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Duquenne P, Capperella J, Fezeu LK, Srour B, Benasi G, Hercberg S, Touvier M, Andreeva VA, St-Onge MP. The Association Between Ultra-Processed Food Consumption and Chronic Insomnia in the NutriNet-Santé Study. J Acad Nutr Diet 2024; 124:1109-1117.e2. [PMID: 38423510 DOI: 10.1016/j.jand.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/02/2024] [Accepted: 02/26/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The consumption of ultra-processed foods (UPF) is on the rise worldwide, and it has been linked to numerous health conditions, such as diabetes, obesity, and cancer. Few studies have focused on the effect of UPF consumption on sleep health and even fewer on chronic insomnia. OBJECTIVE This study investigated the association between UPF intake and chronic insomnia in a large population-based sample. DESIGN This was a cross-sectional analysis using the NutriNet-Santé study data, an ongoing Web cohort in France. PARTICIPANTS/SETTING Thirty-eight thousand five hundred seventy adult males and females who had completed a sleep questionnaire (2014) and at least two 24-hour dietary records were included in the analysis. MAIN OUTCOMES MEASURES Chronic insomnia was defined according to established criteria. Categorization of food and beverages as UPF was based on the NOVA-Group 4 classification. STATISTICAL ANALYSES PERFORMED The cross-sectional association between UPF intake and chronic insomnia was assessed using multivariable logistic regression. RESULTS Among the 38,570 participants (mean age, 50.0 ±14.8 years, 77.0% female) included in the analysis, 19.4% had symptoms of chronic insomnia. On average, UPF represented 16% of the total amount (g/day) of the overall dietary intake. In the fully adjusted model, UPF consumption was associated with higher odds of chronic insomnia (odds ratio [OR] for an absolute 10% greater UPF intake in the diet = 1.06; 95% confidence interval [CI]: 1.02-1.09). Sex-specific OR for chronic insomnia for an absolute 10% greater UPF intake in the diet were 1.09 (1.01-1.18) among males and 1.05 (1.01-1.09) among females. CONCLUSIONS This large epidemiological study revealed a statistically significant association between UPF intake and chronic insomnia, independent of sociodemographic, lifestyle, diet quality, and mental health status covariates. The findings provide insights for future longitudinal research as well as nutrition- and sleep-focused intervention and prevention programs.
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Affiliation(s)
- Pauline Duquenne
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France.
| | - Julia Capperella
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France
| | - Léopold K Fezeu
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France
| | - Bernard Srour
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France
| | - Giada Benasi
- Division of General Medicine and Center of Excellence for Sleep & Circadian Research, Department of Medicine, Columbia University, New York, NY
| | - Serge Hercberg
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France
| | - Mathilde Touvier
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France
| | - Valentina A Andreeva
- Sorbonne Paris Nord University and Paris Cité University, INSERM, INRAE, CNAM, Nutritional Epidemiology Research Team (EREN), Center for Research in Epidemiology and Statistics (CRESS), Bobigny, France; Division of General Medicine and Center of Excellence for Sleep & Circadian Research, Department of Medicine, Columbia University, New York, NY
| | - Marie-Pierre St-Onge
- Division of General Medicine and Center of Excellence for Sleep & Circadian Research, Department of Medicine, Columbia University, New York, NY.
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Suzuki M, Suzuki N, Sakurada K, Tsuchiya N, Ueno Y, Konta T. Insomnia symptoms and related factors in a community-based population: The Yamagata Cohort study. Heliyon 2024; 10:e28228. [PMID: 38532993 PMCID: PMC10963640 DOI: 10.1016/j.heliyon.2024.e28228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 03/09/2024] [Accepted: 03/13/2024] [Indexed: 03/28/2024] Open
Abstract
Objective/background Insomnia is prevalent and is a risk factor for the development of lifestyle-related diseases and early death. To improve insomnia, it is necessary to identify the factors that affect it. This study investigated the associations between insomnia symptoms and mental, physical, and environmental factors in the general Japanese population. Patients/methods The study participants were 7,873 individuals who responded to the Health and Lifestyle Survey questionnaire that included sleep-related items between December 2021 and March 2022. Insomnia symptoms were defined as a score of 6 or higher on the Athens Insomnia Scale (AIS). A multivariate logistic regression analysis was performed to identify factors independently associated with insomnia symptoms. Results Of all subjects, 23.4% had insomnia symptoms. Factors associated with insomnia symptoms were older age, female sex, very difficult living conditions on current income, pain/discomfort, anxiety, lack of happiness, frequent nocturia, long duration from bathing time to bedtime, bedroom lighting, and short walking duration. The subgroup analysis showed stronger associations between walking time in men, higher body mass index in women, time from bathing time to bedtime, and daily walking duration in older adults. Conclusions Insomnia symptoms were common in community-based populations and were independently associated with three different factor groups including physical, psychological, and environmental factors. Improvements in insomnia symptoms require appropriate practical support tailored to an individual's situation.
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Affiliation(s)
- Miho Suzuki
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
- Department of Health and Nutrition, Yamagata Prefectural Yonezawa University of Nutrition Sciences, Yonezawa, Japan
| | - Natsuko Suzuki
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
| | - Kaori Sakurada
- Department of Fundamental Nursing, Yamagata University Graduate School of Nursing, Yamagata, Japan
| | - Norihiko Tsuchiya
- Department of Urology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Yoshiyuki Ueno
- Department of Gastroenterology, Yamagata University Faculty of Medicine,Yamagata,Japan
| | - Tsuneo Konta
- Department of Public Health and Hygiene, Yamagata University Graduate School of Medical Science, Yamagata, Japan
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Yang X, Liu L, Tian Y, Yang C, Ling C, Liu H. Insomnia and Alexithymia in Chinese Adolescents with Major Depressive Disorder: A Cross-Sectional Study of Sex Differences and Associations. Psychol Res Behav Manag 2024; 17:615-625. [PMID: 38404923 PMCID: PMC10893783 DOI: 10.2147/prbm.s446788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
Purpose Insomnia is related to alexithymia in adults, but the relationship between insomnia and alexithymia in adolescents with major depressive disorder remains unclear. This study aimed to investigate the sex differences and the association between insomnia and alexithymia in adolescents with major depressive disorder. Patients and Methods From October 2020 to April 2022, adolescent patients with major depressive disorder were recruited from psychiatric departments of seven hospitals in Anhui Province, China. Their general demographic and clinical information were collected. The 20-item Toronto Alexithymia Scale, the Center for Epidemiologic Studies of Depression Scale, and the Insomnia Severity Index Scale were used to assess their alexithymia, depression, and insomnia symptoms, respectively. The analysis of variance (ANOVA), Student's t-test and Mann-Whitney U-test were used for continuous variables and chi-square tests for categorical variables. Pearson's correlation analysis and Spearman correlation analysis were used to examine the correlation between ISI and demographic and clinical variables. Multiple binary logistic regression analyses with the "Enter" method were carried out to explore the correlations of insomnia. Results The prevalence of insomnia in female adolescent patients was similar to that of male patients (χ2=1.84, p = 0.175). Compared with those without insomnia, patients with insomnia had worse family relationships (F = 7.71, p = 0.021), perceived heavier academic stress (F = 6.32, p = 0.012), more likely to take sedative-hypnotics (F = 5.51, p = 0.019), had higher levels of depression (F = 81.57, p < 0.001) and alexithymia (F = 28.57, p < 0.001). Correlation analysis showed that alexithymia was significantly associated with insomnia in adolescent patients (r = 0.360, p < 0.01). Binary logistic regression analyses showed that, alexithymia was significantly associated with insomnia in female patients (OR = 1.050, p < 0.05) but not male patients. Conclusion In female adolescent patients, alexithymia is a risk factor of insomnia, which is of great importance in the understanding of the psychopathological mechanisms, treatments and psychological interventions of insomnia in adolescents with major depressive disorder.
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Affiliation(s)
- Xiaoxue Yang
- Department of Psychiatry, School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, Anhui Province, People's Republic of China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Lewei Liu
- Department of Psychiatry, School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, Anhui Province, People's Republic of China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Yinghan Tian
- Department of Psychiatry, School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, Anhui Province, People's Republic of China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Cheng Yang
- Department of Psychiatry, School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, Anhui Province, People's Republic of China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Chen Ling
- Department of Psychiatry, School of Mental Health and Psychological Sciences, Anhui Medical University, Hefei, Anhui Province, People's Republic of China
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Huanzhong Liu
- Department of Psychiatry, Chaohu Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
- Anhui Psychiatric Center, Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
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Yang L, Li J, Huang C, Du Y, Li C, Huang B, Hou F, Zhao L, Guo H, Hu J, Ouyang X, Liu J. Altered orientation dispersion index of white matter in individuals with insomnia during the COVID-19 pandemic: A study combining neuroimaging technique and Mendelian randomization. Sleep Med 2024; 114:167-177. [PMID: 38211375 DOI: 10.1016/j.sleep.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/17/2023] [Accepted: 01/05/2024] [Indexed: 01/13/2024]
Abstract
STUDY OBJECTIVES Coronavirus disease 2019 (COVID-19) can lead to insomnia. However, associations between COVID-19-caused insomnia and white matter (WM) changes are unclear. METHODS All subjects had ever been infected with COVID-19. We investigated 89 insomniacs (29 chronic insomniacs, 33 new-onset insomniacs, 27 aggravated insomniacs) and 44 matched non-insomnia participants. Neurite orientation dispersion and density imaging (NODDI) was performed to identify micro-structural alterations of WM, and twelve scales related to sleeping status, memory, attention, learning, emotional status, and executive functions were used. Then, correlations between insomnia/cognitive-behavioral functions and diffusion metrics were tested. To eliminate influence of pre-COVID-19 factors on insomnia, causal relationships between COVID-19 and WM changes were validated by Mendelian randomization (MR) analysis. The significant brain regions of COVID-19-caused insomnia were intersected results of tract-based spatial statistics (TBSS) and MR analyses. RESULTS Compared to non-insomnia group, insomnia group and its subgroups including post-COVID-19 aggravated or unchanged chronic insomnia group had higher orientation dispersion index (ODI) in extensive brain regions. The left superior longitudinal fasciculus (SLF), left posterior thalamic radiation (PTR), and left cingulate gyrus (CG) were specific brain regions in COVID-19-induced insomnia aggravation. After Bonferroni correction, partial correlation analyses within insomnia group showed that ODI in left SLF was positively correlated with Pittsburgh sleep quality index (PSQI), insomnia severity index (ISI), and self-rating anxiety scale (SAS) scores; ODI in the left PTR was positively correlated with PSQI and ISI scores. CONCLUSIONS This study is a continuation of our previous research, which provided potential biomarkers for COVID-19-induced insomnia.
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Affiliation(s)
- Longtao Yang
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jinyue Li
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Chuxin Huang
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yanyao Du
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Cong Li
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Bei Huang
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Feng Hou
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Linlin Zhao
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Huili Guo
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China
| | - Junjiao Hu
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xuan Ouyang
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, and National Center for Mental Disorders, The Second Xiangya Hospital of Central South University, Changsha, 410011, Hunan, China.
| | - Jun Liu
- Department of Radiology, The Second Xiangya Hospital of Central South University, Changsha, China; Clinical Research Center for Medical Imaging in Hunan Province, Changsha, China; Department of Radiology Quality Control Center in Hunan Province, Changsha, China.
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Poluektov MG, Akarachkova ES, Dovgan EV, Kotova OV, Demidova TY, Klimenko AA, Kokorin VA, Ostroumova OD, Ostroumova TM. [Management of patients with insomnia and polymorbidity: expert consensus]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:49-57. [PMID: 37275998 DOI: 10.17116/jnevro202312305249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sleep disorders are becoming increasingly important due to the high comorbidity with other diseases and a significant impact on the patient's quality of life. Insomnia is the most common sleep disorder both in the general population and in patients with multimorbid pathology. Its prevalence in the general population is 6-15%, while in patients with somatic diseases it increases up to 20-40% and can reach 90% in patients with comorbid mental disorders. Another problem is the development of drug-induced insomnia. Insomnia has negative impact on the prognosis of comorbid diseases, including an increased risk of death, more severe disease, and a worse quality of life. The presence of sleep disorders makes it difficult to effectively treat the underlying disease, so it is extremely important to identify and correct these disorders in the early stages, therefore recommendations for the diagnosis of insomnia in polymorbid patients are proposed. Modern methods of treating acute and chronic insomnia and features of insomnia treatment in polymorbid patients are also discussed.
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Affiliation(s)
- M G Poluektov
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - E S Akarachkova
- International society «Stress under control», Moscow, Russia
| | - E V Dovgan
- Smolensk Regional Clinical Hospital, Smolensk, Russia
| | - O V Kotova
- International society «Stress under control», Moscow, Russia
- Peoples' Friendship University of Russia, Moscow, Russia
| | - T Yu Demidova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - A A Klimenko
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V A Kokorin
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - O D Ostroumova
- Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - T M Ostroumova
- Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Appleton SL, Reynolds AC, Gill TK, Melaku YA, Adams RJ. Insomnia Prevalence Varies with Symptom Criteria Used with Implications for Epidemiological Studies: Role of Anthropometrics, Sleep Habit, and Comorbidities. Nat Sci Sleep 2022; 14:775-790. [PMID: 35478719 PMCID: PMC9037734 DOI: 10.2147/nss.s359437] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 04/06/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Estimating insomnia prevalence in epidemiological studies is hampered by variability in definitions and interpretation of criteria. We addressed the absence of a population-based estimate of insomnia in Australia using the widely accepted contemporary International Classification of Sleep Disorders (ICSD-3) criteria, which includes sleep opportunity, and has not been applied in studies to date. Consistent use of these criteria across epidemiological studies, however, requires evidence of the clinical utility of a sleep opportunity criterion for targeting strategies. Methods A cross-sectional national on-line survey (2019 Sleep Health Foundation Insomnia Survey) of Australian adults (18-90 years, n = 2044) was conducted. Chronic insomnia was defined as sleep symptoms and daytime impairment experienced ≥3 times per week, and present for ≥3 months, with adequate sleep opportunity (time in bed (TIB) ≥7.5 hrs). Self-rated general health (SF-1) and ever diagnosed health conditions (including sleep disorders) were assessed. Results Chronic difficulties initiating and maintaining sleep and daytime symptoms (n = 788) were more common in females (41.5%) than males (35.3%), p = 0.004. Excluding participants reporting frequent pain causing sleep disruption and TIB <7.5 hrs generated an insomnia disorder estimate of 25.2% (95% CI: 22.5-28.2) in females and 21.1% (18.4-23.9) in males [23.2% (21.2-25.2) overall]. This compares with 8.6% (7.3-10.0) with insomnia symptoms and TIB <7.5 hrs and 7.5% (6.4-8.7%) ever diagnosed with insomnia. Insomnia symptom groups with TIB <7.5 and ≥7.5 hours demonstrated similar odds of reporting fair/poor health [odds ratio (OR): 3.2 (95% CI: 2.1-4.8) and 2.9 (95% CI: 2.2-3.9) respectively], ≥1 mental health condition, ≥1 airway disease, and multimorbidity. Conclusion Adults with significant sleep and daytime symptomatology and TIB <7.5 hrs did not differ clinically from those with insomnia disorder. Consideration of criteria, particularly adequate sleep opportunity, is required to consistently identify insomnia, and establish health correlates in future epidemiological studies. Further evaluation of the clinical utility of the sleep opportunity criterion is also required.
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Affiliation(s)
- Sarah L Appleton
- Flinders Health and Medical Research Institute – Sleep Health (Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- The Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Amy C Reynolds
- Flinders Health and Medical Research Institute – Sleep Health (Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Tiffany K Gill
- The Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Yohannes Adama Melaku
- Flinders Health and Medical Research Institute – Sleep Health (Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Robert J Adams
- Flinders Health and Medical Research Institute – Sleep Health (Adelaide Institute for Sleep Health), College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Guandalini LS, da Silva EF, Lopes JDL, Santos VB, Lopes CT, de Barros ALBL. Analysis of the evidence of related factors, associated conditions and at-risk populations of the NANDA-I nursing diagnosis insomnia. Int J Nurs Sci 2020; 7:466-476. [PMID: 33195760 PMCID: PMC7644560 DOI: 10.1016/j.ijnss.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/12/2020] [Accepted: 09/10/2020] [Indexed: 02/05/2023] Open
Abstract
Objectives To summarize evidence in the literature on the predictors of insomnia in adults and to determine correspondences with diagnostic indicators of the NANDA-I diagnosis Insomnia. Methods An integrative review performed in Pubmed, Virtual Health Library and CINAHL. Forty-eight articles published in Portuguese, English or Spanish from 2011 to 2018 were included. An analysis of correspondence between the predictors and the NANDA-I related factors and associated conditions for Insomnia was performed. Results There was a correspondence of the predictors found in this review with NANDA-I related factors and associated conditions, except for grieving and frequent naps during the day. Smoking, caffeine intake, dysfunctional sleep beliefs, obesity and caregiver role strain are possible new related factors; chronic illness is a possible new associated condition and individuals going through changes in marital status, economically disadvantaged, female gender, increasing age and night shift worker are possible new at-risk populations. Conclusion The predictors of insomnia that had a correspondence with the NANDA-I elements can support the evidence base of the nursing diagnosis. The predictors found without a correspondence with the diagnosis can be considered for inclusion in the NANDA-I classification, thereby supporting the clinical reasoning of nurses and students.
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Affiliation(s)
- Lidia Santiago Guandalini
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil.,São Paulo Hospital, São Paulo, Brazil
| | | | | | | | - Camila Takao Lopes
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo, São Paulo, Brazil
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