopkins University School of Medicine and MedStar Georgetown University Hospital). The physicians were recruited from June 13, 2016, to April 20, 2018. The analysis includes data that were captured between June 27, 2016, and April 20, 2018.

Main Outcomes and Measures

Attending physician and surgical trainee self-rated intraoperative technical skill using the Septoplasty Global Assessment Tool (SGAT) and visual analog scales. Daytime sleepiness reported by surgical trainees was measured using the Epworth Sleepiness Scale (ESS).

Results

Of 19 surgical trainees, 17 resident physicians (9 female [53%]) and 2 facial plastic surgery fellowship physicians (1 female and 1 male) performed a median of 3.00 septoplasty procedures (range, 1-9 procedures) under supervision by an attending physician. Of the 19 surgical trainees, 10 (53%) were aged 25 to 30 years and 9 (47%) were 31 years or older. The mean ESS score overall was 6.74 (95% CI, 5.96-7.52), and this score did not differ between female and male trainees. The mean ESS score was 7.57 (95% CI, 6.58-8.56) in trainees aged 25 to 30 years and 5.44 (95% CI, 4.32-6.57) in trainees aged 31 years or older. In regression models adjusted for sex, age, postgraduate year, and technical complexity of the procedure, there was a statistically significant inverse association between ESS scores and attending physician-rated technical skill for both SGAT (-0.41; 95% CI, -0.55 to -0.27; P < .001) and the visual analog scale (-0.75; 95% CI, -1.40 to -0.07; P = .03). The association between ESS scores and technical skill was not statistically significant for trainee self-rated SGAT (0.04; 95% CI, -0.17 to 0.24; P = .73) and the self-rated visual analog scale (0.19; 95% CI, -0.79 to 1.2; P = .70).

Conclusions and Relevance

The findings suggest that daytime sleepiness of surgical trainees is inversely associated with attending physician-rated intraoperative technical skill when performing septoplasty. Thus, surgical trainees' ability to learn technical skill in the operating room may be influenced by their daytime sleepiness.

Level of Evidence

NA.

Effects of Sleep Deprivation on Surgeons Dexterity

Sleep deprivation is an ordinary aspect in the global society and its prevalence is increasing. Chronic and acute sleep deprivation have been linked to diabetes and heart diseases as well as depression and enhanced impulsive behaviors. Surgeons are often exposed to long hour on call and few hours of sleep in the previous days. Nevertheless, few studies have focused their attention on the effects of sleep deprivation on surgeons and more specifically on the effects of sleep deprivation on surgical dexterity, often relying on virtual surgical simulators. A better understanding of the consequences of sleep loss on the key surgical skill of dexterity can shed light on the possible risks associated to a sleepy surgeon. In this paper, the authors aim to provide a comprehensive review of the relationship between sleep deprivation and surgical dexterity.

Day-after PCI: Safe for the patient but perhaps not for the Interventionalist

This single-center study retrospectively reviewed 12,680 percutaneous coronary interventions (PCIs) to identify those performed by an operator who was awake the previous night performing PCI. Success and outcomes of PCIs were similar regardless of whether the operator performed PCIs the previous night. This study generally confirms the results of a previous single center study and another study using the NCDR CathPCI Registry. This study suggests that day-after PCI is generally safe, but it behooves cath lab managers and interventionalists to take simple steps to minimize the risk to patients when day-after PCIs are performed.

Live Surgery: Is Operating at Home the Way Forward?

Live surgery events are a popular educational tool, but concerns have been raised, especially regarding patient safety. The Italian Society of Urology has implemented a novel concept in which surgeons operate on their own patients at their own institutions, with the procedures broadcast live at the annual society meetings. This approach retains the live nature of the surgery but removes the risks associated with operating in a foreign environment with distractions.

Effects of Fatigue Based on Electroencephalography Signal during Laparoscopic Surgical Simulation

Background

Following recent advances in technology, there is a growing interest in studying fatigue based on electrophysiological signals as a means of monitoring brain activity. While some existing works relate fatigue to performance, others consider the two as independent entities. Therefore, we must explore this intricate issue, particularly in laparoscopic training, for the sake of patient safety.

Objective

This paper explores and evaluates effects of fatigue on efficiency and accuracy based on laparoscopic surgical training using Electroencephalography (EEG) signal.

Materials and Methods

20 college students performed peg transfer task on laparoscopic simulator, with real-time recording of EEG signals for each subject. To monitor degree of fatigue, a real-time fatigue monitoring system based on fatigue analysis algorithm was designed through the use of EEG in alpha (α) and theta (θ) rhythms. We designed data acquisition and fatigue analysis modules based on MATLAB platform. BrainLink was used to record EEG signals and send them to personal computer wirelessly via Bluetooth. While artifacts from the captured EEG signals were removed using Blind Source Separation (BSS), α and θ rhythms were extracted using wavelet analysis. Fatigue was evaluated based on Regression Model and Mahalanobis Distance (D_C), and its threshold was determined from the experimental results using Receiver Operating Characteristic (ROC) curve analysis.

Results

Completion time and number of errors behaved like a decreasing function during the first few trials while increasing afterwards with the increasing of perceived fatigue level. The results indicate that learning curve of the subjects is increasing until 13th trials when they have attained maximum learning benefits and decreases afterwards due to fatigue.

Conclusion

Regression analysis shows that there are significant learning and fatigue effects when peg transfer task in the training is repeated in a series of trials. However, for the training to be effective and efficient, there should be monitoring during the training to observe where in the learning curve a trainee gains maximum learning benefits. Furthermore, fatigue is a significant indicator of efficiency and accuracy in terms of completion time and errors, respectively.

Neuromuscular fatigue during exercise: Methodological considerations, etiology and potential role in chronic fatigue

The term fatigue is used to describe a distressing and persistent symptom of physical and/or mental tiredness in certain clinical populations, with distinct but ultimately complex, multifactorial and heterogenous pathophysiology. Chronic fatigue impacts on quality of life, reduces the capacity to perform activities of daily living, and is typically measured using subjective self-report tools. Fatigue also refers to an acute reduction in the ability to produce maximal force or power due to exercise. The classical measurement of exercise-induced fatigue involves neuromuscular assessments before and after a fatiguing task. The limitations and alternatives to this approach are reviewed in this paper in relation to the lower limb and whole-body exercise, given the functional relevance to locomotion, rehabilitation and activities of daily living. It is suggested that under some circumstances, alterations in the central and/or peripheral mechanisms of fatigue during exercise may be related to the sensations of chronic fatigue. As such, the neurophysiological correlates of exercise-induced fatigue are briefly examined in two clinical examples where chronic fatigue is common: cancer survivors and people with multiple sclerosis. This review highlights the relationship between objective measures of fatigability with whole-body exercise and perceptions of fatigue as a priority for future research, given the importance of exercise in relieving symptoms of chronic fatigue and/or overall disease management. As chronic fatigue is likely to be specific to the individual and unlikely to be due to a simple biological or psychosocial explanation, tailored exercise programmes are a potential target for therapeutic intervention.

The influence of hours worked prior to delivery on maternal and neonatal outcomes: a retrospective cohort study

BACKGROUND

Long continuous periods of working contribute to fatigue, which is an established risk factor for adverse patient outcomes in many clinical specialties. The total number of hours worked by delivering clinicians before delivery therefore may be an important predictor of adverse maternal and neonatal outcomes.

OBJECTIVE

We aimed to examine how rates of adverse delivery outcomes vary with the number of hours worked by the delivering clinician before delivery during both day and night shifts.

STUDY DESIGN

We conducted a retrospective cohort study of 24,506 unscheduled deliveries at an obstetrics center in the United Kingdom from 2008-2013. We compared adverse outcomes between day shifts and night shifts using random-effects logistic regression to account for interoperator variability. Adverse outcomes were estimated blood loss of ≥1.5 L, arterial cord pH of ≤7.1, failed instrumental delivery, delayed neonatal respiration, severe perineal trauma, and any critical incident. Additive dynamic regression was used to examine the association between hours worked before delivery (up to 12 hours) and risk of adverse outcomes. Models were controlled for maternal age, maternal body mass index, parity, birthweight, gestation, obstetrician experience, and delivery type.

RESULTS

We found no difference in the risk of any adverse outcome that was studied between day vs night shifts. Yet, risk of estimated blood loss of ≥1.5 L and arterial cord pH of ≤7.1 both varied by 30-40% within 12-hour shifts (P<.05). The highest risk of adverse outcomes occurred after 9-10 hours from the beginning of the shift for both day and night shifts. The risk of other adverse outcomes did not vary significantly by hours worked or by day vs night shift.

CONCLUSION

Number of hours already worked before undertaking unscheduled deliveries significantly influences the risk of certain adverse outcomes. Our findings suggest that fatigue may play a role in increasing the risk of adverse delivery outcomes later in shifts and that obstetric work patterns could be better designed to minimize the risk of adverse delivery outcomes.

Accepting multiple simultaneous liver offers does not negatively impact transplant outcomes

Impact of performing multiple liver transplants (LT) in a short period of time is unknown. Consecutively performed LT potentially increase complication rates through team fatigue and overutilization of resources and increase ischemia time. We analyzed the impact of undertaking consecutive LT (Consecutive liver transplant, CLT; LT preceded by another transplant performed not more than 12 h before, both transplants grouped together) on outcomes. Of 1702 LT performed, 314 (18.4%) were CLT. Outcome data was compared with solitary LT (SLT; not more than one LT in 12-h period). Recipient, donor, and graft characteristics were evenly matched between SLT and CLT; second LT of CLT group utilized younger donors grafts with longer cold ischemic times (P = 0.015). Implantation and operative time were significantly lower in CLT recipients on intergroup analysis (P = 0.0001 and 0.002, respectively). Early hepatic artery thrombosis (E-HAT) was higher in CLT versus SLT (P = 0.038), despite absolute number of E-HAT being low in all groups. Intragroup analysis demonstrated a trend toward more frequent E-HAT in first LT, compared to subsequent transplants; however, difference did not reach statistical significance (P = 0.135). In era of organ scarcity, CLT performed at high-volume center is safe and allows pragmatic utilization of organs, potentially reducing number of discarded grafts and reducing waiting list mortality.

Live surgery at conferences - Clinical benefits and ethical dilemmas

Live surgical broadcasts (LSBs) are becoming increasingly popular in urological conferences. These activities can provide excellent training opportunities, as they allow the audience to view an operation conducted by world-renowned surgeons, and have the ability to interact with them in real time. However, several ethical considerations have been raised with this practice, which the participating surgeons and conference organisers must appreciate and address carefully. In this article we highlight the ethical considerations related to LSBs and advise on how these should be addressed. We also present the latest recommendations made by the European Association of Urology Live Surgery Committee and discuss alternatives to LSB.

Night shifts, sleep deprivation, and attention performance in medical students

OBJECTIVE

To determine attention performance of medical students after sleep deprivation due to night shift work.

METHODS

Prospective cohort design. All seventh, eighth and ninth semester students were invited to participate (n= 209). The effectiveness and concentration indices (d2 Test for attention, dependent variable) from 180 students at 3 evaluations during the semester were compared. Eighth and ninth semester students underwent their second evaluation after a night shift. The independent variables were nocturnal sleep measurements.

RESULTS

No differences in nocturnal sleep hours during the previous week (p=0.966), sleep deprivation (p=0.703) or effectiveness in the d2 Test (p=0.428) were found between the groups at the beginning of the semester. At the beginning and the end of the semester, the d2 Test results were not different between groups (p=0.410, p=0.394) respectively. The second evaluation showed greater sleep deprivation in students with night shift work (p=0.001). The sleep deprived students had lower concentration indices (p=0.001).The differences were associated with the magnitude of sleep deprivation (p=0.008). Multivariate regression analysis showed that attention performance was explained by sleep deprivation due to night shift work, adjusting for age and gender. Students with sleep deprivation had worse concentration than those without.

CONCLUSIONS

Sleep deprivation due to night shift work in medical students had a negative impact on their attention performance. Medical educators should address these potential negative learning and patient care consequences of sleep deprivation in medical students due to night shifts.