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Han ER, Chung EK. A qualitative study on the adoption of the new duty hour regulations among medical residents and faculty in Korea. PLoS One 2024; 19:e0301502. [PMID: 38603669 PMCID: PMC11008864 DOI: 10.1371/journal.pone.0301502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 03/15/2024] [Indexed: 04/13/2024] Open
Abstract
Duty hour regulations (DHRs) were enforced in 2017 in Korea to prevent the detrimental effects of excessively prolonged working hours among medical residents. We investigated the adoption of and implications of the new DHRs among medical residents and faculty members. Semi-structured interviews were conducted with 15 medical residents and 9 faculty members across general surgery, internal medicine, obstetrics-gynecology, and pediatrics departments at Chonnam National University Hospital. Based on the constructivist grounded theory, we developed themes from the data by concurrent coding and analysis with theoretical sampling until data saturation. In addition, respondent validation was used to ensure accuracy, and all authors remained reflexive throughout the study to improve validity. The methods of DHRs adoption among residents and faculty members included the following 4 themes: DHRs improved work schedule, residents have more time to learn on their own, clinical departments have come to distribute work, organization members have strived to improve patient safety. Residents have undertaken initial steps towards creating a balance between personal life and work. Teamwork and shift within the same team are the transitions that minimize discontinuity of patient care considering patient safety. Teaching hospitals, including faculty members, should ensure that residents' work and education are balanced with appropriate clinical experience and competency-based training.
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Affiliation(s)
- Eui-Ryoung Han
- Department of Medical Education, Chonnam National University Medical School, Gwangju, South Korea
| | - Eun-Kyung Chung
- Department of Medical Education, Chonnam National University Medical School, Gwangju, South Korea
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2
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Jolles DR, Niemczyk N, Hoehn Velasco L, Wallace J, Wright J, Stapleton S, Flynn C, Pelletier-Butler P, Versace A, Marcelle E, Thornton P, Bauer K. The birth center model of care: Staffing, business characteristics, and core clinical outcomes. Birth 2023; 50:1045-1056. [PMID: 37574794 DOI: 10.1111/birt.12745] [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: 08/15/2021] [Revised: 02/28/2023] [Accepted: 06/24/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVES Interest in expanding access to the birth center model is growing. The purpose of this research is to describe birth center staffing models and business characteristics and explore relationships to perinatal outcomes. METHODS This descriptive analysis includes a convenience sample of all 84 birth center sites that participated in the AABC Site Survey and AABC Perinatal Data Registry between 2012 and 2020. Selected independent variables include staffing model (CNM/CM or CPM/LM), legal entity status, birth volume/year, and hours of midwifery call/week. Perinatal outcomes include rates of induction of labor, cesarean birth, exclusive breastfeeding, birthweight in pounds, low APGAR scores, and neonatal intensive care admission. RESULTS The birth center model of care is demonstrated to be safe and effective, across a variety of staffing and business models. Outcomes for both CNM/CM and CPM/LM models of care exceed national benchmarks for perinatal quality with low induction, cesarean, NICU admission, and high rates of breastfeeding. Within the sample of medically low-risk multiparas, variations in clinical outcomes were correlated with business characteristics of the birth center, specifically annual birth volume. Increased induction of labor and cesarean birth, with decreased success breastfeeding, were present within practices characterized as high volume (>200 births/year). The research demonstrates decreased access to the birth center model of care for Black and Hispanic populations. CONCLUSIONS FOR PRACTICE Between 2012 and 2020, 84 birth centers across the United States engaged in 90,580 episodes of perinatal care. Continued policy development is necessary to provide risk-appropriate care for populations of healthy, medically low-risk consumers.
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Affiliation(s)
- Diana R Jolles
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
- Clinical Faculty, Frontier Nursing University, Hyden, Kentucky, USA
| | - Nancy Niemczyk
- Nurse-Midwife Program, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Jacqueline Wallace
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | - Jennifer Wright
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | - Susan Stapleton
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | - Cynthia Flynn
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
| | | | | | - Ebony Marcelle
- Community of Hope, Washington, District of Columbia, USA
| | | | - Kate Bauer
- American Association of Birth Centers, Perkiomenville, Pennsylvania, USA
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Steffey MA, Risselada M, Scharf VF, Buote NJ, Zamprogno H, Winter AL, Griffon D. A narrative review of the impact of work hours and insufficient rest on job performance. Vet Surg 2023; 52:491-504. [PMID: 36802073 DOI: 10.1111/vsu.13943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 12/13/2022] [Accepted: 01/25/2023] [Indexed: 02/20/2023]
Abstract
OBJECTIVE This review discusses the scientific evidence regarding effects of insufficient rest on clinical performance and house officer training programs, the associations of clinical duty scheduling with insufficient rest, and the implications for risk management. STUDY DESIGN Narrative review. METHODS Several literature searches using broad terms such as "sleep deprivation," "veterinary," "physician," and "surgeon" were performed using PubMed and Google scholar. RESULTS Sleep deprivation and insufficient rest have clear and deleterious effects on job performance, which in healthcare occupations impacts patient safety and practice function. The unique requirements of a career in veterinary surgery, which may include on-call shifts and overnight work, can lead to distinct sleep challenges and chronic insufficient rest with resultant serious but often poorly recognized impacts. These effects negatively impact practices, teams, surgeons, and patients. The self-assessment of fatigue and performance effect is demonstrably untrustworthy, reinforcing the need for institution-level protections. While the issues are complex and there is no one-size-fits-all approach, duty hour or workload restrictions may be an important first step in addressing these issues within veterinary surgery, as it has been in human medicine. CONCLUSION Systematic re-examination of cultural expectations and practice logistics are needed if improvement in working hours, clinician well-being, productivity, and patient safety are to occur. CLINICAL SIGNIFICANCE (OR IMPACT) A more comprehensive understanding of the magnitude and consequence of sleep-related impairment better enables surgeons and hospital management to address systemic challenges in veterinary practice and training programs.
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Affiliation(s)
- Michele A Steffey
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California-Davis, Davis, California, USA
| | - Marije Risselada
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA
| | - Valery F Scharf
- Department of Clinical Sciences, North Carolina State University College of Veterinary Medicine, Raleigh, North Carolina, USA
| | - Nicole J Buote
- Department of Clinical Science, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | | | | | - Dominique Griffon
- Western University of Health Sciences, College of Veterinary Medicine, Pomona, California, USA
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Chen J, Tuersun Y, Yang J, Xiong M, Wang Y, Rao X, Jiang S. Association of depression symptoms and sleep quality with state-trait anxiety in medical university students in Anhui Province, China: a mediation analysis. BMC MEDICAL EDUCATION 2022; 22:627. [PMID: 35982434 PMCID: PMC9388213 DOI: 10.1186/s12909-022-03683-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The prevalence of depression symptoms among medical students is particularly high, and it has increased during the COVID-19 epidemic. Sleep quality and state-trait anxiety are risk factors for depression, but no study has yet investigated the mediating role of state-trait anxiety in the relationship between poor sleep quality and depression symptoms in medical students. This study aims to investigate the relationship among depression symptoms, sleep quality and state-trait anxiety in medical university students in Anhui Province. METHODS This was a cross-sectional survey of 1227 students' online questionnaires collected from four medical universities in Anhui Province using a convenience sampling method. We measured respondents' sleep quality, state-trait anxiety, and depression symptoms using three scales: the Pittsburgh Sleep Quality Index (PSQI), the State-Trait Anxiety Inventory (STAI) and the Self-rating Depression Scale (SDS). We analysed the mediating role of STAI scores on the association between PSQI scores and SDS scores through the Sobel-Goodman Mediation Test while controlling for covariates. P < 0.05 was considered statistically significant. RESULTS A total of 74.33% (912) and 41.40% (518) of the respondents reported suffering from poor sleep quality and depression symptoms. Sleep quality, state-trait anxiety, and depression symptoms were positively associated with each other (β = 0.381 ~ 0.775, P < 0.001). State-trait anxiety partially mediated the association between sleep quality and depression symptoms (Sobel test Z = 15.090, P < 0.001), and this mediating variable accounted for 83.79% of the association when adjusting for potential confounders. Subgroup analysis further revealed that STAI scores partially mediated the association between PSQI scores and SDS scores in females and rural students and fully mediated the association between PSQI scores and SDS scores in males and urban students. CONCLUSIONS This study found that sleep quality and state-trait anxiety have a significant predictive effect on depression symptoms. State-trait anxiety mediated the relationship between sleep quality and depression symptoms, with a more complex mechanism observed among rural and female medical students. Multiple pathways of intervention should be adopted, such as encouraging students to self-adjust, providing professional psychological intervention and timely monitoring, enriching extracurricular activities, and making changes in policies regarding long shifts and working hours.
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Affiliation(s)
- Jiangyun Chen
- School of Health Management, Southern Medical University, Guangzhou, China
| | | | - Jiao Yang
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Man Xiong
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Yueying Wang
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Xinyi Rao
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Shuai Jiang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
- Institute for Hospital Management of Henan Province, Zhengzhou, China.
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Nasseri Y, Oka K, Kasheri E, Cohen J, Ellenhorn J, Cox B, Lee A, Barnajian M. Robotic colorectal procedures: does operative start time impact short-term outcome? Surg Endosc 2022; 36:5669-5675. [PMID: 35277768 DOI: 10.1007/s00464-022-09086-0] [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: 04/05/2021] [Accepted: 01/28/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Yosef Nasseri
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA. .,Department of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Kimberly Oka
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA
| | - Eli Kasheri
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA
| | - Jason Cohen
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA.,Department of General Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Joshua Ellenhorn
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA.,Department of Surgical Oncology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Brian Cox
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Anderson Lee
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA
| | - Moshe Barnajian
- Surgery Group of Los Angeles, 8635 West 3rd Street, Suite 880W, Los Angeles, CA, 90048, USA.,Department of Colorectal Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Thimmapuram J, Pargament R, Tredici SD, Bell T, Yommer D, Daoud D, Powell F, Madhusudhan DK. Sleep Patterns of Resident Physicians and the Effect of Heartfulness Meditation. Ann Neurosci 2021; 28:47-54. [PMID: 34733054 PMCID: PMC8558985 DOI: 10.1177/09727531211039070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 07/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background: Medical residents are vulnerable to poor sleep quality due to intense work
shifts and academic load. Studies objectively quantified with sleep quantity
and quality among resident physicians are limited. Meditation techniques
have been shown to improve sleep but are rarely studied in this population.
The aim of the present study is to evaluate sleep patterns of internal
medicine residents and the effect of a structured Heartfulness meditation
program to improve sleep quality. Methods: A total of 36 residents participated in a pre–post cohort study from January
2019 through April 2019. Sleep was monitored during a one-week outpatient
rotation with two validated assessment tools, namely consensus sleep diary
and actigraphy. After four intervening weeks, when the residents returned to
the same rotation, Heartfulness meditation was practiced and the same
parameters were measured. At the end of the study period, an anonymous
qualitative feedback survey was collected to assess the feasibility of the
intervention. Results: All 36 residents participated in the study (mean age 31.09 years, SD 4.87);
34 residents (94.4%) had complete pre–post data. Consensus sleep diary data
showed decreased sleep onset time from 21.03 to 14.84 min
(P = .01); sleep quality and restfulness scores
increased from 3.32 to 3.89 and 3.08 to 3.54, respectively
(P < .001 for both). Actigraphy showed a change in
sleep onset time from 20.9 min to 14.5 min (P = .003).
Sleep efficiency improved from 83.5% to 85.6% (P = .019).
Wakefulness after initial sleep onset changed from 38.8 to 39.9 min
(P = .682). Sleep fragmentation index and the number of
awakenings decreased from 6.16 to 5.46 (P = .004) and 41.71
to 36.37 (P = .013), respectively. Conclusions: Residents obtained nearly 7 h of sleep during outpatient rotation. Findings
suggest a structured Heartfulness meditation practice to be a feasible
program to improve subjective sleep onset time and several objective
measures among resident physicians.
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Affiliation(s)
- Jayaram Thimmapuram
- Internal Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Robert Pargament
- Internal Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Sonya Del Tredici
- Internal Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Theodore Bell
- Internal Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Deborah Yommer
- WellSpan Pulmonary and Sleep Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Dana Daoud
- Internal Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Frankie Powell
- Internal Medicine, WellSpan York Hospital, York, Pennsylvania, United States
| | - Divya K Madhusudhan
- Global Clinical Scholar Research Training Program, Harvard Medical School, Boston, Massachusetts, United States
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Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents. J Gen Intern Med 2021; 36:1974-1979. [PMID: 33511565 PMCID: PMC8298702 DOI: 10.1007/s11606-020-06516-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Single-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers. OBJECTIVE To explore residents' perception of barriers to accessing overnight supervision. DESIGN Questions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017. PARTICIPANTS All US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed. MAIN MEASURES For our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention. KEY RESULTS Internal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician "always" or "most of the time" (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% "always" or "most of the time"); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% "always" or "most of the time"). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers. CONCLUSIONS Presence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.
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Sleep deprivation aggravates brain injury after experimental subarachnoid hemorrhage via TLR4-MyD88 pathway. Aging (Albany NY) 2021; 13:3101-3111. [PMID: 33479186 PMCID: PMC7880348 DOI: 10.18632/aging.202503] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 12/03/2020] [Indexed: 12/15/2022]
Abstract
Subarachnoid hemorrhage (SAH) is a life-threatening cerebrovascular disease, and most of the SAH patients experience sleep deprivation during their hospital stay. It is well-known that sleep deprivation is one of the key components of developing several neurological disorders, but its effect on brain damage after SAH has not been determined. Therefore, this study was designed to evaluate the effect of sleep deprivation using an experimental SAH model in rats. Induction of sleep deprivation for 24 h aggravated the SAH-induced brain damage, as evidenced by brain edema, neuronal apoptosis and activation of caspase-3. Sleep deprivation also worsened the neurological impairment and cognitive deficits after SAH. The results of immunostaining and western blot showed that sleep deprivation increased the activation of microglial cells. In addition, sleep deprivation differently regulated the expression of anti-inflammatory and pro-inflammatory cytokines. The results of immunofluorescence staining and western blot showed that sleep deprivation markedly increased the activation of Toll-like receptor 4 (TLR4) and myeloid differentiation primary response protein 88 (MyD88). Mechanically, treatment with the TLR4 inhibitor TAK-242 or the MyD88 inhibitor ST2825 significantly attenuated the brain damage and neuroinflammation induced by sleep deprivation after SAH. In conclusion, our results indicate that sleep deprivation aggravates brain damage and neurological dysfunction following experimental SAH in rats. These effects were mediated by the activation of the TLR4-MyD88 cascades and regulation of neuroinflammation.
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Ogunsuji O, Adebayo O, Olaopa O, Amoo A, Igbokwe M, Babalola R, Sokomba A, Atilola O, Ilesanmi O, Durowade K. Evaluating the Relationship between Duty Hours and Quality of Life of Nigerian Early Career Doctors. Hosp Top 2020; 98:118-126. [PMID: 32794436 DOI: 10.1080/00185868.2020.1789521] [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: 10/23/2022]
Abstract
This study explored association between early career doctors (ECDs) duty hours and their quality of life (QoL). Information was collected on socio-demographics, duty hours and QoL of 391 Nigerian ECDs. Results showed median of 70 duty-hours weekly, 10 call-days monthly and 6 sleep-hours daily. Weekly duty-hours and daily sleep-hours were significantly negatively and positively correlated respectively with all four domains of WHOQoL. QoL potentially affects health of ECDs especially mental health. Policies targeted at improving ECDs workforce, working conditions should improve QoL and curtail the potential impact of brain drain and attrition among ECDs in Nigeria.
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Affiliation(s)
- Oluwaseyi Ogunsuji
- Department of Periodontology and Community Dentistry, University College Hospital, Ibadan, Nigeria
| | - Oladimeji Adebayo
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | - Olusegun Olaopa
- Department of Oral and Maxillofacial Surgery, University College Hospital, Ibadan, Nigeria
| | - Abimbola Amoo
- Department of Medical Microbiology, University College Hospital, Ibadan, Nigeria
| | - Martin Igbokwe
- Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Rereloluwa Babalola
- Department of Surgery, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
| | - Aliyu Sokomba
- Department of Community Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Olayinka Atilola
- Department of Psychiatry, Lagos State University/Lagos State University Teaching Hospital, Lagos, Nigeria
| | - Olayinka Ilesanmi
- Department of Community Medicine, University of Ibadan/University College Hospital, Ibadan, Nigeria
| | - Kabir Durowade
- Department of Community Medicine, Federal Teaching Hospital, Ido-Ekiti, Nigeria.,Department of Community Medicine, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, Nigeria
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10
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Catalanotti JS, O’Connor AB, Kisielewski M, Chick DA, Fletcher KE. Association Between Nocturnist Supervision and Perceived Overnight Supervision Adequacy Among Internal Medicine Residents in the US. JAMA 2020; 323:1407-1409. [PMID: 32286638 PMCID: PMC7157484 DOI: 10.1001/jama.2020.0875] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cross-sectional study uses data from a voluntary survey that was administered during the American College of Physicians Internal Medicine In-Training Examination to assess whether residents in programs with nocturnists perceived nighttime supervision differently than those in programs without nocturnists.
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Affiliation(s)
| | - Alec B. O’Connor
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Teunissen C, Burrell B, Maskill V. Effective Surgical Teams: An Integrative Literature Review. West J Nurs Res 2019; 42:61-75. [PMID: 30854942 DOI: 10.1177/0193945919834896] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is imperative to understand the factors that contribute to effective surgical teams. The aim of this integrative review was to evaluate the aids and barriers for perioperative teams in functioning effectively, preventing adverse events, and fostering a culture of safety. The literature search was undertaken of 15 databases, which resulted in 70 articles being included. It was found perioperative teamwork was not widely understood. Findings indicated barriers to effective surgical teams comprised of confusion in tasks and responsibilities, existing hierarchies and prevailing misconceptions and understanding among team members. Although numerous quality initiatives exist, the introduction of protocols and checklists, team effectiveness in the perioperative setting is still insufficient and challenges in establishing effective surgical teams continue. Further research is recommended to obtain a comprehensive perception of environmental influences and barriers surgical teams encounter in the delivery of safe quality care.
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12
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Soni KD, Mahindrakar S, Kaushik G, Kumar S, Sagar S, Gupta A. Do the Care Process and Survival Chances Differ in Patients Arriving to a Level 1 Indian Trauma Center, during-Hours and after-Hours? J Emerg Trauma Shock 2019; 12:128-134. [PMID: 31198280 PMCID: PMC6557059 DOI: 10.4103/jets.jets_76_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country. Methodology Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded. Results Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan-Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST. Conclusions Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.
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Affiliation(s)
- Kapil Dev Soni
- Department of Critical and Intensive Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Santosh Mahindrakar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Gaurav Kaushik
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Sayyah-Melli M, Nikravan Mofrad M, Amini A, Piri Z, Ghojazadeh M, Rahmani V. The Effect of Medical Recording Training on Quantity and Quality of Recording in Gynecology Residents of Tabriz University of Medical Sciences. J Caring Sci 2017; 6:281-292. [PMID: 28971078 PMCID: PMC5618952 DOI: 10.15171/jcs.2017.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 01/22/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction: Medical records contain valuable information
about a patient's medical history and treatment. Patient safety is one of the most
important dimensions of health care quality assurance and performance improvement.
Completing the process of documentation is necessary to continue patient care and
continuous quality improvement of basic services. The aim of the present study was to
evaluate the effect of medical recording education on the quantity and quality of
recording in gynecology residents of Tabriz University of Medical Sciences. Methods: This study is a quasi-experimental study and was
conducted at Al-Zahra Teaching Hospital, Tabriz, Iran, in 2016. Thirty-two second through
fourth year gynecologic residents of Tabriz University of Medical Sciences who were
willing to participate in the study were included by census sampling and participated in
training workshop. Three evaluators reviewed the residents’ records before and after
training course by a checklist. Statistical analyses were performed using SPSS 13
software. P-values less than 0.05 were considered statistically significant. Results: The results showed that before the intervention,
there were significant differences in the quantity of information status among the
evaluators and no significant difference was observed in the recording of qualitative
status. After the workshop, among the 3 evaluators, there were also significant
differences in the quantity of data recording status; however, no significant change was
observed in recording of qualitative status. Conclusion: The study findings revealed that a sectional
training course of correct and standardized medical records has no effect on reforming the
process of recording.
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Affiliation(s)
- Manizheh Sayyah-Melli
- Departement of Obstetrics and Gynecology, Shahid Beheshti University of Medical Sciences, School of Medical Education, Tehran, Iran.,Research Center of Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Malahat Nikravan Mofrad
- Departement of Nursing, School of Nursing & Midwifery, School of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abolghasem Amini
- Department and Center for Educational Research and Development (EDC), Tabriz University of Medical Science, Tabriz, Iran
| | - Zakieh Piri
- Department of Medical Records, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Ghojazadeh
- Research Center of Evidence-Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Vahideh Rahmani
- Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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14
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Ban VS, Madden CJ, Browning T, O'Connell E, Marple BF, Moran B. A novel use of the discrete templated notes within an electronic health record software to monitor resident supervision. J Am Med Inform Assoc 2017; 24:e2-e8. [PMID: 27274023 DOI: 10.1093/jamia/ocw078] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/19/2016] [Indexed: 12/26/2022] Open
Abstract
Objective Monitoring the supervision of residents can be a challenging task. We describe our experience with the implementation of a templated note system for documenting procedures with the aim of enabling automated, discrete, and standardized capture of documentation of supervision of residents performing floor-based procedures, with minimal extra effort from the residents. Materials and methods Procedural note templates were designed using the standard existing template within a commercial electronic health record software. Templates for common procedures were created such that residents could document every procedure performed outside of the formal procedural areas. Automated reports were generated and letters were sent to noncompliers. Results A total of 27 045 inpatient non-formal procedural area procedures were recorded from August 2012 to June 2014. Compliance with NoteWriter template usage averaged 86% in the first year and increased to 94.6% in the second year ( P = .0055). Initially, only 12.5% of residents documented supervision of any form. By the end of the first year, this was above 80%, with the gains maintained into the second year and beyond. Direct supervision was documented to have occurred where required in 62.8% in the first year and increased to 99.8% in the second year ( P = .0001) after the addition of hard stops. Notification of attendings prior to procedures was documented 100% of the time by September 2013. Letters sent to errant residents decreased from 3.6 to 0.83 per 100 residents per week. Conclusion The templated procedure note system with hard stops and integrated reporting can successfully be used to improve monitoring of resident supervision. This has potential impact on resident education and patient safety.
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Affiliation(s)
- Vin Shen Ban
- Department of Neurological Surgery, University of Texas Southwestern Medical Center
| | - Christopher J Madden
- Department of Neurological Surgery, University of Texas Southwestern Medical Center.,Office of the Executive Vice President, Parkland Health and Hospital System, Dallas, Texas
| | - Travis Browning
- Department of Radiology and Division of Informatics, University of Texas Southwestern Medical Center
| | - Ellen O'Connell
- Department of Emergency Medicine, University of Texas Southwestern Medical Center and Parkland Health and Hospital System
| | - Bradley F Marple
- Department of Otolaryngology and Graduate Medical Education, University of Texas Southwestern Medical Center
| | - Brett Moran
- Department of Internal Medicine, University of Texas Southwestern Medical Center.,Information Technology, Parkland Health and Hospital System, Dallas, Texas
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15
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Maximal tachycardia and high cardiac strain during night shifts of emergency physicians. Int Arch Occup Environ Health 2017; 90:467-480. [PMID: 28271382 DOI: 10.1007/s00420-017-1211-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 02/17/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare tachycardia and cardiac strain between 24-hour shifts (24hS) and 14-hour night shifts (14hS) in emergency physicians (EPs), and to investigate key factors influencing tachycardia and cardiac strain. METHODS We monitored heart rate (HR) with Holter-ECG in a shift-randomized trial comparing a 24hS, a 14hS, and a control day, within a potential for 19 EPs. We also measured 24-h HR the third day (D3) after both shifts. We measured perceived stress by visual analog scale and the number of life-and-death emergencies. RESULTS The 17 EPs completing the whole protocol reached maximal HR (180.9 ± 6.9 bpm) during both shifts. Minutes of tachycardia >100 bpm were higher in 24hS (208.3 ± 63.8) than in any other days (14hS: 142.3 ± 36.9; D3/14hS: 64.8 ± 31.4; D3/24hS: 57.6 ± 19.1; control day: 39.2 ± 11.6 min, p < .05). Shifts induced a cardiac strain twice higher than in days not involving patients contact. Each life-and-death emergency enhanced 26 min of tachycardia ≥100 bpm (p < .001), 7 min ≥ 110 bpm (p < .001), 2 min ≥ 120 bpm (p < .001) and 19 min of cardiac strain ≥30% (p = .014). Stress was associated with greater duration of tachycardia ≥100, 110 and 120 bpm, and of cardiac strain ≥30% (p < .001). CONCLUSION We demonstrated several incidences of maximal HR during shifts combined with a high cardiac strain. Duration of tachycardia were the highest in 24hS and lasted several hours. Such values are comparable to those of workers exposed to high physical demanding tasks or heat. Therefore, we suggest that EPs limit their exposure to 24hS. We, furthermore, demonstrated benefits of HR monitoring for identifying stressful events. ClinicalTrials.gov identifier: NCT01874704.
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16
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Klerman EB, Beckett SA, Landrigan CP. Applying mathematical models to predict resident physician performance and alertness on traditional and novel work schedules. BMC MEDICAL EDUCATION 2016; 16:239. [PMID: 27623842 PMCID: PMC5022151 DOI: 10.1186/s12909-016-0751-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 08/19/2016] [Indexed: 05/31/2023]
Abstract
BACKGROUND In 2011 the U.S. Accreditation Council for Graduate Medical Education began limiting first year resident physicians (interns) to shifts of ≤16 consecutive hours. Controversy persists regarding the effectiveness of this policy for reducing errors and accidents while promoting education and patient care. Using a mathematical model of the effects of circadian rhythms and length of time awake on objective performance and subjective alertness, we quantitatively compared predictions for traditional intern schedules to those that limit work to ≤ 16 consecutive hours. METHODS We simulated two traditional schedules and three novel schedules using the mathematical model. The traditional schedules had extended duration work shifts (≥24 h) with overnight work shifts every second shift (including every third night, Q3) or every third shift (including every fourth night, Q4) night; the novel schedules had two different cross-cover (XC) night team schedules (XC-V1 and XC-V2) and a Rapid Cycle Rotation (RCR) schedule. Predicted objective performance and subjective alertness for each work shift were computed for each individual's schedule within a team and then combined for the team as a whole. Our primary outcome was the amount of time within a work shift during which a team's model-predicted objective performance and subjective alertness were lower than that expected after 16 or 24 h of continuous wake in an otherwise rested individual. RESULTS The model predicted fewer hours with poor performance and alertness, especially during night-time work hours, for all three novel schedules than for either the traditional Q3 or Q4 schedules. CONCLUSIONS Three proposed schedules that eliminate extended shifts may improve performance and alertness compared with traditional Q3 or Q4 schedules. Predicted times of worse performance and alertness were at night, which is also a time when supervision of trainees is lower. Mathematical modeling provides a quantitative comparison approach with potential to aid residency programs in schedule analysis and redesign.
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Affiliation(s)
- Elizabeth B. Klerman
- Division of Sleep and Circadian Disorders, Departments of Neurology and Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA
- Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, MA 02115 USA
| | - Scott A. Beckett
- Division of Sleep and Circadian Disorders, Departments of Neurology and Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA
| | - Christopher P. Landrigan
- Division of Sleep and Circadian Disorders, Departments of Neurology and Medicine, Brigham and Women’s Hospital, Boston, MA 02115 USA
- Division of Sleep Medicine, Department of Medicine, Harvard Medical School, Boston, MA 02115 USA
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Boston, MA 02115 USA
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17
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Tevis SE, Ravi S, Buel L, Clough B, Goelzer S. Blueprint for a Successful Resident Quality and Safety Council. J Grad Med Educ 2016; 8:328-31. [PMID: 27413433 PMCID: PMC4936848 DOI: 10.4300/jgme-d-15-00250.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sarah E. Tevis
- Corresponding author: Sarah E. Tevis, MD, University of Wisconsin Hospitals and Clinics, 600 Highland Avenue, Madison, WI 53792, 608.263.6400,
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Kemper KJ, Mo X, Khayat R. Are Mindfulness and Self-Compassion Associated with Sleep and Resilience in Health Professionals? J Altern Complement Med 2015. [PMID: 26218885 DOI: 10.1089/acm.2014.0281] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES To describe the relationship between trainable qualities (mindfulness and self-compassion), with factors conceptually related to burnout and quality of care (sleep and resilience) in young health professionals and trainees. DESIGN Cross-sectional survey. SETTING Large Midwestern academic health center. PARTICIPANTS 213 clinicians and trainees. OUTCOME MEASURES Sleep and resilience were assessed by using the 8-item PROMIS Sleep scale and the 6-item Brief Resilience Scale. Mindfulness and self-compassion were assessed using the 10-item Cognitive and Affective Mindfulness Scale, Revised and the 12-item Self-Compassion Scale. Health was assessed with Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health measures, and stress was assessed with the 10-item Perceived Stress Scale. After examination of descriptive statistics and Pearson correlations, multiple regression analyses were done to determine whether mindfulness and self-compassion were associated with better sleep and resilience. RESULTS Respondents had an average age of 28 years; 73% were female. Professions included dieticians (11%), nurses (14%), physicians (38%), social workers (24%), and other (12%). Univariate analyses showed normative values for all variables. Sleep disturbances were significantly and most strongly correlated with perceived stress and poorer health, but also with less mindfulness and self-compassion. Resilience was strongly and significantly correlated with less stress and better mental health, more mindfulness, and more self-compassion. CONCLUSIONS In these young health professionals and trainees, sleep and resilience are correlated with both mindfulness and self-compassion. Prospective studies are needed to determine whether training to increase mindfulness and self-compassion can improve clinicians' sleep and resilience or whether decreasing sleep disturbances and building resilience improves mindfulness and compassion.
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Affiliation(s)
- Kathi J Kemper
- 1 Department of Pediatrics, College of Nursing: School of Health and Rehabilitation Sciences, Ohio State University College of Medicine , Columbus, OH.,2 Center for Integrative Health and Wellness, Ohio State University College of Medicine , Columbus, OH
| | - Xiaokui Mo
- 2 Center for Integrative Health and Wellness, Ohio State University College of Medicine , Columbus, OH.,3 Center for Biostatistics, Department of Biomedical Informatics, Ohio State University College of Medicine , Columbus, OH
| | - Rami Khayat
- 3 Center for Biostatistics, Department of Biomedical Informatics, Ohio State University College of Medicine , Columbus, OH.,4 The OSU Sleep Heart Program, Department of Medicine, and Davis Heart-Lung Research Institute, Ohio State University College of Medicine , Columbus, OH
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Sundberg K, Frydén H, Kihlström L, Nordquist J. The Swedish duty hour enigma. BMC MEDICAL EDUCATION 2014; 14 Suppl 1:S6. [PMID: 25559074 PMCID: PMC4304284 DOI: 10.1186/1472-6920-14-s1-s6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND The Swedish resident duty hour limit is regulated by Swedish and European legal frameworks. With a maximum average of 40 working hours per week, the Swedish duty hour regulation is one of the most restrictive in the world. At the same time, the effects of resident duty hour limits have been neither debated nor researched in the Swedish context. As a result, little is known about the Swedish conceptual framework for resident duty hours, their restriction, or their outcomes: we call this "the Swedish duty hour enigma." This situation poses a further question: How do Swedish residents themselves construct a conceptual framework for duty hour restrictions? METHODS A case study was conducted at Karolinska University Hospital, Stockholm--an urban, research-intensive hospital setting. Semi-structured interviews were carried out with 34 residents currently in training in 6 specialties. The empirical data analysis relied on theoretical propositions and was conducted thematically using a pattern-matching technique. The interview guide was based on four main topics: the perceived effect of duty hour restrictions on (1) patient care, (2) resident education, (3) resident well-being, and (4) research. RESULTS The residents did not perceive the volume of duty hours to be the main determinant of success or failure in the four contextual domains of patient care, resident education, resident well-being, and research. Instead, they emphasized resident well-being and a desire for flexibility. CONCLUSIONS According to Swedish residents' conceptual framework on duty hours, the amount of time spent on duty is not a proxy for the quality of resident training. Instead, flexibility, organization, and scheduling of duty hours are considered to be the factors that have the greatest influence on resident well-being, quality of learning, and opportunities to attain the competence needed for independent practice.
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Affiliation(s)
- Kristina Sundberg
- Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Frydén
- Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Lars Kihlström
- Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jonas Nordquist
- Department of Research and Education, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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Abstract
Universally, anesthesiologists are expected to be knowledgeable, astutely responding to clinical challenges while maintaining a prolonged vigilance for administration of safe anesthesia and critical care. A fatigued anesthesiologist is the consequence of cumulative acuity, manifesting as decreased motor and cognitive powers. This results in impaired judgement, late and inadequate responses to clinical changes, poor communication and inadequate record keeping. With rising expectations and increased medico-legal claims, anesthesiologists work round the clock to provide efficient and timely services, but are the "sleep provider" in a sleep debt them self? Is it the right time to promptly address these issues so that we prevent silent perpetuation of problems pertinent to anesthesiologist's health and the profession. The implications of sleep debt on patient safety are profound and preventive strategies are quintessential. Anesthesiology governing bodies must ensure requisite laws to prevent the adverse outcomes of sleep debt before patient care is compromised.
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Affiliation(s)
- Ashish Sinha
- Professor and Vice Chairman for Research, Director of Clinical Research, Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Avtar Singh
- Department of Anesthesiology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mulana, Ambala, India
| | - Anurag Tewari
- Department of Anesthesiology, Dayanand Medical College and Hospital, Ludhiana, India
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21
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Hussain MV, Shea SA. The nature of sleep examined via the science of sleep. Nat Sci Sleep 2011; 3:37-8. [PMID: 23616717 PMCID: PMC3630957 DOI: 10.2147/nss.s21283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mohammad Viqar Hussain
- Division of Sleep Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA, USA
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