Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature

The Impact of Sleep Deprivation on Orthopaedic Surgeons: A Systematic Review

Sleep deprivation is known to impact cognition, health and mood. Although the effect of sleep deprivation among medical and certain surgical specialties has been explored, there is a paucity of literature regarding sleep in orthopaedic surgeons. This systematic review attempts to provide a comprehensive overview of the current state of research on sleep in orthopaedic surgeons. Following the PRISMA guidelines for systematic reviews, we conducted a search of MEDLINE, Psychinfo and EMBASE to find all articles about sleep in orthopaedic surgeons. Inclusion criteria were non-review articles discussing sleep in orthopaedic surgery, English text, enrollment of attending or resident or fellow orthopaedic surgeons, reporting of sleep-related variables and publishing in a peer-reviewed journal. Out of 539 studies generated from our search, 10 were included in this review. The resulting study population included 232 residents, 10 fellows and 560 attendings. Average sleep was reported in nine articles; however, only two articles used objective measurements of sleep. Other reported outcomes varied widely, which included cognitive tests, reaction time, burnout/mood, self-reported sleepiness and arthroscopic skill. No articles reported on race, biochemical assays, call schedule, exercise, or utilised any intervention to improve sleep. Our systematic review concludes that not only is there a lack of research on sleep in orthopaedic surgeons, but that future research should include objective sleep measurements, including a greater breadth of outcome measures and potential interventions. Such studies will specifically target improvements in physician mental health and overall well-being, as well as promote durable patient safety.

Psychotic-like experiences and associated factors in resident physicians: A Canadian cross-sectional study

AIM

Medical residency training is associated with a range of sociodemographic, lifestyle and mental health factors that may confer higher risk for psychotic-like experiences (PLEs) in residents, yet little research has examined this question. Thus, we aimed to document the prevalence and associated factors of PLEs among resident physicians.

METHODS

Physicians enrolled in residency programmes in the Province of Québec, Canada (four universities) were recruited in Fall 2022 via their programme coordinators and social media. They completed an online questionnaire assessing PLEs in the past 3 months (the 15-item Community Assessment of Psychic Experiences), as well as sociodemographic characteristics, lifestyle and mental health. Analyses included survey weights and gamma regressions.

RESULTS

The sample included 502 residents (mean age, 27.6 years; 65.9% women). Only 1.3% (95% CI: 0.5%, 4.0%) of residents met the screening cut-off for psychotic disorder. Factors associated with higher scores for PLEs included racialised minority status (relative difference: +7.5%; 95% CI: +2.2%, +13.2%) and English versus French as preferred language (relative difference: +7.9% 95% CI: +3.1%, +12.9%), as well as each additional point on scales of depression (relative difference: +0.8%; 95% CI: +0.3%, +1.3%) and anxiety (relative difference: +1.3%; 95% CI: +0.8%, +1.7%). In secondary analyses, racialised minority status was associated with persecutory items, but not with other PLEs. Gender, residency programmes and lifestyle variables were not associated with PLEs.

CONCLUSIONS

This study found low reports of PLEs in a sample of resident physicians. Associations of PLEs with minoritised status may reflect experiences of discrimination.

Effects and implementation of an intervention to improve sleep, fatigue and recovery among healthcare workers with night shifts: A pre- and post-test study

BACKGROUND

Previous intervention studies among night workers mainly focused on single interventions and found inconclusive evidence for effectiveness. A comprehensive intervention approach that includes individual and environmental components has been argued as important. Gaining insight into contributing factors for the implementation of interventions for night workers and effectiveness is important to distinguish between theory and programme failure.

OBJECTIVES

To evaluate the effects and implementation of the PerfectFit@Night intervention to improve sleep, fatigue and recovery of night workers in healthcare, using the RE-AIM framework, which assesses reach, effectiveness, adoption, implementation and maintenance of interventions.

DESIGN

A prospective pre-post study design, with two measurements before and three and six months after the intervention.

SETTING

Twelve different departments of a university hospital in the Netherlands.

PARTICIPANTS

Healthcare workers working night shifts (n = 210).

METHODS

PerfectFit@Night consisted of environmental (provision of a powernap bed and healthy food, and workshop healthy rostering) and individual elements (e-learning and sleep coaching) and was implemented for three months in a phased manner. Questionnaires, logbooks and interview data were used. Effects of the intervention on sleep, fatigue and recovery were evaluated with mixed-effects models, and implementation factors of reach, adoption, implementation and maintenance were evaluated.

RESULTS

Night shift-related insomnia (-11 %-points, 95 % CI: -19 %, -4 % at three months), need for recovery (β: -2.45, 95 % CI: -4.86, -0.03 at six months) and fatigue (OR: 0.46, 95 % CI: 0.25, 0.86 at six months) decreased significantly after the intervention. No changes were found for subjective sleep quality and sleep duration. Barriers and facilitators for implementation were identified for each intervention element at individual (e.g., dietary preferences), organisational (e.g., responsibilities at work) and workplace levels (e.g., location of power nap bed), and for the intervention itself (e.g., useful information in e-learning). Although satisfaction was high and continuation was preferred, embedding of the intervention in the daily routine was limited. Facilitators for future implementation include a positive attitude towards the intervention, clear guidelines regarding intervention elements, appointment of night workers as ambassadors, and suitable conditions in terms of work demands and for the intervention elements.

CONCLUSIONS

The multi-faceted PerfectFit@Night intervention reduced insomnia, fatigue and need for recovery in night workers in healthcare. The most important facilitators to improve the implementation of PerfectFit@Night exist at the organisational level (e.g., positive attitude within the culture and suitable work demands). Combining effect and implementation evaluation is crucial to identify barriers and facilitators that hamper or enhance intervention effects.

TRIAL REGISTRATION

The study was registered in the Netherlands Trial Register on 17 January 2021 (trial number NL9224).

The show must go on: fostering residents' sustainable employability in medical education - a qualitative exploration of the Resident Leadership Program

BACKGROUND

Residents' sustainable employability (SE) is threatened by high burn-out rates, sleep deficits, and career dissatisfaction. Medical education may contribute to residents' SE by providing them with opportunities to influence their employment contexts and to develop conscious self-regulation. This paper explores how residents, participating in the Resident Leadership Program (RLP), are enabled to work on, and learn about, their SE.

METHODS

The RLP took place between February and July 2021 and consisted of lectures on, and practice in, quality improvement (QI) work. SE was the theme that governed residents' QI projects. In this study, residents were interviewed individually before the program (n = 8), were observed while participating in the program (45 h) and were interviewed in three groups after the program (n = 8). The data were analysed in accordance with the 'flexible-coding' method.

RESULTS

The findings are presented in four 'acts' mirroring an unfolding play as a metaphor to show how residents' understanding of context, self-regulations, and quality improvement work-relevant to their SE-changed in the RLP. The acts include 'setting the stage', describing how residents experienced the context of medicine; 'acting the part', depicting how residents managed their employment contexts using self-regulation; 'changing the décor', elaborating on residents' QI projects; and 'growing one's role', presenting residents' take-aways from participating in the RLP that may benefit their SE. These take-aways encompassed awareness of the importance of SE, a reconsideration and/or adjustment of self-regulation, feeling better equipped to navigate employment contexts, and increased joy in work because of contributing to peers' SE through QI work.

CONCLUSIONS

Our results indicate that medical education is a fruitful environment for providing important lessons and tools for residents to work on and learn about their SE, likely benefiting their SE throughout their careers.

Effects of Sleep Quality, Acute Sleep Deprivation, and Napping on Facial Emotion Recognition Accuracy and Speed

Objective

To investigate the effects of sleep quality, sleep deprivation, and napping on facial emotion recognition (FER) accuracy and speed.

Methods

This research included a cross-sectional study (102 qualified participants) and a randomized controlled study (26 in the napping group and 24 in the control group). The stimuli for the FER task were obtained from the Chinese Facial Affective Picture System (CFAPS). Four facial expressions (fearful, disgusted, sad, and angry) were used. The Pittsburgh Sleep Quality Index (PSQI), Self-Rating Anxiety Scale, and Self-Rating Depression Scale were used to measure participants' sleep quality and psychological conditions. In Study 1, FER ability was compared between good and poor sleepers. In Study 2, all participants were sleep-deprived for one night, and completed the FER task before and after sleep deprivation. After different interventions (ie, napping for one hour, or walking around for ten minutes), the participants completed the third FER task.

Results

Study 1: Poor sleepers were able to recognize sad expressions more accurately compared with good sleepers. Study 2: 30-h sleep deprivation had no significant effect on the accuracy (ACC). Napping after sleep deprivation improved the FER ACC of upper-face expressions and marginally significantly improved the FER ACC of disgusted expressions.

Conclusion

Better sleep quality was linked to lower FER accuracy, particularly in recognizing sad expressions, while no significant differences in recognition speed were observed. Additionally, 30 hours of sleep deprivation did not affect FER accuracy, but napping after sleep deprivation improved accuracy for upper-face and marginally for disgusted expressions.

Incorporating biofeedback into the Mindfulness in Motion Intervention for health care professionals: Impact on sleep and stress

CONTEXT

Health care providers (HCP) experience high stress and burnout rates. Mindfulness Based Interventions (MBI) with biofeedback may help improve resiliency but require further research.

DESIGN AND STUDY PARTICIPANTS

Aims were to evaluate changes in sleep patterns, nocturnal physiology, stress, mood disturbances, and perceived experience with biofeedback during the Mindfulness in Motion (MIM) intervention. Data from 66 HCP were included after removing those below 75 % compliance with wearable sensors and wellness surveys. Participants were enrolled in MIM, including eight weekly one-hour virtually delivered synchronous group meetings and ∼10 min of mindfulness home practice at least 3 times per week using a mobile application. Participants wore wearable sensors to monitor sleep and nocturnal physiology and completed short daily stress and mood disturbances.

RESULTS

According to mixed effect models, no sleep nor physiological metrics changed across MIM (p > 0.05). More time was spent in bed after MIM sessions (8.33±1.03 h) compared to night before (8.05±0.93 h; p = 0.040). Heart rate variability was lower nights after MIM (33.00±15.59 ms) compared to nights before (34.50±17.04 ms; p = 0.004) but was not clinically meaningful (effect= 0.033). Significant reductions were noted in perceived stress at weeks 3 through 8 compared to Baseline and lower Total Mood Disturbance at weeks 3, 5, 6, and 8 compared to Baseline (p < 0.001).

CONCLUSIONS

Participating in the MIM with mobile applications and wearable sensors reduced perceived stress and mood disturbances but did not induce physiological changes. Additional research is warranted to further evaluate objective physiological outcomes while controlling for confounding variables (e.g., alcohol, medications).

Subclinical hypomanic experiences in young adults after sleep deprivation are independent of depressive disorders, chronotype or 5-HTTLPR polymorphism

INTRODUCTION

The acute antidepressant effect of sleep deprivation (SD) in patients with depressive disorders has been studied for more than 60 years. However, hypomanic mood swings after partial or total SD have also been described in people without diagnosed mental disorders. Studying this phenomenon in the general population may yield insights about the mechanisms of therapeutic SD, mania and bipolar disorders.

METHODS

A cross-sectional sample of young adults was recruited and classified into those who described having regularly occurring subclinical hypomanic experiences (ROHE) after SD and those who did not. History of psychiatric and physical illness, with screening for depression and mania, as well as alcohol or drug consumption, family history of depressive disorders or suicide, 5-HTTLPR polymorphism, and MEQ-SA chronotype were collected.

RESULTS

A total of 251 participants were included; 39.0% indicated regularly having subclinical hypomanic experiences after SD. These experiences were not associated with depressive or mania screening, history of psychiatric illness, family history, 5-HTTLPR polymorphism, or MEQ-SA chronotype.

CONCLUSIONS

ROHE after non-therapeutic SD seem to be a relatively common phenomenon in young adults, independent of depressive mood state. Our results suggest that therapeutic SD may depend on a physiological phenomenon of subclinical affective disturbance after SD that affects a part of the general population, independent of psychiatric diagnosis. Further studies could elucidate associated factors and contribute to our understanding of (hypo-)manic mood states.

The prevalence of sleep deprivation and its impact among medical officers in a tertiary hospital, a cross-sectional study from Malaysia

Sleep deprivation (SD), defined as an inability to get a minimum of 7 hours of regular sleep at night is a serious health problem that impacts the performance of medical professionals. This study aims to determine the impact of sleep deprivation on perceived performance among medical officers (MOs). A cross-sectional study design involved 231 MOs from six disciplines in Hospital Tuanku Ja'afar, a tertiary center in the south of Malaysia. A self-administered questionnaire was introduced in the English language. The questionnaire involved the sociodemographic characteristics; job-related factors, and the Sleep Deprivation Impact Scale (SDIS). The SDIS is a 12-question scale, rated on a 5-point Likert scale from strongly disagree to strongly agree. A higher SDIS score reflected a higher impact of sleep deprivation. A total of 206 MOs returned the completed questionnaire yielding a response rate of 89.17%. The mean age of respondents was 31.68 (±3.49) years. Most of the respondents were female, of Malay ethnicity, and married. More than three-quarters (78.64%) reported sleep deprivation. Being less effective in communication and formulating diagnosis (3 (1.01) vs 2.5 (1.15),p = 0.005); taking longer time to do things (3.44 (1.07) vs 2.8 (1.34),p = 0.001); and feeling unsafe while driving (3.56 (1.25) vs 2.93 (1.55),p = 0.006) manifested significantly higher mean among sleep-deprived respondents. In conclusion, sleep deprivation is a prevalent problem; that adversely affects crucial functioning domains that may endanger patients and healthcare providers alike. Radical countermeasures are required to ensure satisfactory sleep duration and address areas jeopardizing MO safety.

Assessment of the importance of sleep quality and the effects of deprivation on Sudanese healthcare professionals amidst conflict in Sudan

Background

Quality sleep is vital for well-being, especially for healthcare workers facing high risks of fatigue and burnout. Sleep deprivation impairs cognitive and motor functions, contributing to medical errors. Addressing sleep disorders among healthcare professionals is crucial for enhancing patient care. Tailored interventions are needed to support their well-being and improve healthcare outcomes.

Objective

To evaluate the effect of Sleep Quality and its Deprivation on Sudanese Healthcare Professionals amidst conflict in Sudan.

Methods

A cross-sectional online survey of Sudanese doctors was conducted using convenience sampling. The questionnaire covered sleep quality, daytime sleepiness, and psychological well-being. Pilot testing ensured questionnaire clarity. Data collection utilized Google Forms distributed through social media and professional networks. A minimum sample size of 384 was calculated. Statistical analysis included descriptive statistics and various tests for significance. Data were securely stored and analyzed using SPSS and R software.

Results

Among 649 participants, 404 (62.2%) were women, with a mean age of 30.34 years. Most were single (434, 66.9%). General practitioners constituted the largest professional group (267, 41.1%), followed by registrars/residents (142, 21.9%). Participants took an average of 43.70 minutes to fall asleep and slept an average of 5.90 hours per night. According to the PSQI, 300 (46.2%) reported mild sleep disturbance, 287 (44.2%) moderate, 42 (6.5%) severe, and only 20 (3.1%) normal sleep. The ESS revealed 285 (43.9%) with lower normal daytime sleepiness, 188 (29.0%) with higher normal, and various levels of excessive daytime sleepiness. Stress levels varied, with 398 (61.3%) reporting normal stress, while anxiety ranged from 248 (38.2%) normal to 148 (22.8%) extremely severe.

Conclusion

This study emphasizes the importance of addressing sleep quality, mental health, and performance challenges among Sudanese healthcare professionals. It highlights the need for hospitals to implement measures enabling more time off, adequate sleep, and reduced on-call service days. Healthcare workers must recognize the significance of these factors for their well-being and patient care quality. The research outcomes can raise awareness about the necessity of regulating healthcare practitioners' working hours and ensuring adequate sleep.

Pathologist workload, burnout, and wellness: connecting the dots

No standard tool to measure pathologist workload currently exists. An accurate measure of workload is needed for determining the number of pathologists to be hired, distributing the workload fairly among pathologists, and assessing the overall cost of pathology consults. Initially, simple tools such as counting cases or slides were used to give an estimate of the workload. More recently, multiple workload models, including relative value units (RVUs), the Royal College of Pathologists (RCP) point system, Level 4 Equivalent (L4E), Work2Quality (W2Q), and the University of Washington, Seattle (UW) slide count method, have been developed. There is no "ideal" model that is universally accepted. The main differences among the models come from the weights assigned to different specimen types, differential calculations for organs, and the capture of additional tasks needed for safe and timely patient care. Academic centers tend to see more complex cases that require extensive sampling and additional testing, while community-based and private laboratories deal more with biopsies. Additionally, some systems do not account for teaching, participation in multidisciplinary rounds, quality assurance activities, and medical oversight. A successful workload model needs to be continually updated to reflect the current state of practice.Awareness about physician burnout has gained attention in recent years and has been added to the World Health Organization's International Classification of Diseases (World Health Organization, WHO) as an occupational phenomenon. However, the extent to which this affects pathologists is not well understood. According to the WHO, burnout syndrome is diagnosed by the presence of three components: emotional exhaustion, depersonalization from one's work (cynicism related to one's job), and a low sense of personal achievement or accomplishment. Three drivers of burnout are the demand for productivity, lack of recognition, and electronic health records. Prominent consequences of physician burnout are economic and personal costs to the public and to the providers.Wellness is physical and mental well-being that allows individuals to manage stress effectively and to thrive in both their professional and personal lives. To achieve wellness, it is necessary to understand the root causes of burnout, including over-work and working under stressful conditions. Wellness is more than the absence of stress or burnout, and the responsibility of wellness should be shared by pathologists themselves, their healthcare organization, and governing bodies. Each pathologist needs to take their own path to achieve wellness.

Impact of on-call shifts on working memory and the role of burnout, sleep, and mental well-being in trainee physicians

BACKGROUND

Optimal cognitive functions, including working memory (WM), are crucial to enable trainee physicians to perform and excel in their clinical practice. Several risk factors, including on-call shifts, poor mental health, burnout, and sleep problems, can impair clinical practice in trainee physicians, potentially through cognitive impairment; however, these associations have not been fully explored.

OBJECTIVE

This study investigated the effect of on-call shifts on WM among trainee physicians and its association with burnout, depression, anxiety, affect, and sleep.

MATERIALS AND METHODS

This cross-sectional study involved 83 trainee physicians (45% male). We measured demographic and training-related factors including on-call shifts and working hours. We also assessed depressive symptoms (PHQ-9), both state and trait anxiety (STAI total score), burnout (OLBI total score), positive and negative affect scores (PANAS), and sleep disturbances (PSQI total score). WM was evaluated using spatial working memory (SWM) strategy scores that reflected performance and total error counts.

RESULTS

Trainee physicians with more on-calls per month had significantly worse depressive symptoms, burnout scores, and sleep, as well as more negative affect. While controlling for covariates, being on-call more times per month was significantly associated with worse WM. Worse depressive symptoms and burnout scores were also significantly associated with impaired WM.

CONCLUSION

Working more on-call shifts is associated with compromised WM. Trainee physicians who experienced more depressive symptoms and burnout had worse WM.

The Effects of Daytime Variation on Short-term Outcomes of Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

OBJECTIVE

To evaluate the effects of time of surgery on the short-term outcomes of patients undergoing off-pump coronary artery bypass grafting (OPCABG).

DESIGN

A retrospective cohort study.

SETTING

A single large-volume cardiovascular center.

PATIENTS

Patients undergoing elective OPCABG between September 2019 and July 2022.

INTERVENTIONS

Patients were divided into the following 2 groups according to the start time of surgery: morning (AM group, before 11 AM) and afternoon (PM group, after 11 AM). Propensity-score matching (PSM) with a 1:1 matching ratio was used to create comparable cohorts.

MEASUREMENTS AND MAIN RESULTS

The primary endpoint was the composite incidence of mortality and morbidities during hospitalization. Secondary endpoints included postoperative bleeding and transfusion, mechanical ventilation duration (MVD), and lengths of stay (LOS) in the intensive care unit (ICU) and hospital. From a consecutive series of 1,039 patients, PSM yielded 317 well-matched pairs. There was no difference in the composite incidence of in-hospital mortality and morbidities between the AM and PM groups (16.4% v 17.4%, p = 0.832). However, patients in the PM group were associated with less postoperative blood loss over the first 24 hours (470 v 540 mL, p = 0.002), decreased MVD (14 v 16 hours, p < 0.001), and shorter LOS in ICU (46 v 68 hours, p = 0.002) compared to patients in AM group.

CONCLUSIONS

The current study suggested a lack of relevance regarding the time of surgery with in-hospital mortality and morbidities in patients undergoing OPCABG.

Supervisory Alliance in Medical Training: Associations with Educational Engagement and Satisfaction

Objectives

While medical education requires frequent interactions with attending physicians and supervisors, little research has explored the role of supervisory alliance in the learning process. In other learning environments, supervisory alliance, or the bond between a supervisor and trainee, is considered a key ingredient of effective supervision. Medical educators or attending physicians who aim to enhance learning and engagement in medical education may benefit from understanding specific factors that increase or decrease engagement and how those might intersect within a context that requires learning through supervision. This cross-sectional study examined associations between supervisory alliance and (a) program satisfaction, (b) educational engagement, (c) and career purpose.

Methods

Participants were medical trainees from the rural Northeast (n = 108, response rate = 81%) who completed an electronic and anonymous survey.

Results

Multiple linear regression was used to examine whether total supervisory alliance independently predicted behavioral and emotional engagement in learning while controlling for hours slept, hours worked, and burnout. Supervisory alliance predicted trainees' career purpose, program satisfaction, and emotional engagement in learning.

Conclusions

Findings from this study lay groundwork for consideration of the role of supervisory alliance in medical learning processes. Future research might explore whether targeted mentorship programs or faculty enhancement training that focuses on the supervisory relationship might positively impact learning outcomes.

Medical residency in Portugal: a cross-sectional study on the working conditions

Objectives

The current European crisis in human resources in health has opened the debate about working conditions and fair wages. This is the case with Resident doctors, which have faced challenges throughout Europe. In Portugal, they account for about a third of the doctors in the Portuguese National Health Service. No studies to date objectively demonstrate the working conditions and responsibilities undertaken. This study aims to quantify the residents' workload and working conditions.

Methods

Observational, retrospective cross-sectional study which involved a survey on the clinical and training activity of Portuguese residents, actively working in September 2020. The survey was distributed through e-mail to residents' representatives and directly to those affiliated with the Independent Union of Portuguese Doctors. The descriptive analysis assessed current workload, and logistic regression models analyzed associations with geographical location and residency seniority.

Results

There were a total of 2,012 participants (19.6% of invited residents). Of the residents giving consultations, 85.3% do so with full autonomy. In the emergency department, 32.1% of the residents work 24 h shifts and 25.1% work shifts without a specialist doctor present. Regarding medical training, 40.8% invest over EUR 1,500 annually. Autonomy in consultations was associated with being a Family Medicine resident (OR 4.219, p < 0.001), being a senior resident (OR 5.143, p < 0.001), and working in the Center (OR 1.685, p = 0.009) and South regions (OR 2.172, p < 0.001). Seniority was also associated with investing over EUR 1,500 in training annually (OR 1.235, p = 0.021).

Conclusion

Residents work far more than the contracted 40 h week, often on an unpaid basis. They present a high degree of autonomy in their practice, make a very significant personal and financial investment in medical training, with almost no time dedicated to studying during working hours. There is a need to provide better working conditions for health professionals, including residents, for the sake of the sustainability of health systems across Europe.

Safety and efficacy of delaying lung transplant surgery to a morning start

Objective

We aimed to evaluate the safety and efficacy of delaying lung transplantation until morning for donors with cross-clamp times occurring after 1:30 am.

Methods

All consented adult lung transplant recipients between March 2018 and May 2022 with donor cross-clamp times between 1:30 am and 5 am were enrolled prospectively in this study. Skin incision for enrolled recipients was delayed until 6:30 am (Night group). The control group was identified using a 1:2 logistic propensity score method and included recipients of donors with cross-clamp times occurring at any other time of day (Day group). Short- and medium-term outcomes were examined between groups. The primary endpoint was early mortality (30-day and in-hospital).

Results

Thirty-four patients were enrolled in the Night group, along with 68 well-matched patients in the Day group. As expected, donors in the Night group had longer cold ischemia times compared to the Day group (344 minutes vs 285 minutes; P < .01). Thirty-day mortality (3% vs 3%; P = .99), grade 3 primary graft dysfunction at 72 hours (8% vs 4%; P = .40), postoperative complications (26% vs 38%; P = .28), and hospital length of stay (15 days vs 14 days; P = .91) were similar in the 2 groups. No significant differences were noted between groups in 3-year survival (70% vs 77%; P = .30) or freedom from chronic lung allograft dysfunction (91% vs 95%; P = .75) at 3 years post-transplantation. The median follow-up was 752.5 days (interquartile range, 487-1048 days).

Conclusions

Lung transplant recipients with donor cross-clamp times scheduled after 1:30 am may safely have their operations delayed until 6:30 am with acceptable outcomes. Adoption of such a policy in clinically appropriate settings may lead to an alternative workflow and improved team well-being.

Impact of shift work on dementia: a systematic review and dose-response meta-analysis

OBJECTIVES

Although shift work has been reported as having a link to dementia, evidence remains inconsistent, and a comprehensive dose-response meta-analysis of the association is still lacking. We therefore conducted this meta-analysis to explore the association between shift work and the risk of dementia.

STUDY DESIGN

Systematic review and dose-response meta-analysis.

METHODS

PubMed, Embase, and Web of Science databases were systematically searched. Fixed or random-effects models were used to estimate the summary relative risks (RRs) and 95% confidence intervals (95% CIs). Generalized least squares regression was used to estimate dose-response associations, and restricted cubic splines were used to examine possible linear or non-linear associations.

RESULTS

Five articles (10 studies) with 72,999 participants and 23,067 cases were eventually included in the meta-analysis. The summary RRs and 95% CIs of dementia risk with shift work and night shift work versus daytime work were 1.13 (95% CI: 1.05-1.21, I2 = 46.70%) and 1.13 (95% CI: 1.03-1.24, I2 = 9.20%), respectively. The risk of dementia increased by 1% (RR = 1.01, 95% CI: 1.01-1.02, I2 = 41.3%) with each 1-year increase in the duration of shift work. We found a non-linear dose-response association between the duration of shift work and the risk of dementia (Pnon-linearity = 0.006). Though the shape of the curve was steeper with the duration of shift work <7 years, the increase was more gradual after 7 years.

CONCLUSION

Our findings suggest that shift work may be a risk factor for future dementia and that controlling the length of shift work is a feasible measure that may contribute to prevent dementia.

Long-term ear-EEG monitoring of sleep - A case study during shift work

The interest in sleep as a potential clinical biomarker is growing, but the standard method of sleep assessment, polysomnography, is expensive, time consuming, and requires a lot of expert assistance for both set-up and interpretation. To make sleep analysis more available both in research and in the clinic, there is a need for a reliable wearable device for sleep staging. In this case study, we test ear-electroencephalography. A wearable, where electrodes are placed in the outer ear, as a platform for longitudinal at-home recording of sleep. We explore the usability of the ear-electroencephalography in a shift work case with alternating sleep conditions. We find the ear-electroencephalography platform to be reliable both in terms of showing substantial agreement to polysomnography after long-time use (with an overall agreement, using Cohen's kappa, of 0.72) and by being unobtrusive enough to wear during night shift conditions. We find that fractions of non-rapid eye movement sleep and transition probability between sleep stages show great potential as sleep metrics when exploring quantitative differences in sleep architecture between shifting sleep conditions. This study shows that the ear-electroencephalography platform holds great potential as a reliable wearable for quantifying sleep "in the wild", pushing this technology further towards clinical adaptation.

Doctors' alertness, contentedness and calmness before and after night shifts: a latent profile analysis

BACKGROUND

While night shifts are crucial for patient care, they threaten doctors' well-being and performance. Knowledge of how the impact of night shifts differs for doctors is needed to attenuate the adverse effects of night shifts. This study aimed to obtain more precise insight into doctors' feelings surrounding night shift by: identifying profiles based on doctors' alertness, contentedness and calmness scores before and after night shifts (research question (RQ) 1); assessing how doctors' pre- and post-shift profiles change (RQ2); and determining associations of doctors' demographics and shift circumstances with alertness, contentedness and calmness change (RQ3).

METHODS

Latent Profile Analysis using doctors' pre- and post-shift self-rated alertness, contentedness and calmness scores was employed to identify pre- and post-shift profiles (RQ1). A cross-tabulation revealed pre- and post-shift profile changes (RQ2). Multiple regressions determined associations of demographics (i.e. age, sex, specialty) and night shift circumstances (i.e. hours worked pre-call, hours awake pre-call, shift duration, number of consecutive shifts, total hours of sleep) with alertness, contentedness and calmness change (RQ3).

RESULTS

In total, 211 doctors participated with a mean age of 39.8 ± 10 years; 47.4% was male. The participants included consultants (46.4%) and trainees (53.6%) of the specialties surgery (64.5%) and obstetrics/gynaecology (35.5%). Three pre-shift (Indifferent, Ready, Engaged) and four post-shift profiles (Lethargic, Tired but satisfied, Excited, Mindful) were found. Most doctors changed from Ready to Tired but satisfied, with alertness reducing most. Age, specialty, sleep, shift duration and the number of consecutive shifts associated with alertness, contentedness and calmness changes.

CONCLUSIONS

The results provided nuanced insight into doctors' feelings before and after night shifts. Future research may assess whether specific subgroups benefit from tailored interventions.

Resident Sleep During Traditional Home Call Compared to Night Float

Purpose  This article aims to compare resident sleep while on night float with a traditional home call. Methods  We conducted a crossover observational study assessing sleep patterns of seven postgraduate year-2 ophthalmology residents at the University of Washington from 2019 to 2021 using the Fitbit Alta HR device. Overnight call was scheduled from 5 p.m. to 8 a.m. on weekdays, and 8 a.m. to 8 a.m. on weekends. The residency program implemented a partial night float rotation, during which two to three nights of consecutive call were assigned to a resident without other clinical duties. Sleep was recorded using the Fitbit Alta HR for residents while on a 5-week partial night float rotation, on 10-week home call rotations, with postcall relief, and for stretches of seven or more days without call responsibilities. Mixed model regression analysis was used to compare average sleep on home call, night float, and periods without call. Results  Sleep data were recorded for a total of 1,015 nights, including 503 nights on home call rotation and 230 nights on night float rotation. Residents slept more during periods away from call compared to either night float or home call rotations ( p  < 0.001). Residents experienced increased average overall sleep during 10-week rotations on night float compared to home call ( p  = 0.008). While there was no difference in overnight sleep on call between night float and home call ( p  = 0.701), residents experienced more sleep overall while on call on night float compared to home call due to more sleep being recorded during postcall naps ( p  = 0.016). Conclusion  Implementing a night float system can increase resident sleep by allowing for more sleep recovery during time away from clinical duties.

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

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

Sleep in Residents: A Comparison between Anesthesiology and Occupational Medicine Interns

Sleep deprivation is a significant risk to the health and judgment of physicians. We wanted to investigate whether anesthesiology residents (ARs) who work only one night shift per week have different physical and mental health from occupational medicine residents (OMRs) who do not work at night. A total of 21 ARs and 16 OMRs attending a university general hospital were asked to wear an actigraph to record sleep duration, heart rate and step count and to complete a questionnaire for the assessment of sleep quality, sleepiness, fatigue, occupational stress, anxiety, depression and happiness. ARs had shorter sleep duration than OMRs; on average, they slept 1 h and 20 min less (p < 0.001). ARs also had greater daytime sleepiness, a higher heart rate and lower happiness than OMRs. These results should be interpreted with caution given the cross-sectional nature of the study and the small sample size, but they are an incentive to promote sleep hygiene among residents.

Poor quality sleep is associated with greater carotid intima media thickness among otherwise healthy resident doctors

Background

Sleep is important for maintaining the metabolic processes in the body, and hence, disruption in sleep leads to metabolic derangement and accelerated atherosclerosis. The effect of sleep duration on subclinical atherosclerosis has been examined in several studies; however, data regarding sleep quality is lacking. The study aimed to assess the association between sleep quality and carotid intima-media thickness among healthy young doctors.

Materials and Methods

This was an observational cross-sectional study among 110 healthy young resident doctors. Anthropometric data were recorded and morning fasting venous blood samples were collected to assess fasting blood sugar, lipid profile and glycosylated haemoglobin (HbA1c). Pittsburgh Sleep Quality Index and Berlin questionnaire assessed subjective sleep quality and risk for obstructive sleep apnea, respectively. Carotid ultrasonography was done to detect the intima-media thickness.

Results

Average age of the participants was 26.45 (±1.43) years, and 51.8% were male. Self-reported poor sleep quality was found in 54.5%. Carotid intima-media thickness (CIMT) was increased among 44.5% of participants. In the multivariate analysis, only poor sleep quality appeared to be associated with higher CIMT (P < 0.001, OR = 7.4; 95% CI = 2.70-20.32). When different components of sleep quality was analyzed through multivariate logistic regression, subjective sleep onset latency (>30 min), sleep efficiency (<85%) and sleep disturbance was found to be associated with the increased CIMT.

Conclusion

Poor sleep quality, especially prolonged sleep onset latency, poor sleep efficiency, and sleep disturbance are associated with increased carotid intima-media thickness among healthy young adults.

Training satisfaction and well-being among veterinary anaesthesia residents: time for action

OBJECTIVE

To explore the satisfaction and well-being experienced by anaesthesia residents during their training, and to investigate factors that may have influenced their experiences.

STUDY DESIGN

Cross-sectional online anonymous voluntary survey.

SAMPLE POPULATION

A total of 150 (of approximately 600 canvassed) former veterinary anaesthesia residents.

METHODS

Participants were invited to complete an internet-based survey regarding the satisfaction and well-being experienced during their residency. Multiple choice, categorical, dichotomous, Likert-type rating scales and slider questions were used to investigate five domains (demographic, working conditions, educational environment, training satisfaction, well-being). Sampling adequacy, questionnaire reliability and participant responses were investigated by Kaiser-Meyer-Olkin (KMO) indices, Cronbach's α and standard statistical techniques, respectively (p < 0.05).

RESULTS

The questionnaire demonstrated good sampling adequacy (median KMO index 0.74; range 0.51-0.89) and high item 'reliability' (α = 0.82-0.94). Of the 150 responders, (25% participation rate) 62% were satisfied, 14% were neutral and 24% were dissatisfied with their residency training; 60.6% would do the residency again, 39.3% would not or were unsure. Sex and age did not correlate with training satisfaction (p > 0.05). Salary/stipend was considered inadequate by 70% of responders; 66% received no on-call supplement. Greater supervisory input, a good working environment and extra income when on-call were positively correlated with training satisfaction (p < 0.01). The majority (94.6%) of trainees suffered from at least one medical condition during their residency, with fatigue, sleep disturbance or anxiety reported by > 62%.

CONCLUSIONS

Although a quarter of responders were dissatisfied with their residency, several modifiable factors were identified, particularly with respect to supervisors' input, working environment and pay, which could inform improvements for future residency programmes. Most trainees experienced negative health impacts; however, this parallels the general situation in both the medical and veterinary professions, which requires greater attention from the supervisors, trainees and colleges.

The social and mental impact on healthcare workers: A comparative and cross-sectional study during two waves of the COVID-19 pandemic in Taiwan

The coronavirus disease 2019 (COVID-19) pandemic has caused a heavily burden on healthcare workers (HCWs) worldwide. The aim of this study was to compare differences in psychological and social impact between two waves of the pandemic among first- and second-line HCWs in Taiwan. The current study derived data from two cross-sectional surveys conducted in 2020 and 2021. Levels of depression, sleep disturbance, psychological distress, social impact, and demographic variables were collected through self-reported questionnaires. The independent t test was used to compare differences in scores between the first and second wave of the pandemic. Differences between first- and second-line HCWs were also analyzed. A total of 711 HCWs in the first wave and 560 HCWs in the second wave were recruited. For the first- and second-line HCWs, the social impact during the second wave was higher than during the first wave, and they expressed a higher intention to maintain social distancing and were more aware of the pandemic overseas in the second wave. The first-line HCWs had a trend of worse sleep quality during the second wave. In addition, sleep quality was worse in the first-line HCWs than in the second-line HCWs during both waves. The second-line HCWs expressed a greater desire to seek COVID-19-related information than the first-line HCWs during the first wave, and more intended to maintain social distancing during the second wave. Our results show the importance of evaluating the social and mental health burden of HCWs, and especially first-line workers.

Time-restricted feeding is an intervention against excessive dark-phase sleepiness induced by obesogenic diet

High-fat diet (HFD)-induced obesity is a growing epidemic and major health concern. While excessive daytime sleepiness (EDS) is a common symptom of HFD-induced obesity, preliminary findings suggest that reduced wakefulness could be improved with time-restricted feeding (TRF). At present, however, the underlying neural mechanisms remain largely unknown. The paraventricular thalamic nucleus (PVT) plays a role in maintaining wakefulness. We found that chronic HFD impaired the activity of PVT neurons. Notably, inactivation of the PVT was sufficient to reduce and fragment wakefulness during the active phase in lean mice, similar to the sleep-wake alterations observed in obese mice with HFD-induced obesity. On the other hand, enhancing PVT neuronal activity consolidated wakefulness in mice with HFD-induced obesity. We observed that the fragmented wakefulness could be eliminated and reversed by TRF. Furthermore, TRF prevented the HFD-induced disruptions on synaptic transmission in the PVT, in a feeding duration-dependent manner. Collectively, our findings demonstrate that ad libitum access to a HFD results in inactivation of the PVT, which is critical to impaired nocturnal wakefulness and increased sleep, while TRF can prevent and reverse diet-induced PVT dysfunction and excessive sleepiness. We establish a link between TRF and neural activity, through which TRF can potentially serve as a lifestyle intervention against diet/obesity-related EDS.

Impact of the resident duty hours on in-training examination score: A nationwide study in Japan

PURPOSE

The relationship between duty hours (DH) and the performance of postgraduate residents is needed to establish appropriate DH limits. This study explores their relationship using the General Medicine In-training Examination (GM-ITE).

MATERIALS AND METHODS

In this cross-sectional study, GM-ITE examinees of 2019 had participated. We analyzed data from the examination and questionnaire, including DH per week (eight categories). We examined the association between DH and GM-ITE score, using random-intercept linear models with and without adjustments.

RESULTS

Five thousand five hundred and ninety-three participants (50.7% PGY-1, 31.6% female, 10.0% university hospitals) were included. Mean GM-ITE scores were lower among residents in Category 2 (45-50 h; mean score difference, -1.05; p < 0.001) and Category 4 (55-60 h; -0.63; p = 0.008) compared with residents in Category 5 (60-65 h; Reference). PGY-2 residents in Categories 2-4 had lower GM-ITE scores compared to those in Category 5. University residents in Category 1 and Category 5 showed a large mean difference (-3.43; p = 0.01).

CONCLUSIONS

DH <60-65 h per week was independently associated with lower resident performance, but more DH did not improve performance. DH of 60-65 h per week may be the optimal balance for a resident's education and well-being.

Integrated Functional Neuroimaging, Monoamine Neurotransmitters, and Behavioral Score on Depressive Tendency in Intensive Care Unit Medical Staffs Induced by Sleep Deprivation After Night Shift Work

BACKGROUND

Intensive care unit (ICU) medical staffs undergoing sleep deprivation with perennial night shift work were usually at high risk of depression. However, shift work on depression-related resting-state functional magnetic resonance imaging was still not fully understood. The objective of this study was to explore the effects of sleep deprivation in ICU medical staffs after one night of shift work on brain functional connectivity density (FCD) and Hamilton Depression Rating Scale (HAMD) scores. Also, serum neurotransmitter concentrations of serotonin (5-HT) and norepinephrine (NE) were obtained simultaneously.

METHODS

A total of 21 ICU medical staffs without psychiatric history were recruited. All participants received HAMD score assessment and resting-state functional magnetic resonance imaging scans at two time points: one at rested wakefulness and the other after sleep deprivation (SD) accompanied with one night of shift work. Global FCD, local FCD, and long-range FCD (lrFCD) were used to evaluate spontaneous brain activity in the whole brain. In the meantime, peripheral blood samples were collected for measurement of serum 5-HT and NE levels. All these data were acquired between 7:00 and 8:00 am to limit the influence of biological rhythms. The correlations between the FCD values and HAMD scores and serum levels of neurotransmitters were analyzed concurrently.

RESULTS

Functional connectivity density mapping manifested that global FCD was decreased in the right medial frontal gyrus and the anterior cingulate gyrus, whereas lrFCD was decreased mainly in the right medial frontal gyrus. Most of these brain areas with FCD differences were components of the default mode network and overlapped with the medial prefrontal cortex. The lrFCD in the medial frontal gyrus showed a negative correlation with HAMD scores after SD. Compared with rested wakefulness, serum levels of 5-HT and NE decreased significantly, whereas HAMD scores were higher after SD within subjects.

CONCLUSIONS

Our study suggested that sleep deprivation after night shift work can induce depressive tendency in ICU medical staffs, which might be related to alterative medial prefrontal cortex, raised HAMD scores, and varying monoamine neurotransmitters.

A cross sectional study: The association between sleeping quality and stress among second and third medical students at the University of Jordan

OBJECTIVE

Medicine is considered one if not the most stressful educational field. Thus, the aim of this study is to investigate the prevalence of stress and poor sleeping quality among medical students and the association between them.

METHOD

This cross-sectional study was conducted at the University of Jordan on second- and third-year medical students. The questionnaire consisted of: 1) Demographics; 2) The assessment tools which were Pittsburgh Quality of Sleep Index (PSQI) and Kessler Psychological Distress Status (K10). Binary logistic regression, chi-square and linear regression were used to investigate the association between PSQI, K10, and their determinants.

RESULTS

The mean for PSQI score was 6.76 ± 3.32. PSQI scores interpretation revealed that 61.7% of the 282 participants of this study were poor sleepers. Logistic regression results showed that only the category of not napping at all from the napping hours variable was significantly associated with sleeping quality. Furthermore, the mean of K10 scores was 24.5 ± 8.5. K10 scores revealed that 66.3% of the participants were stressed. Logistic regression results showed that gender and regular exercise were significantly associated with psychological distress. Additionally, chi-square test, logistic regression and linear regression showed that PSQI was significantly associated with K10 (P <0.01).

CONCLUSIONS

Stress and poor sleeping quality in medical students at the University of Jordan were highly prevalent and strongly associated. What determined PSQI was daytime napping, and for K10 were regular exercise and gender. Further investigations into stress and sleep quality in the Arabian region are needed.

Self in medicine: Determinants of physician well-being and future directions in improving wellness

CONTEXT

Medicine, a profession dedicated to the wellness of patients, is struggling with a crisis of physician and trainee wellness. Physicians and trainees are burning out at alarming rates. Historically, medicine has been characterised by challenging working conditions and inattention to physician wellness and self-care. Healthy physicians are better at promoting wellness to their patients, and physicians who are suffering from burnout can deliver compromised patient care.

DISCUSSION

In recent years, research has increasingly focused on the causes of unwellness among doctors, and a broad range of health determinants have been identified. Studies of interventions for improving trainee and physician wellness have identified individual-focused and organisational approaches that can address the root causes of burnout. Insights from the corporate workplace may help guide interventions. Strategies for addressing physician burnout and improving wellness will involve innovative and multifaceted approaches. Despite a growing emphasis of physician wellness in the literature, implementation of wellness interventions is lagging, and quality improvement methods can address these challenges.

CONCLUSION

Physician wellness is a shared responsibility among doctors, health care organisations and governing bodies. Addressing burnout and improving physician wellness will require transformational change and the embracement of a culture of wellness in medicine. Quality improvement methods are the next step in identifying effective wellness interventions and the targeted groups of physicians and trainees who will most benefit.

Sleep Difficulties Among COVID-19 Frontline Healthcare Workers

OBJECTIVE

To identify COVID-19 work-related stressors and experiences associated with sleep difficulties in HCW, and to assess the role of depression and traumatic stress in this association.

METHODS

A cross-sectional study of HCW using self-report questionnaires, during the first peak of the pandemic in Israel (April 2020), conducted in a large tertiary medical center in Israel. Study population included 189 physicians and nurses working in designated COVID-19 wards and a comparison group of 643 HCW. Mean age of the total sample was 41.7 ± 11.1, 67% were female, 42.1% physicians, with overall mean number of years of professional experience 14.2 ± 20. The exposure was working in COVID-19 wards and related specific stressors and negative experiences. Primary outcome measurement was the Insomnia Severity Index (ISI). Secondary outcomes included the Primary Care-Post Traumatic Stress Disorder Screen (PC-PTSD-5); the Patient Health Questionnaire-9 (PHQ-9) for depression; the anxiety module of the Patient-Reported Outcomes Measurement Information System (PROMIS); Pandemic-Related Stress Factors (PRSF) and witnessing patient suffering and death.

RESULTS

Compared with non-COVID-19 HCW, COVID-19 HCW were more likely to be male (41.3% vs. 30.7%) and younger (36.91 ± 8.81 vs. 43.14 ± 11.35 years). COVID-19 HCW reported higher prevalence of sleep difficulties: 63% vs. 50.7% in the non-COVID group (OR 1.62, 95% CI 1.15-2.29, p = 0.006), mostly difficulty maintaining sleep: 26.5% vs. 18.5% (OR 1.65, 95% CI 1.11-2.44, p = 0.012). Negative COVID-19 work-related experiences, specifically witnessing patient physical suffering and death, partially explained the association. Although past psychological problems and current depression and PTSD were associated with difficulty maintaining sleep, the main association remained robust also after controlling for those conditions in the full model.

CONCLUSION AND RELEVANCE

COVID-19 frontline HCW were more likely to report sleep difficulties, mainly difficulty maintaining sleep, as compared with non-COVID-19 HCW working at the same hospital. Negative patient-care related experiences likely mediated the increased probability for those difficulties. Future research is needed to elucidate the long-term trajectories of sleep difficulties among HCW during large scale outbreaks, and to identify risk factors for their persistence.

Wellbeing as Defined by Resident Physicians: A Qualitative Study

The importance of resident wellbeing is increasingly recognized by the ACGME as essential. While prior studies have quantified wellbeing/burnout, few have defined wellbeing from the resident-physician perspective. A REDCap® survey was distributed to residents in various programs, responses were grouped by theme, and data analyzed via chi-square. From 19 institutions, 53/670 responded, from university (34.0%), community (30.2%), and community/university-affiliated (30.2%) programs, mostly surgical (84.9%), followed by medical (9.4%). Wellbeing was defined by mental and spiritual/religious health (33.8%), overall health (23.0%), free time/time management (23.0%), and job/salary satisfaction (18.9%). Proposed changes to traditional training included fewer hours and more schedule flexibility (38.2%), and increased/improved support/feedback (14.7%). Nearly half of the respondents perceived lacking education on career longevity. Wellbeing is paramount to the personal/professional development of residents. Data on resident-defined wellbeing are lacking. The improved understanding of wellbeing defined here can be used to improve residency training programs.

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.

Low back pain and its correlations with poor sleep quality among health care providers

Objective

Methods

Results

Conclusion

Self-Valuation Challenges in the Culture and Practice of Medicine and Physician Well-being

OBJECTIVE

To compare physicians with workers in other fields on measures of self-valuation (SV) and determine the effect of adjusting for SV on the relationship between being a physician and risk for burnout.

PATIENTS AND METHODS

A random sample of physicians from the American Medical Association Physician Masterfile and a probability sample from the general US population were used. Data were collected for this cross-sectional study between October 12, 2017 and March 15, 2018. Burnout was indicated by a score of 27 or higher on Emotional Exhaustion or 10 or higher on Depersonalization, using the Maslach Burnout Inventory. Self-valuation was measured with Self-valuation Scale items.

RESULTS

Physicians (248/832=29.8%) more than workers in other fields (1036/5182=20.0%) "often" or "always" felt more self-condemnation than self-encouragement to learn from the experience when they made a mistake. Physicians (435/832=52.3%) more than workers in other fields (771/5182=14.9%) "often" or "always" put off taking care of their own health due to time pressure. Physicians had greater odds of burnout before (odds ratio [OR], 1.51; 95% CI, 1.30 to 1.76) but not after adjusting for SV responses (OR, 0.93; 95% CI, 0.78 to 1.11). After adjustment for SV, work hours, sex, and age, physicians had lower odds of burnout than workers in other fields (OR, 0.82; 95% CI, 0.68 to 0.99).

CONCLUSION

Self-valuation is lower in physicians compared with workers in other fields and adjusting for SV eliminated the association between being a physician and higher risk for burnout. Experimental design research is needed to determine whether the association of SV with burnout is causal and the degree to which SV is malleable to intervention at individual, organization, and professional culture levels.

Does Interaction between Sleep Quality and Major Dietary Patterns Predicts Depression among Overweight and Obese Women in Iran?

Background:

Although major dietary patterns and sleep quality independently affect psychiatric disorders, their interactive association on depression is not clear. This study assesses the independent association of dietary patterns and sleep quality on depression, and also investigates their interactive associations on depression among overweight and obese women in Iran

Methods:

Cross-sectional study was conducted among 304 participants, age 18 and above in 2018 at Tehran Iran. Usual dietary intake was collected with 174-FFQ. Participants’ biochemical parameters and depression were measured using standard protocol. Major dietary patterns were extracted by factor analysis and grouped into Fruits&Vegetable group (healthy dietary pattern), High Fat diary&Red Meat group (unhealthy dietary pattern) and Crackers&High Energy Drinks group (western dietary patterns).

Results:

After adjusting for confounders poor sleep was associated with moderate and high depression; AOR (95%CI): 0.41(0.19–0.90) and 0.29(0.13–0.60) respectively. However, healthy dietary patterns (tertiles 2^nd and 3^rd) interact with sleep for depression; AOR (95%CI): 4.168(1.166–14.992) and 2.966(1.068–8.234) respectively. Unhealthy dietary pattern tertiles 2^nd and 3^rd interact with sleep for depression; AOR (95%CI): 2.925(1.055–8.113) and 4.216(1.182–15.042) respectively and Western dietary pattern tertile 3^rd interacts with sleep for depression; AOR (95%CI): 4.264(1.494–12.169).

Conclusion:

Sleep deprivation could be associated with depression. However, sleep quality could interacts with dietary patterns to be associate with depression among overweight and obese people.

Sleep, Cognition, and Yoga

Stress is one of the major problems globally, associated with poor sleep quality and cognitive dysfunction. Modern society is plagued by sleep disturbances, either due to professional demands or lifestyle or both the aspects, often leading to reduced alertness and compromised mental function, besides the well documented ill effects of disturbed sleep on physiological functions. This pertinent issue needs to be addressed. Yoga is an ancient Indian science, philosophy and way of life. Recently, yoga practice has become increasingly popular worldwide. Yoga practice is an adjunct effective for stress, sleep and associated disorders. There are limited well controlled published studies conducted in this area. We reviewed the available literature including the effect of modern lifestyle in children, adolescents, adults and geriatric population. The role of yoga and meditation in optimizing sleep architecture and cognitive functions leading to optimal brain functioning in normal and diseased state is discussed. We included articles published in English with no fixed time duration for literature search. Literature was searched mainly by using PubMed and Science Direct search engines and critically examined. Studies have revealed positive effects of yoga on sleep and cognitive skills among healthy adults as well as patients of some neurological diseases. Further, on evaluating the published studies, it is concluded that sleep and cognitive functions are optimized by yoga practice, which brings about changes in autonomic function, structural changes, changes in metabolism, neurochemistry and improved functional brain network connectivity in key regions of the brain.

Anxiety in Residents in China: Prevalence and Risk Factors in a Multicenter Study

PURPOSE

To explore the prevalence of major anxiety and its associated risk factors in residents in China.

METHOD

This multicenter, cross-sectional study was conducted from December 2019 to February 2020; 1,343 residents from 8 hospitals in Northeast China were included in the final analysis (effective response rate of 86.48%). Demographic characteristics, dietary habits, life-related factors, work-related factors, and psychological characteristics were collected from participants via a self-reported questionnaire. This questionnaire measured sleep quality, physical activity, anxiety, perceived organizational support, psychological capital, and burnout. Adjusted odds ratios (ORs) and 95% confidence intervals were determined using binary logistic regression. Cutoff values and the area under the curve were calculated for risk factors using receiver operating characteristic curve analysis.

RESULTS

Of participants, 441 (32.80%) reported anxiety symptoms and 133 (9.90%) reported major anxiety symptoms. Four independent risk factors for major anxiety were identified: poor sleep quality (OR = 1.282, P < .001) and 3 dimensions of burnout: higher emotional exhaustion (OR = 1.085, P < .001), higher depersonalization (OR = 1.064, P = .002), and reduced personal accomplishment (OR = 0.951, P < .001). The optimal cutoff values for these risk factors were 7, 10, 9, and 22 scores, respectively.

CONCLUSIONS

This study found a considerable prevalence of major anxiety symptoms in residents in China and identified poor sleep quality and higher levels of burnout as having a close association with major anxiety. These findings enrich the existing literature on anxiety and demonstrate a critical need for additional studies that investigate intervention strategies to improve sleep quality and combat burnout, which could improve the mental health of residents.

Excessive Daytime Sleepiness: A Clinical Review

Excessive daytime sleepiness (EDS) is a highly prevalent condition that is associated with significant morbidity. The causes of EDS are varied, and include inadequate sleep, sleep disordered breathing, circadian rhythm sleep-wake disorders, and central disorders of hypersomnolence (narcolepsy, idiopathic hypersomnia, and Kleine-Levin syndrome). Additionally, EDS could represent a symptom of an underlying medical or psychiatric disorder. Assessment of EDS includes a thorough sleep, medical, and psychiatric history, targeted clinical examination, and appropriate use of actigraphy to measure sleep duration and sleep-wake patterns, polysomnography to assess for associated conditions such as sleep-related breathing disorders or other factors that might disrupt nighttime sleep, multiple sleep latency testing to ascertain objective sleepiness and diagnose central disorders of hypersomnolence, and measurement of cerebrospinal fluid hypocretin-1 concentration. Treatment of EDS secondary to central disorders of hypersomnolence is primarily pharmacologic with wakefulness-promoting agents such as modafinil, stimulants such as methylphenidate and amphetamines, and newer agents specifically designed to improve wakefulness; behavioral interventions can provide a useful adjunct to pharmacologic treatment. When excessive sleepiness is secondary to other conditions, the treatment should focus on targeting the primary disorder. This review discusses current epidemiology, provides guidance on clinical assessments and testing, and discusses the latest treatment options. For this review, we collated the latest evidence using the search terms excessive sleepiness, hypersomnia, hypersomnolence, treatment from PubMed and MEDLINE and the latest practice parameters from the American Academy of Sleep Medicine.

Medication Errors in Surgery: A Classification Taxonomy and a Pilot Study in Postcall Residents

INTRODUCTION

The post-call state in postgraduate medical trainees is associated with impaired decision-making and increased medical errors. An association between post-call state and medication prescription errors for surgery residents is yet to be established. Our objective was to determine whether post-call state is associated with increased proportion of medication prescription errors committed by surgery residents in an academic hospital without a computerized physician order entry (CPOE) system.

METHODS

This prospective observational study was conducted at a tertiary academic hospital between June 28 and August 31, 2017. It compared the proportion of medication prescription errors committed by surgery residents in their post-call (PC) and no-call (NC) states. A novel taxonomy was developed to classify medication prescription errors.

RESULTS

Sixteen of twenty-one eligible residents (76%) participated in this study. Self-reported hours of sleep per night was significantly higher in the NC group compared to the PC group (6(4-8) vs 2(0-4) hours, P < 0.01). PC residents committed a significantly higher proportion of medication prescription errors versus NC residents (9.2% vs 3.2%; p=0.04). Decision-making and prescription-writing errors comprised 33% and 67% of errors, respectively.

CONCLUSIONS

The post-call state in surgery residents is associated with a significantly higher proportion of medication prescription errors in a hospital without a CPOE system. Decision-making and prescription-writing errors could potentially be addressed by additional educational interventions.

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.

Sleep duration and satisfaction among physicians in tertiary public hospitals in China: a large sample national survey

OBJECTIVES

To investigate the sleep duration and level of satisfaction among physicians in tertiary public hospitals in China, and to explore associated factors.

METHODS

A national online cross-sectional survey was conducted. Totally 20,786 physicians from 136 hospitals participated in the survey. Data were collected using an online self-reported questionnaire. Descriptive and logistic regression statistics were performed using the STATA software.

RESULTS

The mean total sleep duration was 6.37 ± 0.87 h. Of all participants, 61.06% (n = 12,691) reported short sleep duration (less than 7 h per day). 46.97% (n = 9764) were not satisfied with their sleep. An older age and job-related factors (longer working hours per week, specialty including internal medicine, Ob/GYN and emergency medicine, working more night shifts, heavier workload, and working in East China) were significantly associated with reported short sleep duration.

CONCLUSIONS

The majority of physicians in Chinese public hospitals experienced insufficient sleep duration. Changes are required to improve the wellbeing of physicians and patient outcomes.

Association of Time of Day When Endovascular Therapy for Stroke Starts and Functional Outcome

OBJECTIVE

To investigate the association between endovascular therapy (EVT) start time in acute ischemic stroke (AIS) and midterm functional outcome.

METHODS

This retrospective cohort study included all patients with AIS treated with EVT from 2 stroke center registries from January 2012 to December 2018. The primary outcome was the score on the modified Rankin Scale (mRS) and the utility-weighted mRS (uw-mRS) at 90 days. A proportional odds model was used to calculate the common odds ratio (OR) as a measure of the likelihood that the intervention at a given EVT start time would lead to lower scores on the mRS (shift analysis).

RESULTS

A total of 1,558 cases were equally allotted into 12 EVT start time periods. The primary outcome favored EVT start times in the morning at 08:00-10:20 and 10:20-11:34 (OR, 0.53; 95% confidence interval [CI], 0.38 to 0.75; p < 0.001; OR, 0.62; 95% CI, 0.44 to 0.87; p = 0.006, respectively), while it disfavored EVT start times at the end of the working day at 15:55-17:15 and 18:55-20:55 (OR, 1.47; 95% CI, 1.03-2.09; p = 0.034; OR, 1.49; 95% CI, 1.03-2.15; p = 0.033). Symptom onset to EVT start time was significantly higher and use of IV tissue plasminogen activator significantly lower between 10:20 and 11:34 (p < 0.004 and p = 0.012, respectively).

CONCLUSION

EVT for AIS in the morning leads to better midterm functional outcome, while EVT at the end of the work day leads to poorer midterm functional outcome. Difference in baseline factors, standard workflow, and technical efficacy metrics could not be identified as potential mediators of this effect.

Dose-Response Relationship between Night Work and the Prevalence of Impaired Fasting Glucose: The Korean Worker's Special Health Examination for Night Workers Cohort

Many studies have been conducted regarding the association between night work and diabetes, but the association between impaired fasting glucose (IFG) and night work is still unclear. The aim of this study was to evaluate this association using the Special Health Examination (SHEW) for Korean night workers. Laboratory, questionnaire, and physical examination data were collected for 80,077 manual workers between 2014 and 2016 from Korea Medical Institute, and associations of the data with IFG were evaluated using a multivariate logistic regression model. The odds ratios for IFG among those who worked night shifts for 2~5 years, 5~12 years, and 12 years or over (ref: <2 years) after adjusting for abdominal obesity were 1.14 (0.90–1.45), 1.41 (1.10–1.81), and 1.75 (1.41–2.19), respectively. A dose–response relationship was identified between the duration of night work and the prevalence of IFG (p for trend <0.05). A dose relationship remained significant when a subgroup of non-obese participants was analyzed. We identified an association and a dose–response relationship between the number of years of night work and IFG. To prevent the development of diabetes in night workers, we suggest that they should be pre-emptively screened and treated from the stage of IFG.

A Prospective Observational Study Comparing Effects of Call Schedules on Surgical Resident Sleep and Physical Activity Using the Fitbit

BACKGROUND

Surgical residency training has an extended tradition of long hours. Residency programs use a variety of call schedules to combat resident fatigue and sleep deprivation while maintaining adherence to duty hour restrictions. Nonetheless, there is a paucity of data regarding objective measurements of sleep during the different call schedules included in general surgery training.

OBJECTIVE

The primary objective of this study was to compare the quantity of sleep in 24-hour time frames across all types of shifts worked by general surgery residents at our institution. The secondary objective was to measure activity level in total steps during various time frames.

METHODS

This prospective observational study was performed between April 4 and August 26, 2018, with general surgery residents. Each resident was assigned a Fitbit Charge 2 to wear during all rotations, including general surgery and subspecialty services.

RESULTS

Twenty-six out of 31 residents voluntarily participated in the study (84%). In-house call (IHC) had significantly less sleep in a 24-hour time frame than home call and night float (144 vs 283 vs 246 minutes, P < .001 and P < .028). IHC had significantly more steps than home call (11 245 vs 8756 steps, P = .039). The smallest number of steps was obtained when residents were not working (7904 steps).

CONCLUSIONS

Our data demonstrate that surgical residents on IHC have significantly less sleep compared to all other types of on-call time frames. Residents on IHC have the most steps across all time frames.

Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers

OBJECTIVES

Insufficient sleep affects circadian hormonal profiles and inflammatory markers and may modulate attention, executive functioning and decision-making. Medical professionals and specifically resident physicians, who are involved in long-term nightshift schedules during their post-graduate training, are prone to acute and chronic sleep deprivation and disruption, putting them at risk for making medical errors. The aim of the study was to evaluate the impact of chronic and acute-on-chronic sleep deprivation and disruption among residents on selected physiological and cognitive measures.

METHODS

Thirty-three medical and surgical residents were evaluated twice - at baseline and after a 26-hour shift. Eighteen young attending physicians who did not engage in nightshift schedules served as controls and were evaluated once. Measures included morning cortisol and high-sensitivity C-reactive protein (hs-CRP), computerised tests of attention and behaviour, the Behaviour Rating Inventory of Executive Function, a risk-taking questionnaire and the Pittsburgh Sleep Quality Index.

RESULTS

Residents, but not attendings, reported chronic sleep disruption and deprivation. Residents at baseline exhibited reduced morning cortisol levels and elevated hs-CRP levels, compared to attendings. Residents at baseline had impaired global executive function compared to attendings. A nightshift with acute sleep deprivation further reduced residents' executive function. Residents at baseline and after a nightshift demonstrated increased impulsivity and slower processing time than attendings. Residents and attendings did not differ in risk-taking tendencies which were assessed in a separate cohort.

CONCLUSIONS

In a real-life setting, resident physicians exhibit increased low-grade systemic inflammation (hs-CRP) and impaired HPA-axis function. Their chronic sleep curtailment is associated with greater impulsivity, slower cognitive processing, and impaired executive function. Future research is warranted to understand how improving working schedule by increasing sleep duration may minimise the short-term and potential long-term risks to physicians in training.

Increased Patient Safety-Related Incidents Following the Transition into Daylight Savings Time

BACKGROUND

"Spring forward," the start of daylight savings time (DST), reduces sleep opportunity by an hour. Insufficient sleep in healthcare workers resulting from the spring forward time change could potentially result in an increase in medical errors.

OBJECTIVE

We examined the change in reported patient safety-related incidents (SRIs), in the week following the transition into and out of DST over a period of 8 years.

DESIGN

Observational study SETTING: A US-based large healthcare organization with sites across multiple states MEASUREMENTS: Voluntarily reported SRIs that occurred 7 days prior to and following the spring and fall time changes for years 2010-2017 were ascertained. SRIs likely resulting from human error were identified separately. The changes in the number of SRIs (either all SRIs or SRIs restricted to those likely resulting from human error) from the week before and after the time change (either spring or fall) were modeled using a negative binomial mixed model with a random effect to correct for non-independent observations in consecutive weeks.

RESULTS

Over the 8-year period, we observed 4.2% (95% CI: - 1.1 to 9.7%; p = 0.12) and 8.8% (95% CI: - 2.5 to 21.5%; p = 0.13) increases in overall SRIs in the 7 days following DST when compared with 7 days prior for spring and fall, respectively. By restricting to SRIs likely resulting from human errors, we observed 18.7% (95% CI: 5.6 to 33.6%; p = 0.004) and 4.9% (95% CI: - 1.3 to 11.5%; p = 0.12) increases for spring and fall, respectively.

CONCLUSION

Policy makers and healthcare organizations should evaluate delayed start of shifts or other contingency measures to mitigate the increased risk of SRIs during transition to DST in spring.

Shiftwork and Alcohol Consumption: A Systematic Review of the Literature

INTRODUCTION

Shiftwork can be a risk factor for a number of different somatic and psychological health conditions, especially sleep disorders. Shiftworkers sleep less than dayworkers, and 20-40% of them suffer from difficulties initiating and maintaining sleep, which result in reduced capacity for work and social life. A common coping strategy might be the use of alcohol, which presents a health and safety hazard as it further impairs sleep quality and exacerbates sleepiness in the workplace. This review aimed to assess the extent of such possible connections.

METHODS

We performed a systematic search of the scientific literature on shiftwork and alcohol consumption in PubMed, PsycInfo, and Cochrane Library. Only original studies comparing shiftworkers with non-shiftworkers were included. The recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-Analyses were followed.

RESULTS

Fourteen articles are included in this review. Six studies report some kind of connection between shift- or nightwork and alcohol consumption, especially as a sleep aid. Conflicting or negative results are reported by 3 studies.

DISCUSSION

Shiftwork, especially working at night and in rotation shifts, is associated with binge drinking disorder in different professions. The reasons for pathological consumption of alcohol can be self-medication of sleep problems or coping with stress and psychosocial problems typical for shiftwork. Nurses aged over 50 years represent one important risk group. These results can be important for preventive programs against sleep disorders, including measures other than drinking alcohol as a sleep aid in the workplace of shiftworkers.

Assessment of Physician Sleep and Wellness, Burnout, and Clinically Significant Medical Errors

Importance

Sleep-related impairment in physicians is an occupational hazard associated with long and sometimes unpredictable work hours and may contribute to burnout and self-reported clinically significant medical error.

Objective

To assess the associations between sleep-related impairment and occupational wellness indicators in physicians practicing at academic-affiliated medical centers and the association of sleep-related impairment with self-reported clinically significant medical errors, before and after adjusting for burnout.

Design, Setting, and Participants

This cross-sectional study used physician wellness survey data collected from 11 academic-affiliated medical centers between November 2016 and October 2018. Analysis was completed in January 2020. A total of 19 384 attending physicians and 7257 house staff physicians at participating institutions were invited to complete a wellness survey. The sample of responders was used for this study.

Exposures

Sleep-related impairment.

Main Outcomes and Measures

Association between sleep-related impairment and occupational wellness indicators (ie, work exhaustion, interpersonal disengagement, overall burnout, and professional fulfillment) was hypothesized before data collection. Assessment of the associations of sleep-related impairment and burnout with self-reported clinically significant medical errors (ie, error within the last year resulting in patient harm) was planned after data collection.

Results

Of all physicians invited to participate in the survey, 7700 of 19 384 attending physicians (40%) and 3695 of 7257 house staff physicians (51%) completed sleep-related impairment items, including 5279 women (46%), 5187 men (46%), and 929 (8%) who self-identified as other gender or elected not to answer. Because of institutional variation in survey domain inclusion, self-reported medical error responses from 7538 physicians were available for analyses. Spearman correlations of sleep-related impairment with interpersonal disengagement (r = 0.51; P < .001), work exhaustion (r = 0.58; P < .001), and overall burnout (r = 0.59; P < .001) were large. Sleep-related impairment correlation with professional fulfillment (r = -0.40; P < .001) was moderate. In a multivariate model adjusted for gender, training status, medical specialty, and burnout level, compared with low sleep-related impairment levels, moderate, high, and very high levels were associated with increased odds of self-reported clinically significant medical error, by 53% (odds ratio, 1.53; 95% CI, 1.12-2.09), 96% (odds ratio, 1.96; 95% CI, 1.46-2.63), and 97% (odds ratio, 1.97; 95% CI, 1.45-2.69), respectively.

Conclusions and Relevance

In this study, sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Interventions to mitigate sleep-related impairment in physicians are warranted.