Circadian rhythm, shift work, and emergency medicine

Influence of shift work on periodontitis according to the occupation group

This study aimed to investigate the effects of shift work on periodontal disease in blue-and white-collar workers and to examine the interaction effects between occupation and work patterns. Data were collected from the Korea National Health and Nutrition Examination Survey conducted by the Korean Ministry of Health and Welfare for a total of nine years from 2007 to 2015. Participants with missing outcome variables were excluded from the analysis and a total of 32,336 participants were included in the final analysis. Univariable odds ratios (OR) were calculated using a logistic regression model with 95% confidence interval (CI). A multivariable logistic regression analysis was performed using the backward elimination method. The CONTRAST statement was used to analyze the interaction effect between occupation and work patterns. Multivariable logistic regression analysis revealed that interaction effects are present between the terms, occupational type and work pattern. Crude OR of shift work for periodontitis was 1.269 [CI 1.213-1.327, P < 0.05]. However, following adjustment for multiple confounding factors and the interaction effect term considered, this OR (1.269) increased to 1.381 [CI 1.253-1.523] in white-collar group while it decreased to 1.198 [1.119-1.283] in blue-collar. Crude OR of blue-collar (OR = 3.123, CI 2.972-3.281, P < 0.05) decreased to 1.151 [CI 1.049-1.262] when interaction effect to the shift work was considered. Shift work pattern increases the risk for periodontitis and this adverse effect is greater when white-collar workers are engaged comparing to blue-collar. The result of this study suggests that 24/7 lifestyle of the modern society poses health risks to the relevant people and the potential harm can be greater to white-collar workers.

A Series of Personalized Virtual Light Therapy Interventions for Fatigue: Feasibility Randomized Crossover Trial for N-of-1 Treatment

BACKGROUND

Fatigue is one of the most common symptoms treated in primary care and can lead to deficits in mental health and functioning. Light therapy can be an effective treatment for symptoms of fatigue; however, the feasibility, scalability, and individual-level heterogeneity of light therapy for fatigue are unknown.

OBJECTIVE

This study aimed to evaluate the feasibility, acceptability, and effectiveness of a series of personalized (N-of-1) interventions for the virtual delivery of bright light (BL) therapy and dim light (DL) therapy versus usual care (UC) treatment for fatigue in 60 participants.

METHODS

Participants completed satisfaction surveys comprising the System Usability Scale (SUS) and items assessing satisfaction with the components of the personalized trial. Symptoms of fatigue were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) daily, PROMIS weekly, and ecological momentary assessment (EMA) questionnaires delivered 3 times daily. Comparisons of fatigue between the BL, DL, and UC treatment periods were conducted using generalized linear mixed model analyses between participants and generalized least squares analyses within individual participants.

RESULTS

Participants rated the usability of the personalized trial as acceptable (average SUS score=78.9, SD 15.6), and 92% (49/53) of those who completed satisfaction surveys stated that they would recommend the trial to others. The levels of fatigue symptoms measured using the PROMIS daily fatigue measure were lower or improved in the BL (B=-1.63, 95% CI -2.63 to -0.63) and DL (B=-1.44, 95% CI -2.50 to -0.38) periods relative to UC. The treatment effects of BL and DL on the PROMIS daily measure varied among participants. Similar findings were demonstrated for the PROMIS weekly and EMA measures of fatigue symptoms.

CONCLUSIONS

The participant scores on the SUS and satisfaction surveys suggest that personalized N-of-1 trials of light therapy for fatigue symptoms are both feasible and acceptable. Both interventions produced significant (P<.05) reductions in participant-reported PROMIS and EMA fatigue symptoms relative to UC. However, the heterogeneity of these treatment effects across participants indicated that the effect of light therapy was not uniform. This heterogeneity along with high ratings of usability and satisfaction support the use of personalized N-of-1 research designs in evaluating the effect of light therapy on fatigue for each patient. Furthermore, the results of this trial provide additional support for the use of a series of personalized N-of-1 research trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04707846; https://clinicaltrials.gov/ct2/show/NCT04707846.

Aberrant single-subject morphological cerebellar connectome in chronic insomnia

BACKGROUND

To systematically investigate the topological organisation of morphological networks of the cerebellum using structural MRI and examine their clinical relevance in chronic insomnia (CI).

METHODS

One hundred and one patients with CI and 102 healthy controls (HCs) were recruited in this study. Individual morphological networks of the cerebellum were constructed based on regional grey matter volume, and topologically characterised using weighted graph theory-based network approaches. Between-group comparisons were performed using permutation tests, and Spearman's correlation was used to examine the relationships between topological alterations and clinical variables.

RESULTS

Compared with HCs, patients with CI exhibited a lower normalised clustering coefficient. Locally, CI patients exhibited lower nodal efficiency in the cerebellar lobule VIIb and vermis regions, but higher nodal efficiency in the right cerebellar lobule VIIIa regions. No correlations were observed between network alterations and clinical variables.

CONCLUSIONS

Individual morphological network analysis provides a new strategy for investigating cerebellar morphometric changes in CI, and our findings may have important implications in establishing diagnostic and categorical biomarkers.

Manual Chest Compression versus Automated Chest Compression Device during Day-Time and Night-Time Resuscitation Following Out-of-Hospital Cardiac Arrest: A Retrospective Historical Control Study

OBJECTIVE

We assessed the effectiveness of automated chest compression devices depending on the time of admission based on the frequency of iatrogenic chest injuries, the duration of in-hospital resuscitation efforts, and clinical outcomes among out-of-hospital cardiac arrest (OHCA) patients.

METHODS

We conducted a retrospective historical control study of OHCA patients in Japan between 2015-2022. The patients were divided according to time of admission, where day-time was considered 07:00-22:59 and night-time 23:00-06:59. These patients were then divided into two categories based on the in-hospital cardiopulmonary resuscitation (IHCPR) device: manual chest compression (mCC) group and automatic chest compression devices (ACCD) group. We used univariate and multivariate ordered logistic regression models adjusted for pre-hospital confounders to evaluate the impact of ACCD use during IHCPR on outcomes (IHCPR duration, CPR-related chest injuries, and clinical outcomes) in the day-time and night-time groups.

RESULTS

Among 1101 patients with OHCA (day-time, 809; night-time, 292), including 215 patients who underwent ACCD during IHCPR in day-time (26.6%) and 104 patients in night-time group (35.6%), the multivariate model showed a significant association of ACCD use with the outcomes of in-hospital resuscitation and higher rates of return in spontaneous circulation, lower incidence of CPR-related chest injuries, longer in-hospital resuscitation durations, greater survival to Emergency Department and hospital discharge, and greater survival with good neurological outcome to hospital discharge, though only in the night-time group.

CONCLUSIONS

Patients who underwent ACCD during in-hospital resuscitation at night had a significantly longer duration of in-hospital resuscitation, a lower incidence of CPR-related chest injuries, and better outcomes.

Prevalence and Risk Factors of Insomnia and Sleep-aid Use in Emergency Physicians in Japan: Secondary Analysis of a Nationwide Survey

INTRODUCTION

Emergency physicians (EP) are suspected to have a high prevalence of insomnia and sleep-aid use. Most prior studies about sleep-aid use in EPs have been limited by low response rates. In this study our aim was to investigate the prevalence of insomnia and sleep-aid use among early-career Japanese EPs and assess the factors associated with insomnia and sleep-aid use.

METHODS

We collected anonymous, voluntary, survey-based data regarding chronic insomnia and sleep-aid use from board-eligible EPs taking the initial Japanese Association of Acute Medicine board certification exam in 2019 and 2020. We describe the prevalence of insomnia and sleep-aid use and analyzed demographic and job-related factors using multivariable logistic regression analysis.

RESULTS

The response rate was 89.71% (732 of 816). The prevalence of chronic insomnia and sleep-aid use was 24.89% (95% CI 21.78-28.29%) and 23.77% (95% CI 20.69-27.15%), respectively. Factors associated with chronic insomnia were long working hours (odds ratio [OR] 1.02, 1.01-1.03, per one-hour/week), and "stress factor" (OR 1.46, 1.13-1.90). Factors associated with sleep-aid use were male gender (OR 1.71, 1.03-2.86), unmarried status (OR 2.38, 1.39-4.10), and "stress factor" (OR 1.48, 1.13-1.94). The "stress factor" was mostly influenced by stressors in dealing with patients/families and co-workers, concern about medical malpractice, and fatigue.

CONCLUSIONS

Early-career EPs in Japan have a high prevalence of chronic insomnia and sleep-aid use. Long working hours and stress were associated with chronic insomnia, while male gender, unmarried status, and stress were associated with the use of sleep aids.

Ambulance personnel's perceptions on their workplace well-being: A descriptive interpretative study

BACKGROUND

Ambulance personnel face numerous challenges during their working hours. Exposure to stressful situations and other factors in the outpatient emergency medical service can affect the health of ambulance personnel as well as their well-being.

OBJECTIVE

The main objective of this study was to explore the perceptions of ambulance personnel regarding their physical and mental well-being at the workplace.

METHODS

A qualitative descriptive-interpretative research design was used. Individual face-to-face and online interviews were conducted between February and April 2022. A total of 26 interviews were conducted to explore employees' perceptions regarding the impact of work on their health and well-being.

RESULTS

Ambulance personnel described in detail their perceptions of the impact of work on their physical and mental health and well-being. Three main themes emerged from our data: 1) the impact of work on the psychophysical condition of ambulance personnel; 2) the impact of work on the lifestyle of ambulance personnel; 3) the impact of work and the work environment on the lives of ambulance personnel.

CONCLUSION

Long-term work in emergency medical services affects the health and well-being of ambulance personnel. As demonstrated by this study, raising awareness on the importance of preventive and health promotion programmes, understanding employees' problems by considering their opinions, and providing relevant training are extremely important tools for preventing such problems among employees.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

Series of virtual light therapy interventions for fatigue: a feasibility pilot study protocol for a series of personalised (N-of-1) trials

INTRODUCTION

Fatigue is one of the most commonly recorded patient symptoms that can result in deficits in aspects of psychomotor functioning, cognition, work performance and mood. Research shows that bright light and dim light therapy may be an efficacious way to reduce symptoms of fatigue. Still, the feasibility, scalability, individual treatment effects and adverse event heterogeneity of these treatments are unknown.

METHODS AND ANALYSIS

The current study evaluates the feasibility, acceptability and effectiveness of a series of personalised (N-of-1) interventions for virtual delivery of bright light therapy and dim light therapy versus usual care treatment for fatigue in 60 participants. We hypothesise that this study will provide valuable information about implementing virtual, N-of-1 randomised controlled trials (RCTs) for fatigue. It will also offer results about determining participants' ratings of usability and satisfaction with the virtual, personalised intervention delivery system; evaluating participants' improvement of fatigue symptoms; and, in the long term, identify ways to integrate N-of-1 light therapy trials into patient care.

ETHICS AND DISSEMINATION

This trial was approved by the Northwell Health Institutional Review Board. The trial results will be published in a peer-reviewed journal. All publications resulting from this series of personalised trials will follow the Consolidated Standards of Reporting Trials extension for N-of-1 trials CENT 2015 reporting guidelines.

REGISTRATION DETAILS

This trial is registered in www.

CLINICALTRIALS

gov (number NCT04707846).

TRIAL REGISTRATION NUMBER

NCT04707846.

Survival From Pediatric Out-of-Hospital Cardiac Arrest During Nights and Weekends: An Updated Japanese Registry-Based Study

BACKGROUND

Disparities in survival after pediatric out-of-hospital cardiac arrest (OHCA) between on-duty hours and off-duty hours have previously been reported. However, little is known about whether these disparities have remained in recent years.

OBJECTIVES

This study aimed to examine the association of outcomes after pediatric OHCA with time of day and day of week.

METHODS

This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Pediatric (<18 years) patients who experienced OHCA between 2012 and 2017 were included. A multivariable logistic regression model was used to examine the association of both time of day (day/evening vs night) and day of week (weekday vs weekend) with outcomes after OHCA. The primary outcome was 1-month survival.

RESULTS

A total of 7,106 patients (mean age, 5.7 ± 6.5 years; 60.9% male) were included. 1,897 events (26.7%) occurred during night hours, and 2,096 events (29.5%) occurred on weekends. Overall, 1,192 (16.8%) survived 1 month after OHCA. After adjusting for potential confounders, 1-month survival during day/evening (1,047/5,209 [20.1%]) was significantly higher than that at night (145/1,897 [7.6%]) (adjusted odds ratio: 2.31 [95% CI: 1.87-2.86]), whereas there was no significant difference in 1-month survival between weekdays (845/5,010 [16.9%]) and weekends (347/2,096 [16.6%]) (adjusted odds ratio: 1.04 [95% CI: 0.88-1.23]).

CONCLUSIONS

One-month survival after pediatric OHCA remained significantly lower during night than during day/evening, although disparities in 1-month survival between weekdays and weekends have been eliminated over time. Further studies are warranted to investigate the mechanisms underlying decreased survival at night.

A Computational Framework for Modeling Biobehavioral Rhythms from Mobile and Wearable Data Streams

This paper presents a computational framework for modeling biobehavioral rhythms - the repeating cycles of physiological, psychological, social, and environmental events - from mobile and wearable data streams. The framework incorporates four main components: mobile data processing, rhythm discovery, rhythm modeling, and machine learning. We evaluate the framework with two case studies using datasets of smartphone, Fitbit, and OURA smart ring to evaluate the framework’s ability to (1) detect cyclic biobehavior, (2) model commonality and differences in rhythms of human participants in the sample datasets, and (3) predict their health and readiness status using models of biobehavioral rhythms. Our evaluation demonstrates the framework’s ability to generate new knowledge and findings through rigorous micro- and macro-level modeling of human rhythms from mobile and wearable data streams collected in the wild and using them to assess and predict different life and health outcomes.

Outcomes of in-hospital cardiac arrest among hospitals with and without telemedicine critical care

BACKGROUND

Survival rates following in-hospital cardiac arrest (IHCA) are lower during nights and weekends (off-hours), as compared to daytime on weekdays (on-hours). Telemedicine Critical Care (TCC) may provide clinical support to improve IHCA outcomes, particularly during off-hours.

OBJECTIVE

To evaluate the association between hospital availability of TCC and IHCA survival.

METHODS

We identified 44,585 adults at 280 U.S. hospitals in the Get With The Guidelines® - Resuscitation registry who suffered IHCA in an Intensive Care Unit (ICU) or hospital ward between July 2017 and December 2019. We used 2-level hierarchical multivariable logistic regression to investigate whether TCC availability was associated with better survival, overall, and during on-hours (Monday-Friday 7:00 a.m.-10:59p.m.) vs. off-hours (Monday-Friday 11:00p.m.-6:59 a.m., and Saturday-Sunday, all day, and US national holidays).

RESULTS

14,373 (32.2%) participants suffered IHCA at hospitals with TCC, and 27,032 (60.6%) occurred in an ICU. There was no difference between TCC and non-TCC hospitals in acute resuscitation survival rate or survival to discharge rates for either IHCA occurring in the ICU (acute survival odds ratio [OR] 1.02, 95% CI 0.92-1.15; survival to discharge OR 0.94 [0.83-1.07]) or outside of the ICU (acute survival OR 1.03 [0.91-1.17]; survival to discharge OR 0.99 [0.86-1.12]. Timing of cardiac arrest did not modify the association between TCC availability and acute resuscitation survival (P =.37 for interaction) or survival to discharge (P =.39 for interaction).

CONCLUSIONS

Hospital availability of TCC was not associated with improved outcomes for in-hospital cardiac arrest.

Effect of shift work on fatigue, reaction time and accuracy of nurses in the department of neurology: A cross-sectional observational study

AIMS

The purpose of our study was mainly to explore the effect of different shift work on cognitive and executive performance in a real clinical environment among nurses from China.

BACKGROUND

Working in shifts can disrupt circadian rhythm, resulting in reduced sleep duration, which can have a detrimental effect on cognitive function. To provide continuous service for patient care, shift work is often a special requirement for nurses. The Stroop test can be used to measure selective attention and reaction time during executive function. However, there have been limited studies about the effect of shift work on the cognitive performance of nurses by Stroop tests. Additionally, no study has been conducted in nurses working in shifts from China.

METHODS

Registered nurses in general ward, Department of Neurology, from West China Hospital of Sichuan University, were eligible and consecutively included if they were simultaneously responsible for the day, evening and night shifts on the shift work schedule. A fatigue questionnaire and Stroop tests were performed for each subject separately before and after three working shifts (morning, evening and night shift) to measure changes in fatigue, reaction time and accuracy.

RESULTS

Eighteen registered nurses (4 males and 14 females) were included in our study, with a median age of 25 years old. The fatigue degree was significantly increased after day and evening shifts (p=0.015 and <0.001, respectively). Compared with those in the preshifts, the reaction time in the neutral task and incongruent task was significantly quicker after the day shift (p=0.001, p<0.001) and night shift (p=0.008, 0.019). In contrast, the reaction time after the evening shift was mildly increased, although without significance. There was no significant difference in accuracy among the three different working shifts. In addition, there was a negative correlation between the fatigue score and reaction time on the incongruent task in the Stroop test before the day shift (r=-0.542, p=0.020). The fatigue score in the postday shift was found to be inversely related to working hours in the daytime (r=-0.500, p=0.034).

CONCLUSIONS

Our study showed that increased fatigue was found in nurses after day and evening shifts, and shift work can affect the reaction time after the evening shift. However, there was no significant difference in accuracy and a high level of attention could be maintained among the three working shifts, suggesting a highly developed sense of responsibility in our nurses.

IMPLICATIONS FOR NURSING MANAGEMENT

In addition to focusing on the common adverse effects of evening or night shifts on nurses, fatigue in the day shift should be paid special attention to by the leadership in the nursing management. Also, nurse managers can implement specific strategies to reduce fatigue after the day shift by shortening the working hours in the daytime appropriately, setting rest periods in the day shift or dividing nurses into morning and afternoon shifts.

Quality of sleep in a sample of Egyptian medical residency

Background

Sleep disturbances among medical staff are common serious entities with devastating consequences. Numerous studies have analyzed the effects of residency on the quality of sleep of the medical trainees in various specialties, but only few studies were conducted in Egypt.

Results

One hundred fifty medical residents from various medical and surgical specialties who work in the hospitals of Ain Shams University, Egypt, agreed to participate in our study. Sociodemographic and work-related data were collected by a semi-structured sheet. Sleep quality was assessed by self-administered questionnaire—Pittsburgh Sleep Quality Index (PSQI). According to the PSQI, 96.7% of the residents had poor sleep quality with mean PSQI score of 10.4 ± 2.5. No statistically significant difference was detected among the different specialties. Poorer sleep quality was more frequent among senior residents who spent longer duration in residency. The number of hours of sleep before residency and the number of days off during residency were the main predictors of total PSQI score and determinants of sleep quality

Conclusions

Poor sleep quality is highly prevalent among medical residents and is associated with work-related factors. It is necessary to consider residents’ sleep estate and conduct more analyses to diagnose, treat, and improve their sleep quality.

Robotic colorectal procedures: does operative start time impact short-term outcome?

BACKGROUND

Previous publications revealed more complications in afternoon versus morning surgeries. With much attention given to robotic surgery outcomes, we sought to evaluate whether morning versus afternoon start time matters.

METHODS

In a retrospective review of a prospective database, 210 robotic colorectal surgeries were grouped into 97 morning versus 113 afternoon cases. Preoperative risk factors, intraoperative events, and 30-day postoperative outcomes were compared. An independent samples t-test, Fisher's exact test, and linear regression were used for categorical and continuous variables.

RESULTS

Morning patients were significantly younger than afternoon patients (59.5 vs. 65.5, p = 0.004), but there were no significant differences in gender, mean BMI, Charlson Comorbidity Index score, total operative time, console time, estimated blood loss, indications for surgery, and resection type. Morning patients had a significantly shorter mean length of stay (6.0 vs. 8.0 days, p = 0.021), but no significant differences in overall postoperative complications (0.30 vs. 0.30, p = 0.715), wound infection (5.2% vs. 7.1%, p = 0.564), anastomotic leak (0% vs. 2.7%, p = 0.251), ileus/small bowel obstruction (29.9% vs. 22.1%, p = 0.199), and 30-day readmission (8.2% vs. 7.1%, p = 1.000). When analyzing time of day as a continuous variable, we found no significant associations with intra- or postoperative complications.

CONCLUSION

We found no correlation between surgery start time and intra- or postoperative outcomes. This can be partly attributed to these cases being non-emergent and performed primarily by two experienced surgeons with highly trained operating room robotic staff in a large volume tertiary center. This, along with decreased fatigue attributed to superior ergonomics of robotic surgery, may have mitigated previously reported differences between morning and afternoon procedures.

A Time to Rest, a Time to Dine: Sleep, Time-Restricted Eating, and Cardiometabolic Health

Cardiovascular disease (CVD) poses a serious health and economic burden worldwide. Modifiable lifestyle factors are a focus of research into reducing the burden of CVD, with diet as one of the most investigated factors. Specifically, the timing and regularity of food intake is an emerging research area, with approaches such as time-restricted eating (TRE) receiving much attention. TRE involves shortening the time available to eat across the day and is associated with improved CVD outcomes compared with longer eating windows. However, studies that have examined TRE have not considered the impact of sleep on CVD outcomes despite recent evidence showing that sleep duration can influence the timing and amount of food eaten. In this article, we argue that as TRE and sleep influence each other, and influence the same cardiometabolic parameters, experiencing inadequate sleep may attenuate any positive impact TRE has on CVD. We examine the relationship between TRE and CVD, with sleep as a potential mediator in this relationship, and propose a research agenda to investigate this relationship. This will provide necessary evidence to inform future interventions aimed at reducing the burden of CVD.

Association of Nights and Weekends with Survival of Traumatic Out-of-Hospital Cardiac Arrest following Traffic Collisions: Japanese Registry-Based Study

BACKGROUND

The process of care for traumatic out-of-hospital cardiac arrest (OHCA) may be different at night and on the weekend. However, little is known about whether the rate of survival after OHCA is affected by the time of day and day of the week.

METHODS

This observational study analyzed the Japanese government-led nationwide population-based registry data of OHCA patients. Patients who experienced traumatic OHCA following traffic collisions from 2013 to 2017 were included in the study. A multivariable logistic regression model was used to examine the association of both time of day (day/evening vs. night) and day of the week (weekday vs. weekend) with outcomes after traumatic OHCA. Night was defined as 23:00 p.m. to 6:59 a.m., and weekends were defined as Saturday and Sunday. The primary outcome was one-month survival.

RESULTS

A total of 8500 patients (mean [SD] age, 57.7 [22.3] years; 68.6% male) were included. 2267 events (26.7%) occurred at night, and 2482 events (29.2%) occurred on weekends. Overall, 173 patients (2.0%) survived one month after OHCA. After adjusting for potential confounders, one-month survival during the day/evening (148/6233 [2.4%]) was significantly higher than during the night (25/2267 [1.1%]) (adjusted OR, 1.95 [95%CI, 1.24-3.07]), whereas there was no significant difference in one-month survival between weekdays (121/6018 [2.0%]) and weekends (52/2482 [2.1%]) (adjusted OR, 0.97 [95%CI, 0.69-1.38]).

CONCLUSIONS

One-month survival after traumatic OHCA was significantly lower during the night than during the day/evening, although there was no difference in one-month survival between weekdays and weekends. Further studies are warranted to investigate the underlying mechanisms of decreased survival at night.

On-Call Duties: The Perceived Impact on Veterinarians' Job Satisfaction, Well-Being and Personal Relationships

Objective: To assess the impact of on-call duties on veterinarians' job satisfaction, well-being and personal relationships.

Design: Cross-sectional survey.

Sample: The sample was obtained from Veterinary Information Network (VIN) members in private practice within the United States.

Procedures: A link to an anonymous online survey was distributed via an email invitation to all Veterinary Information Network (VIN) members with access from August 15, 2017 to October 21, 2017.

Results: A total of 1,945 responses were recorded. The majority of those who reported having on-call duties were female associates. Composite scales were created to assess the impact of on-call shifts on job satisfaction and well-being. Multiple linear regression was conducted and found that gender (p = 0.0311), associate status (p < 0.0001), and age (p = 0.0293) were all significantly associated with on-call related job satisfaction. Additionally, multiple linear regression found that gender (p = 0.0039), associate status (p < 0.0057), and age (p < 0.0001) were all significantly associated with on-call related well-being. On-call shifts were reported by many to have a negative impact on job satisfaction and well-being; this was especially pronounced for female associates. Females had on-call related job satisfaction scores that were, on average, 1.27 points lower than that of males (lower scores equates to lower job satisfaction). Further, females' average on-call related well-being scores were 1.15 points higher than that of males (lower scores equates to higher well-being).

Conclusions and Clinical Relevance: This study suggests that on-call shifts have a negative impact on veterinarian job satisfaction, well-being and personal relationships. The negative impact on job satisfaction and well-being is greatest for female associates. Veterinary medicine has been identified as a stressful occupation that can lead to psychological distress. It is therefore important to critically assess current practices that appear to increase stress and reduce emotional well-being. For this reason, it is suggested that veterinary hospitals explore alternative options to traditional on-call shifts.

Night Shift and Decreased Brain Activity of ICU Nurses: A Near-Infrared Spectroscopy Study

Background: Shift working is associated with a profound desynchronization of circadian rhythm and in particular, night-shift work disrupts normal circadian physiology. Sleep deprivation affects the functioning of certain brain areas and thus impairs cognitive performance. The purpose of this study was to investigate the effects of the night shift on cognitive performance and cerebral oxygenation/haemodynamics. Methods: A prospective, observational, comparative, randomized and cross-over study was carried out. A total of 74 intensive care unit nurses in Spain were included in the study. The following variables were measured: sociodemographic, burnout, anxiety, baseline cerebral oxygenation levels on night and day shift using a near-infrared spectroscopy system and cognitive task performance during a verbal fluency task to evaluate the alterations in the prefrontal cortex, assessed as changes in regional saturation index. Results: The average regional saturation index decreased significantly in the night shift (r = 0.560, p < 0.001). The ICU nurses showed a significant decrease in the verbal fluency test on average (8.53 ± 8.49, p < 0.001) and, in general, there was also a significant increase in anxiety score (3.17 ± 7.56, p = 0.001). Conclusions: Sleep deprivation during the night shift was considered to be related to decreased dorsolateral PFC reactivity. After the night shift, the nurses showed a decrease in prefrontal cortex activity and in cognitive performance.

Association between sleep characteristics, ideal cardiovascular health, and systemic inflammation, NHANES 2017-2018

There is conflicting evidence regarding the associations between sleep deprivation and inflammatory biomarkers indicative of cardiovascular disease risk, such as high-sensitivity C-reactive protein (hsCRP). The association between sleep habits and hsCRP was quantified in a nationally representative sample of adults in the United States and mediation by ideal cardiovascular health metrics was explored. A cross-sectional analysis of cardiovascular disease-free participants aged 20-79 years from the 2017-2018 National Health and Nutrition Examination Survey was conducted. The primary exposures were self-reported sleep duration, sleep debt (difference between the average weekday and weekend sleep duration), and ideal cardiovascular health (11-14 points). The primary outcome was hsCRP (high-risk ≥ 3.0 mg/L). Multivariable robust Poisson models were used to estimate prevalence ratios after multiple imputation. A subgroup analysis of shift workers was also conducted. Of 4027 participants included (mean age 46 years; 52% female; 41% shift workers), the prevalence of sleeping <6 h on weekdays was 9%, with 40% sleeping ≥9 h on weekends. One-quarter had a high (≥2 h) sleep debt, 82% had poor cardiovascular health, and 34% had high-risk hsCRP. There were no significant associations between weekday sleep duration or sleep debt with high-risk hsCRP, even among shift workers. Mediation analysis was not conducted. Ideal cardiovascular health was associated with a lower prevalence of high-risk hsCRP (prevalence ratios, 0.60, 95% CI, 0.48-0.75). The lack of significant associations suggests a complex interrelationship of hsCRP with factors beyond sleep duration. Examination of populations at highest risk of chronic sleep deprivation could help to elucidate the association with systemic inflammation-related outcomes.

Comparison of Sleep and Attention Metrics Among Nurses Working Shifts on a Forward- vs Backward-Rotating Schedule

IMPORTANCE

The association of fast backward-rotating shift work (ie, anticlockwise sequence of afternoon, morning, and night shifts) with subjective and objective measures of sleep-wake quality, daytime attention, and tiredness of health care workers has not yet been established.

OBJECTIVE

To investigate the association of shift rotation direction with tiredness, sleepiness, and sustained attention among nurses working forward- and backward-rotating shifts.

DESIGN, SETTING, AND PARTICIPANTS

Data of this cohort study were collected from nurses working at 5 midsized Italian hospitals. The nurses had either a forward-rotating schedule (ie, morning to afternoon to night) and or a backward-rotating schedule (ie, afternoon to morning to night). The data were collected from July 2017 to February 2020. Data analysis was performed from May to October 2020.

EXPOSURES

Participants were working either forward- or backward-rotating schedules, in which the sequence of 3 shifts (morning, afternoon, and night) changed in a clockwise or anticlockwise direction.

MAIN OUTCOMES AND MEASURES

Sleep data were collected using the Karolinska Sleepiness Scale and Pittsburgh Sleep Quality Index. Sustained attention was measured using the Psychomotor Vigilance Task. Tiredness was evaluated using the Tiredness Symptom Scale.

RESULTS

A total of 144 nurses (mean [SE] age, 41.3 [0.8] years; 92 women [63.9%]) participated in the study; 80 nurses had forward-rotating schedules, and 64 had backward-rotating schedules. Nurses with irregular sleep-wake patterns due to night shift work had poor sleep quality (46 [57.5%] in forward-rotating schedule group; 37 [57.8%] in backward-rotating schedule group). Nurses working backward-rotating shifts exhibited significantly greater sleepiness (F1,139 = 41.23; P < .001) and cognitive slowing (ie, longer median reaction times; F1,139 = 42.12; P < .001) than those working forward rotations. Importantly, these differences were not affected by age, years of employment, and quality of sleep. Of nurses working on a backward-rotating schedule, 60 (93.8%) reported elevated sleepiness (Karolinska Sleepiness Scale score ≥7) after the night shift. The median reaction time (F1,139 = 42.12; P < .001), 10% fastest reaction time (F1,139 = 97.07; P < .001), minor lapses (F1,139 = 46.29; P < .001), and reaction time distribution (F1,139 = 60.13; P < .001) of nurses on backward-rotating schedules indicated a lower level of vigilance, which is negatively associated with neurobehavioral performance.

CONCLUSIONS AND RELEVANCE

In this study, both shift rotation models were negatively associated with health and cognitive performance. These findings suggest that forward shift rotation may be more beneficial than backward rotation for several measured performance attentional outcomes and sleepiness. Optimization of shift rotations should be implemented to decrease the combination of the negative outcomes associated with shift work and reduce the potential risk of medical errors in health care systems.

'Quit while you are ahead - and smell the roses!' A survey of retired Fellows of the Australian and New Zealand College of Anaesthetists

There are no published data on the age of retirement of anaesthetists in Australia and New Zealand. We surveyed 622 retired Fellows of the Australian and New Zealand College of Anaesthetists to determine their ages of complete retirement from clinical practice, demographics, and whether they had retired at the age they had intended to retire. We also aimed to explore factors affecting the decision to retire, the practice of 'winding down', common post-retirement activities, and the arrangement of personal and professional affairs. Responses were received from 371 specialists (response rate 60%). The mean (standard deviation) age of retirement was 65.2 (6.9) years. The mean (standard deviation) retirement ages ranged from 62.0 (7.1) years (those who retired earlier than planned) to 68.0 (4.3) years (those who retired later than they had intended). The mean (standard deviation) age of retirement of the male respondents was 66.0 (6.5) years, and for female respondents was 62.7 (7.7) years. Two hundred and thirty-three respondents (63%) reported winding down their practice prior to retirement, and 360 (97%) had made a will. Poor health and loss of confidence were the two most common factors in the retirement decisions of those who retired earlier than they had planned. Our results may assist current practitioners plan for retirement, and suggest strategies to help health services, departments and private groups accommodate individuals in winding down their practice.

Associations between sleep, stress, and cardiovascular health in emergency medical services personnel

OBJECTIVE

Our objective was to quantify the associations between sleep duration and perceived and chronic stress with ideal cardiovascular health (CVH) among emergency medical services (EMS) personnel from county-based EMS agencies.

METHODS

We conducted a cross-sectional survey of cardiovascular disease (CVD)-free EMS personnel from 4 US EMS agencies. The questionnaire consisted of the Pittsburgh Sleep Quality Index (PSQI), Perceived Stress Scale (PSS), Chronic Burden Scale, and the CVH components (smoking, body mass index, physical activity, diet, blood glucose, blood pressure, cholesterol, each scored 0-2 points). The components were summed and ideal CVH considered 11-14 points. Mixed effects logistic regression models with a random intercept for agency were used to estimate the odds of ideal CVH for good sleep quality (PSQI < 5 points), recommended sleep duration (7 to < 9h), low perceived stress (PSS < 26 points), and low chronic stress (0 recent stressful events).

RESULTS

We received 379 responses (response rate = 32%). There was low prevalence of good sleep quality (23%) and recommended sleep duration (25%), but 95% reported low perceived stress, and 33% had low chronic stress. Ideal CVH was reported by 30%. No significant associations between ideal CVH and sleep quality, perceived stress, or chronic stress were found. There was a nearly 2-fold increase in the odds of ideal CVH with recommended sleep duration (odds ratio: 1.83, 95% confidence interval: 1.08-3.10).

CONCLUSION

In this sample of EMS personnel, only recommended sleep duration was associated with ideal CVH. Future longitudinal studies are needed to understand the relationship between sleep, stress, and CVD in this understudied occupational group.

Mental health risks differentially associated with immunocompromised status among healthcare workers and family members at the pandemic outset

The mental health of healthcare workers (HCWs) is critical to their long-term well-being and future disaster preparedness. Goal 1 of this study was to identify rates of mental health problems experienced by HCWs. Goal 2 was to test a model of risk stemming from pandemic-related stressors and vulnerability factors. This cross-sectional study included HCWs (N ​= ​2,246 [1,573 clinical providers; 673 non-clinical staff]) in the Rocky Mountain West who voluntarily completed an online survey in April/May 2020. Respondents completed measures for traumatic stress symptoms, depression, anxiety, alcohol use, and sleep. Logistic regressions stratified by professional role (clinical versus non-clinical) were specified to predict clinical screening cutoff (positive/negative) as a function of five pandemic-related stressors (immunocompromised self; immunocompromised household member; care provision to infected patients; clinical management role; positive cases). Results showed that more than half of HCWs surveyed (52.5%) screened positive (above cutoff) for traumatic stress, depression, or anxiety, with ~20% reporting problematic alcohol use, and variable insufficient sleep from ~10% off shift to ~50% on shift. Clinical employees with an immunocompromised household member had increased odds of screening positive for a mental health problem. Non-clinical HCWs who were immunocompromised were at elevated risk for screening positive a mental health problem. Being female, minority status, and younger increased odds for mental health problems. Implications include alleviating a portion of the mental health burden of HCWs involved in response to the SARS-CoV-2 pandemic by considering policies to protect immunocompromised HCWs and their families (e.g., vaccine priorities, telework options).

Cardiometabolic, Dietary and Physical Health in Graduate Paramedics during the First 12-Months of Practice - A Longitudinal Study

Objective: Shift work is an established risk factor for poor health yet is necessary for paramedics to provide continuous care to the public. It is unknown how early into a career shift work may begin to impact health. This study sought to identify changes in cardiometabolic health, diet, aerobic capacity, physical activity and health-related quality of life (HRQoL) in graduate paramedics during the first 12-months of their career.Methods: Fifty-six paramedics with no history of regular shift work (28 female, 28 male; median age 24.5, IQR 23-26 years) were recruited for this study. Dietary patterns (food frequency questionnaires) and HRQoL (36-Item Short Form Questionnaire) were assessed at baseline, 6- and 12-months. Body weight, body mass index (BMI) and blood samples (fasting lipids, glucose, insulin and C-reactive protein) were measured at baseline and 12-months to ascertain cardiometabolic health risk. A subset of participants (n = 19; 10 female, 9 male) wore a physical activity monitor for 12 months and completed baseline and 12-month maximal aerobic capacity assessments (V̇O_2max).Results: Body weight and BMI decreased in males and increased in females (-0.7% versus 1.7%, p = 0.02). HRQoL and dietary intake did not change over 12-months, except for a small decrease in fat intake (-1%). Consumption of core/healthy foods was lower than recommended at all timepoints. Biomarkers of cardiometabolic health were within normal range and did not change over 12-months, excepting insulin where a small non-significant increase was seen (+0.5 mIU/L, p = 0.61). Baseline V̇O_2max was 41.4 (37.1-49.1) ml.kg^-1.min^-1, with no change noted at 12-months. Comparison of quarterly physical activity data showed no difference in steps per day (p = 0.47) or moderate to vigorous physical activity (MVPA, p = 0.92) across the 12-months. Paramedics completed less MVPA on day shifts compared to rostered days off (-14.68 minutes, p = 0.04).Conclusions: Dietary patterns, HRQoL, cardiometabolic health, aerobic capacity and physical activity levels did not change meaningfully in the first year of practice. Some dietary behaviors and physical activity levels could be improved and may mitigate health effects of exposure to shift work. Long-term follow-up of this group may aid in developing programs to enhance health for paramedics and other health workers.

Assessment of Cardiometabolic Health, Diet and Physical Activity in Helicopter Rescue Paramedics

Objective: Shift work is an established risk factor for weight gain, cardiovascular disease, Type II diabetes mellitus, and impaired health-related quality of life (HRQoL). Prolonged exposure to shift work is common in paramedics and other emergency medical service (EMS) providers. Sub-populations of EMS workers may have varying health outcomes when exposed to shift work, but the reasons for this have not been investigated. We sought to describe cardiometabolic health, dietary patterns, physical activity, and health-related quality of life (HRQoL) in a sample of experienced intensive care flight paramedics (ICFPs) working for a Helicopter Emergency Medical Service (HEMS).Methods: Fifteen paramedics (median age 45, IQR 42-48 years) were recruited to undertake a range of health assessments. These included a food frequency questionnaire to assess dietary patterns, sampling of biomarkers to determine cardiometabolic health risk, maximal aerobic capacity assessment via treadmill running and assessment of HRQoL via the SF-36 survey. In an extension of the study protocol, ten of the fifteen participants wore a physical activity monitor for one year.Results: Median (IQR) weight was 79.9 (72.3-89.3) kg, body fat percentage 23.3 (21.9-26.5) %, body mass index (BMI) 25.1 (21.9-27.4) kg.m², and waist to height ratio 0.48 (0.45-0.54). Dietary analyses showed high discretionary food intake. Biomarkers of cardiometabolic health risk were all within normal range. HRQoL was 86.2/100 for physical health and 85.1/100 for mental health. V̇O_2max was 47.0 (43.0-54.6) mL.kg^-1.min^-1. The ten participants that wore activity monitors completed 11,235 (8334-15,380) steps per day and undertook 50 (12-98) minutes per day/350 (84-686) minutes per week of moderate to vigorous physical activity. The least amount of physical activity was conducted on day shifts.Conclusions: For ICFPs included in this study, HRQoL, cardiometabolic and physical activity outcomes are representative of good health. Although shift work influences the amount of physical activity, ICFPs exceeded minimum recommendations even when rostered to duty. Despite lengthy careers in EMS, ICFPs demonstrate an excellent health profile that is likely due to high physical activity levels and healthy BMI. This information may be useful in guiding health interventions in the wider EMS workforce.

Risk of insomnia and hypnotics use among emergency physicians

This study investigated the risk of insomnia and hypnotics use among emergency physicians. This cross-sectional study recruited physicians working in Taiwanese hospitals in 2015 and the general population as the participants. Data from 1,097 emergency physicians obtained from the National Health Insurance Research Database were grouped into the case group, whereas 14,112 nonemergency physicians and 4,388 people from the general population were categorized into the control groups. This study used logistic regression and conditional logistic regression to compare the risks of insomnia between emergency and nonemergency physicians and between emergency physicians and the general population, respectively. The prevalence of insomnia among emergency physicians, nonemergency physicians and general population was 5.56%, 4.08%, and 1.73%, respectively. Compared with nonemergency physicians and the general population, emergency physicians had a significantly higher risk of insomnia. The proportions of emergency physicians, nonemergency physicians, and general population using hypnotics were 19.96%, 18.24%, and 13.26%, respectively. Among emergency physicians who used hypnotics, 49.77%, 25.57%, and 24.66% used only benzodiazepines, only nonbenzodiazepines, and both benzodiazepines and nonbenzodiazepines, respectively. Nonpharmacological interventions to improve insomnia and reminder of safe use of hypnotics to emergency physicians can serve as references for hospitals in developing health-promoting activities.

Interactions between home, work, and sleep among firefighters

BACKGROUND

Firefighters endure large occupational burdens and generally operate under conditions of chronic sleep deficiency and circadian disruption due to long shifts, plus interrupted sleep due to emergency calls during the night. A typical shift for firefighters is 24-h on/48-h off, and firefighters are expected to use time-off to recover from any sleep debt, while balancing social, family, and home responsibilities. This qualitative study sets out to assess family dynamics and how firefighters prioritize sleep and recovery at home based on relationship or family status, as well as a fire department's current shift schedule.

METHODS

Focus groups were conducted via convenience sampling in Portland, OR, with full-time firefighters, battalion chiefs, and their spouses. Grounded theory, using NVivo 12 Plus, was used to code transcripts to reveal reoccurring concepts and themes.

RESULTS

Major themes centered around the increase of nonemergent calls contributing to compassion fatigue. Spouses can help improve the sleep of firefighters by creating opportunities for recuperative sleep at home. However, spouses also conveyed underlying tones of "resentment" relating to their firefighter being unavailable for emotional and instrumental support. While married firefighters discussed choosing family and home obligations over reducing sleep debt to maintain relationships, single and divorced firefighters spoke of fewer conflicts impeding their ability to prioritize sleep at home.

CONCLUSIONS

These results improve our understanding of how firefighters prioritize sleep at home based on family dynamics and can inform future decision-making for fire departments in addressing concerns related to work-family conflict, sleep loss, and compassion fatigue among their members.

Does time of day influences outcome in out-of-hospital cardiac arrest patients?: A meta-analysis of cohort studies

BACKGROUND

Whether time of day has impact on outcomes after out-of-hospital cardiac arrest (OHCA) remains controversial. However, there are no evidence syntheses describing the impact of time differences on outcomes from OHCA.

METHODS

A meta-analysis of cohort studies exploring the association between time of day and survival in patients with OHCA was performed. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model.

RESULTS

Ten studies involving 252,848 patients and 24,646 survivals were included. Patients with night-time OHCA had significantly lower short-term survival compared to patients with daytime OHCA (OR, 1.20; 1.07-1.36; P < .001). The relationship between temporal differences and survival was consistent in most subgroups. For long-term survival, it remained unclear whether night-time was associated with reduced OHCA survival at 12 months (OR, 1.47; 0.71-3.06; P < .001). Three studies including 183,129 patients examined the association between weekend and survival in OHCA patients. Survival did not differ on weekends compared to weekdays (OR, 1.00; 0.9 7-1.04; P = .918).

CONCLUSIONS

Night-time is associated with a lower survival in OHCA patients. However, similar findings are not observed in OHCA patients on weekends. Caution is required in interpretation of these results accounting for high level of heterogeneity and large, well designed, randomized trials are warranted.

Beyond the Maslach burnout inventory: addressing emergency medicine burnout with Maslach's full theory

Burnout, a psychological syndrome emerging as a prolonged response to chronic interpersonal stressors on the job, remains a substantial problem for emergency physicians, leading to decreased quality of care and attrition from the workforce. The majority of prior work on burnout in emergency medicine has focused on individualized solutions, which have demonstrated modest efficacy for ameliorating burnout. However, recent studies suggest that burnout in medicine is primarily caused by workplace factors (eg, unmanageable workloads, unreasonable time pressures) and therefore requires solutions at an organizational level. In her decades of research across industries, Christina Maslach identified 6 domains of organizations that can either promote engagement or lead to burnout. In this article, we apply Maslach's 6 domains to emergency medicine to provide a systematic framework for alleviating burnout and promoting engagement among emergency physicians. By considering the domains of workload, reward, control, fairness, community, and value congruence, emergency medicine leaders can develop and deploy more effective interventions aimed at improving the experience and longevity of physicians across our specialty.

Association between time of out-of-hospital cardiac arrest and survival: Examination of the all-Japan Utstein registry and comparison with the 2005 and 2010 international resuscitation guidelines

BACKGROUND

Existing studies have yielded conflicting results regarding the relationship between the time of occurrence of out-of-hospital cardiac arrests and the associated outcomes. We examined whether the one-month survival rate for out-of-hospital cardiac arrests differed depending on whether the cardiac arrest occurred during the day or night. Further, we examined whether this rate differed when comparing the period succeeding the 2005 International Resuscitation Guidelines (2006-2010) with that following the 2010 guidelines (2011-2015).

METHOD

Using data from the All-Japan Utstein Registry for 2006-2015, adult out-of-hospital cardiac arrest patients whose collapse was witnessed and for whom the collapse-to-hospital-arrival interval was shorter than 120 min were included in this study. Patients were categorized in terms of whether their arrest occurred during the post-2005- or post-2010-guideline period. The primary measure was the one-month survival with a favorable neurological outcome.

RESULTS

Of 481,624 cases analyzed, 20% occurred at night. For both guideline periods, nighttime out-of-hospital cardiac arrests were associated with significantly lower one-month survival rates than daytime incidents (used as a reference; adjusted odds ratio: 0.69 and 0.63, 95% confidence interval: 0.65-0.73 and 0.60-0.65, and P < 0.001 and <0.001 for the 2005 and 2010 guideline periods, respectively).

CONCLUSIONS

One-month survival with a favorable neurological outcome was significantly lower for patients who experienced nighttime out-of-hospital cardiac arrests, compared to daytime out-of-hospital cardiac arrests. This could be addressed by improving cardiopulmonary resuscitation training for bystanders and expanding and improving nighttime emergency medical services.

Reduced Neuromuscular Performance in Night Shift Orthopedic Nurses: New Insights From a Combined Electromyographic and Force Signals Approach

The effect of sleep–wake rhythm disruption on neuromuscular control and muscle fatigue has received little attention. Because nurse shift work is so varied, including overnight duty, rotating shift schedules, early awakening, and interrupted nocturnal sleep, it offers an interesting model to study this paradigm. It has been investigated so far using only subjective markers. A combined approach based on the simultaneous analysis of surface electromyographic (sEMG) and force signals can objectively detect possible deficits in neuromuscular control and muscle fatigue. With this study we investigated neuromuscular activation and muscle contraction capacity at submaximum and maximum level in nurses working two night-shift schedules and compared them to levels in nurses working entirely in day shifts. Sleep quality and activity levels were also assessed. The study sample was 71 nurses grouped by their shift work schedule: night shift for 5 days (NS₅, n = 46), night shift for 10 days (NS₁₀, n = 9), and only day/swing shift (DS, n = 16). Before and after the shift-work cycle, maximum voluntary contraction (MVC) force and muscle activation, neuromuscular control, and muscle fatigability were measured in the finger flexor muscles. Activity level and sleep quality during the shift-work cycle were recorded with a wrist actigraph. After the shift-work cycles, MVC force and muscle activation were decreased (−11 ± 3% and −33 ± 3%, p < 0.001) as was neuromuscular control (−36 ± 8%, p = 0.007), whereas muscle fatigability was increased (+ 19 ± 9%, p = 0.006) in the NS₅ and the NS₁₀ group. Sleep quality was lower in the NS₅ and the NS₁₀ group (−8 ± 1.8% and −15%3, respectively, p < 0.001), while the activity level for the three groups was similar. There was a clear reduction in neuromuscular control and an increase in muscle fatigue in the nurses working the night shift. These findings may inform of work schedule planning or recommendations for devising new recovery strategies to counteract neuromuscular alterations in night shift nurses.

[Modification of immediate survival after in-hospital cardiac arrest during evenings and weekends]

OBJECTIVE

To determine whether cardiac arrests occurring at night or during the weekend, carry lower immediate survival.

METHOD

An analysis of logistic regression was performed, adjusted for age, sex, time to care of the cardiac arrest and first monitored rhythm, to determine whether there are differences in immediate survival.

RESULTS

The immediate survival of the cohort studied (n=121) was 32 patients (26%). A difference of 13% in immediate survival between both periods studied was found. The logistic regression analysis taking immediate survival as an effect, showed that suffering an in-hospital cardiac arrest during evenings or weekends was a variable that is not associated with a successful outcome. The OR: .48 (95% CI: .20-1.12; P=.08).

CONCLUSIONS

Patients who suffer a cardiac arrest in our centre during evenings or weekends are more vulnerable.

Top 10 evidence-based countermeasures for night shift workers

Emergency edicine providers are responsible for ensuring the emergency department is staffed 24 hours a day. As such, providers must efficiently transition between day, swing and night shift on an almost weekly basis. There is no formal education in medical school or residency on how to approach the transition to and from night shift, remain alert and productive and maximise sleep during the day. There are a multitude of blogs and online sources discussing night shift, but few, if any, provide an evidence-based approach. This article will provide the top 10 evidence-based recommendations to increase sleep, maximise performance, decrease fatigue on shift and improve quality of life outside the workplace.

Are Owls and Larks Different When it Comes to Aggression? Genetics, Neurobiology, and Behavior

This review focuses on the contribution of circadian rhythms to aggression with a multifaceted approach incorporating genetics, neural networks, and behavior. We explore the hypothesis that chronic circadian misalignment is contributing to increased aggression. Genes involved in both circadian rhythms and aggression are discussed as a possible mechanism for increased aggression that might be elicited by circadian misalignment. We then discuss the neural networks underlying aggression and how dysregulation in the interaction of these networks evoked by circadian rhythm misalignment could contribute to aggression. The last section of this review will present recent human correlational data demonstrating the association between chronotype and/or circadian misalignment with aggression. With circadian rhythms and aggression being a burgeoning area of study, we hope that this review initiates more interest in this promising and topical area.

Shallow metabolic depression and human spaceflight: a feasible first step

Synthetic torpor is an induced state of deep metabolic depression (MD) in an organism that does not naturally employ regulated and reversible MD. If applied to spaceflight crewmembers, this metabolic state may theoretically mitigate numerous biological and logistical challenges of human spaceflight. These benefits have been the focus of numerous recent articles where, invariably, they are discussed in the context of hypothetical deep MD states in which the metabolism of crewmembers is profoundly depressed relative to basal rates. However, inducing these deep MD states in humans, particularly humans aboard spacecraft, is currently impossible. Here, we discuss shallow MD as a feasible first step toward synthetic torpor during spaceflight and summarize perspectives following a recent NASA-hosted workshop. We discuss methods to safely induce shallow MD (e.g., sleep and slow wave enhancement via acoustic and photoperiod stimulation; moderate sedation via dexmedetomidine), which we define as an ~20% depression of metabolic rate relative to basal levels. We also discuss different modes of shallow MD application (e.g., habitual versus targeted, whereby shallow MD is induced routinely throughout a mission or only under certain circumstances, respectively) and different spaceflight scenarios that would benefit from its use. Finally, we propose a multistep development plan toward the application of synthetic torpor to human spaceflight, highlighting shallow MD's role. As space agencies develop missions to send humans further into space than ever before, shallow MD has the potential to confer health benefits for crewmembers, reduce demands on spacecraft capacities, and serve as a testbed for deeper MD technologies.

Circadian Profile of an Emergency Medicine Department: Scheduling Practices and Their Effects on Sleep and Performance

BACKGROUND

Shiftwork causes circadian disruption and is the primary reason for attrition from Emergency Medicine.

OBJECTIVES

We aimed to develop concrete recommendations to mitigate negative effects of shiftwork based on measures of work, sleep, alertness, and performance in emergency physicians.

METHODS

Thirty-one Emergency Medicine residents were surveyed retrospectively about sleep and alertness on different shifts. Additionally, the sleep, performance, and alertness of 22 Emergency Medicine resident and attending physicians was tracked continuously over 4 weeks via sleep logs, actigraphy, real-time reported sleepiness, and performance on a vigilance task. Schedules were analyzed for circadian disruption. Physicians also predicted their sleep schedules, which were compared with actual schedules; participants tracked extensions of shifts, schedule changes, and shifts in other hospitals.

RESULTS

Daily rhythms were apparent in real-time performance and alertness data, with peaks at around 4 pm. Sleep difficulty was highest, sleep shortest, and alertness and performance lowest for night shifts. Emergency Medicine residents tended to cluster multiple night shifts in a row, despite evidence of accumulating sleep debt over consecutive shifts. There were many shifts that caused high circadian disruption, which could be avoided by simple amendments to scheduling practices.

CONCLUSIONS

Circadian principles should be applied as suggested by the American College of Emergency Physicians. Chronotype should be considered in scheduling. Night shifts, particularly, should not be extended. Clustering all night shifts in a row should probably be discouraged. The additional vulnerabilities for night shift could be mitigated by adopting napping mid- or post night shift and by providing pay differentials.

Improving Resident Well-Being During Shiftwork: Are Casino Shifts the Answer?

PURPOSE

The objective of this study is to quantitatively evaluate the well-being of residents doing casino shifts compared with those doing standard overnight shifts while working in an academic pediatric emergency department.

METHODS

A randomized prospective survey study was performed over a period of 1 year on all residents who were scheduled to complete a 28-day block. Each block (28-day period) within the year was designated as either a "standard" or "casino" block. The standard overnight shifts were scheduled from midnight to 0800 hours, and casino shifts occurred from either 2000 to 0400 hours (casino A) and 0400 to 1200 hours (casino B). Participating residents were asked to complete both a preblock and postblock survey. The primary outcome was defined as differences in resident well-being as assessed by the brief resident wellness profile (BRWP). A mood faces graphical rating item to assess overall mood was used as a secondary outcome measures as well as a 10-item survey based on World Health Organization domains for quality of life and adapted to reflect completion of shiftwork.

RESULTS

A total of 124 (90%) of 138 residents completed the study and were included in the analysis. No significant difference in resident well-being measured by BRWP between those in the standard and casino shift groups (17 ± 2.5 for preblock standard and 16.9 ± 2.8 for casino, P = 0.904; 17.1 ± 2.7 for postblock standard and 17.2 ± 3.1 for casino, P = 0.817), or in the relative change of the BRWP preblock and postblock between the 2 groups (standard, 0.35 ± 2.7; casino, 0.29 ± 3.0; P = 0.926). No significant difference in the mood faces rating scale scores or the 10-item postblock survey was found.

CONCLUSIONS

In the first study examining the effects of casino shifts on trainees, we found no effect of standard overnight versus casino shifts on their well-being. This counters the benefits previously seen in emergency department consultant staff and highlights the need for more studies specifically in trainees.

Trends in Survival After In-Hospital Cardiac Arrest During Nights and Weekends

BACKGROUND

Survival after in-hospital cardiac arrest (IHCA) is lower during nights and weekends (off-hours) compared with daytime during weekdays (on-hours). As overall IHCA survival has improved over time, it remains unknown whether survival differences between on-hours and off-hours have changed.

OBJECTIVES

This study sought to examine temporal trends in survival differences between on-hours and off-hours IHCA.

METHODS

We identified 151,071 adults at 470 U.S. hospitals in the Get with the Guidelines-Resuscitation registry during 2000 to 2014. Using multivariable logistic regression with generalized estimating equations, we examined whether survival trends in IHCA differed during on-hours (Monday to Friday 7:00 am to 10:59 pm) versus off-hours (Monday to Friday 11:00 pm to 6:59 am, and Saturday to Sunday, all day).

RESULTS

Among 151,071 participants, 79,091 (52.4%) had an IHCA during off-hours. Risk-adjusted survival improved over time in both groups (on-hours: 16.0% in 2000, 25.2% in 2014; off-hours: 11.9% in 2000, 21.9% in 2014; p for trend <0.001 for both). However, there was no significant change in the survival difference over time between on-hours and off-hours, either on an absolute (p = 0.75) or a relative scale (p = 0.059). Acute resuscitation survival improved significantly in both groups (on-hours: 56.1% in 2000, 71% in 2014; off-hours: 46.9% in 2000, 68.2% in 2014; p for trend <0.001 for both) and the difference between on-hours and off-hours narrowed over time (p = 0.02 absolute scale, p < 0.001 relative scale). In contrast, although post-resuscitation survival also improved over time in both groups (p for trend < 0.001 for both), the absolute and relative difference persisted.

CONCLUSIONS

Despite an overall improvement in survival, lower survival in IHCA during off-hours compared with on-hours persists.

Tales from the Night:: Emergency MR Imaging in Pediatric Patients after Hours

Overnight in-house radiology has rapidly become an important part of contemporary practice models, and is increasingly the norm in pediatric radiology. MR imaging is an indispensable first-line and problem-solving tool in the pediatric population. This has led to increasingly complex MR imaging being performed "after hours" on pediatric patients. This article reviews the factors that have led to widespread overnight subspecialty radiology and the associated challenges for overnight radiologists, and provides an overview of up-to-date imaging techniques and imaging findings of the most common indications for emergent MR imaging in the pediatric population.

Psychophysiological concomitants of burnout: Evidence for different subtypes

BACKGROUND

There is evidence that chronic stress and emotional exhaustion are related to physiological dysregulations, which could negatively impact physical and mental health. This study aimed to identify the specific physiological clusters which are most reliable and prominently associated with burnout. Emphasis was placed on variables of the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Burnout was assessed using the Emotional Exhaustion subscale of the German version of the Maslach Burnout Inventory (MBI-GS).

METHODS

A sample of 105 individuals aged between 28 and 60 years (M = 42.7, SD = 7.75) and working under highly demanding conditions participated in this study. 46 participants reported a low risk of burnout, and 58 participants a high risk. They underwent 24 h of ECG monitoring, had cortisol awakening response collected, and had blood pressure measured two times within a week.

RESULTS

Compromised HRV, higher cortisol values, and higher blood pressure were found in individuals with high burnout symptoms. Furthermore, a discriminant function analysis on cardiac and neuroendocrine variables suggested two subgroups within the high burnout individuals, with only one group showing evidence for autonomic dysfunction as indicated by lower vagal efference.

CONCLUSIONS

Results suggest that burnout might not necessarily imply physiological disturbances, thus calling for a more differentiated and individualized view of burnout.

Differences in durations, adverse events, and outcomes of in-hospital cardiopulmonary resuscitation between day-time and night-time: An observational cohort study

BACKGROUND

Although patients with out-of-hospital cardiac arrest (OHCA) have a lower survival rate during night-time than during day-time, the cause of this difference remains unclear. We aimed to assess CPR parameters according to time period based on in-hospital cardiopulmonary resuscitation (IHCPR) duration and the frequency of iatrogenic chest injuries among OHCA patients.

METHODS

This two-centre observational cohort study evaluated non-traumatic OHCA patients who were transferred between 2013-2016. These patients were categorised according to whether they received day-time treatment (07:00-22:59) or night-time treatment (23:00-06:59). Differences in IHCPR duration, CPR-related chest injuries, return of spontaneous circulation, and survivals to emergency department and hospital discharge were compared using a generalised estimating equation model adjusted for pre-hospital confounders. Sensitivity analysis was also performed using a propensity score matching method.

RESULTS

Among 1254 patients (day-time: 948, night-time: 306), the night-time patients had a significantly shorter IHCPR duration (27.8 min vs. 23.6 min, adjusted difference: -5.1 min, 95% confidence interval [CI]: -6.7, -3.4), a higher incidence of chest injuries (40.4% vs. 67.0%, adjusted odds ratio [AOR]: 1.27, 95% CI: 1.20, 1.35), and a lower rate of return of spontaneous circulation (38.4% vs. 26.5%, AOR: 0.93, 95% CI: 0.88, 0.98). No significant differences were observed in the rates of survival to emergency department and hospital discharge. The propensity score-matched analysis revealed similar results.

CONCLUSIONS

Patients who underwent night-time treatment for OHCA had an increased risk of CPR-related chest injuries despite their shorter resuscitation duration. Further studies are needed to clarify the underlying mechanism(s).

Night and rotational work exposure within the last 12 months and risk of incident hypertension

Objectives Shift work, such as alternating day and nights, causes chronobiologic disruptions which may cause an increase in hypertension risk. However, the relative contributions of the components of shift work ‒ such as shift type (eg, night work) and rotations (ie, switching of shift times; day to night) ‒ on this association are not clear. To address this question, we constructed novel definitions of night work and rotational work and assessed their associations with risk of incident hypertension. Methods A cohort of 2151 workers at eight aluminum manufacturing facilities previously studied for cardiovascular disease was followed from 2003 through 2013 for incident hypertension, as defined by ICD-9 insurance claims codes. Detailed time-registry data was used to classify each worker's history of rotational and night work. The associations between recent rotational work and night work in the last 12 months and incident hypertension were estimated using adjusted Cox proportional hazards models. Results Elevated hazard ratios (HR) were observed for all levels of recent night work (>0-5, >5-50, >50-95, >95-100%) compared with non-night workers, and among all levels of rotational work (<1, 1-10, >10-20, >20-30, and >30%) compared with those working <1% rotational work. In models for considering the combination of night and rotational work, workers with mostly night work and frequent rotations (≥50% night and ≥10% rotation) had the highest risk of hypertension compared to non-night workers [HR 4.00, 95% confidence interval (CI )1.69-9.52]. Conclusions Our results suggest recent night and rotational work may both be associated with higher rates of incident hypertension.