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Booker LA, Mills J, Bish M, Spong J, Deacon-Crouch M, Skinner TC. Nurse rostering: understanding the current shift work scheduling processes, benefits, limitations, and potential fatigue risks. BMC Nurs 2024; 23:295. [PMID: 38685019 PMCID: PMC11057102 DOI: 10.1186/s12912-024-01949-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/18/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Implementing appropriate shift work schedules can help mitigate the risk of sleep impairment and reduce fatigue of healthcare workers, reducing occupational health and safety risks. In Australia, the organisation has a responsibility to make sure all reasonable measures are taken to reduce fatigue of staff. Therefore, it is important to assess what the current rostering processes is for staff responsible for creating the rosters for nurses. AIM The aims of the project were to understand (1) who creates the rosters and what the process is, (2) what training and knowledge these staff have in establishing rostering schedules that optimise the sleep and wellbeing of staff, and (3) what the benefits and limitations are of current rostering practices. METHODS Findings were generated through semi-structured interviews, using cluster coding to form categories. Twenty four nurses responsible for rostering staff were interviewed from three different sites in Victoria (one metropolitan and two regional/rural hospitals). Data was analysed using selected grounded theory methods with thematic analysis. RESULTS The common themes that came out of the interviews were that rostering staff were under prepared, unaware of fatigue and safety guidelines and polices from governing bodies and had not received any education or training before taking on the role. The most common rostering style was self-rostering, where staff could submit preferences. However, there were concerns about staff fatigue but were divided as to who should be responsible, with many saying it was up to staff to preference shifts that they could cope with. The final theme was cultural barriers to change. CONCLUSION While self-rostering resulted in staff having more freedom and flexibility, shift preferences may be influenced more so by a need to fit with lifestyle rather than to minimise fatigue and increase safety in the workplace. Greater consideration of the impact of shift work schedules on fatigue is required to ensure that the layers of clinical governance in health care organisations minimise the risk of occupation health and safety issues for employees delivering direct patient care.
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Affiliation(s)
- Lauren A Booker
- School of Psychology & Public Health, La Trobe University, Bendigo, VIC, 3552, Australia.
- Institute for Breathing and Sleep, Austin Health, Melbourne, 3084, Australia.
| | - Jane Mills
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, VIC, 3552, Australia
| | - Melanie Bish
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, VIC, 3552, Australia
| | - Jo Spong
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, VIC, 3552, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, 3084, Australia
| | - Melissa Deacon-Crouch
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, VIC, 3552, Australia
| | - Timothy C Skinner
- School of Psychology & Public Health, La Trobe University, Bendigo, VIC, 3552, Australia
- Department of Psychology, Centre for Health and Society, University of Copenhagen, Copenhagen, Denmark
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane RI, McDonald CF, Ridgers A, Robbins R, Varma P, Rajaratnam SMW, Czeisler CA. Association of Chronotype and Shiftwork with COVID-19 Infection. J Occup Environ Med 2024:00043764-990000000-00542. [PMID: 38595269 DOI: 10.1097/jom.0000000000003103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
OBJECTIVE This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work. METHODS Cross-sectional survey of 19,821 U.S. adults. RESULTS COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift/remote work, sleep duration and comorbidities, morning chronotype was associated with a higher (aOR: 1.15, 95% CI 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74). CONCLUSION Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.
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Affiliation(s)
| | | | | | | | | | | | | | - Rashon I Lane
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane RI, McDonald CF, Ridgers A, Robbins R, Varma P, Wiley JF, Rajaratnam SMW, Czeisler CA. Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 Infection. Am J Med 2024:S0002-9343(24)00109-8. [PMID: 38401674 DOI: 10.1016/j.amjmed.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/09/2024] [Accepted: 02/11/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Obstructive sleep apnea is associated with COVID-19 infection. Less clear is whether obstructive sleep apnea is a risk factor for the development of post-acute sequelae of SARS-CoV-2 infection (PASC). STUDY DESIGN Cross-sectional survey of a general population of 24,803 US adults to determine the association of obstructive sleep apnea with PASC. RESULTS COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence of persistent (>3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models, obstructive sleep apnea was associated with all putative PASC-related symptoms with the highest adjusted odds ratios being fever (2.053) and nervous/anxious (1.939). In 4 logistic regression models of overall PASC derived from elastic net regression, obstructive sleep apnea was associated with PASC (range of adjusted odds ratios: 1.934-2.071); this association was mitigated in those with treated obstructive sleep apnea. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%. CONCLUSION In a general population sample, obstructive sleep apnea is associated with the development of PASC-related symptoms and a global definition of PASC. Treated obstructive sleep apnea mitigates the latter risk. The presence of 3 or more PASC symptoms may be useful in identifying cases and for future research.
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Affiliation(s)
- Stuart F Quan
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass; Division of Sleep Medicine.
| | - Matthew D Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass; Division of Sleep Medicine
| | - Mark É Czeisler
- Francis Weld Peabody Society, Harvard Medical School, Boston, Mass; School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura K Barger
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass; Division of Sleep Medicine
| | - Lauren A Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Melinda L Jackson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Rashon I Lane
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass
| | - Christine F McDonald
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia; Faculty of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anna Ridgers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne, Victoria, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Rebecca Robbins
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass; Division of Sleep Medicine
| | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Joshua F Wiley
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Shantha M W Rajaratnam
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass; Division of Sleep Medicine; School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Charles A Czeisler
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Mass; Division of Sleep Medicine
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Booker LA, Spong J, Hodge B, Deacon-Crouch M, Bish M, Mills J, Skinner TC. Differences in shift and work-related patterns between metropolitan and regional/rural healthcare shift workers and the occupational health and safety risks. Aust J Rural Health 2024; 32:141-151. [PMID: 38063243 DOI: 10.1111/ajr.13075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 11/20/2023] [Accepted: 11/24/2023] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES To explore if there are differences in shift patterns and work-related factors between metropolitan and regional/rural healthcare shift workers and their risk of poor sleep and mental health. Furthermore, explore whether these factors impact on medical errors, workplace and car/near car accidents. DESIGN A cross-sectional study. SETTING An anonymous online survey of healthcare shift workers in Australia. PARTICIPANTS A total of 403 nurses, midwives and paramedics completed the survey. MAIN OUTCOME MEASURES Sample characteristics, employment location, shift work-related features, sleep and mental health measurements, workplace accidents, medical errors and car/near car accident post shift. RESULTS Regional/rural healthcare shift workers were significantly older, had more years' experience, worked more nights, on-call and hours per week. Those in metropolitan areas took significantly longer (minutes) to travel to work, had higher levels of anxiety, increased risk of shift work disorder, reported significantly more workplace accidents and were more likely to have a car/near car accident when commuting home post shift. Both groups reported ~25% having a medical error in the past year. Workplace accidents were related to more on-call shifts and poor sleep quality. Medical errors were associated with fewer years' experience, more evening shifts and increased stress. Car accidents were associated with metropolitan location and increased depression. CONCLUSION Differences in work-related factors between metropolitan and regional/rural healthcare shift workers were observed. Some of these factors contributed to occupational health and safety risks. Further exploration is needed to understand how to reduce occupational health and safety risks, and improve employee and patient safety both in both regional/rural and metropolitan areas.
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Affiliation(s)
- Lauren A Booker
- School of Psychology & Public Health, La Trobe University, Bendigo, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
| | - Jo Spong
- Institute for Breathing and Sleep, Austin Health, Melbourne, Victoria, Australia
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Brad Hodge
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Melissa Deacon-Crouch
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Melanie Bish
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Jane Mills
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Timothy C Skinner
- School of Psychology & Public Health, La Trobe University, Bendigo, Victoria, Australia
- Department of Psychology, Centre for Health and Society, University of Copenhagen, Copenhagen, Denmark
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Booker LA, Wilson D, Spong J, Fitzgibbon C, Deacon-Crouch M, Lenz KE, Skinner TC. Maternal Circadian Disruption from Shift Work and the Impact on the Concentration of Melatonin in Breast Milk. Breastfeed Med 2024; 19:33-39. [PMID: 38150529 DOI: 10.1089/bfm.2023.0252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background and Objective: Melatonin in breast milk exhibits a 24-hour circadian rhythm, present in nighttime breast milk but nearly undetectable in daytime breast milk. Shift work can disrupt the circadian timing of individuals, evident in changes in melatonin in saliva and urine samples. However, it is unknown whether these changes are also reflected in breast milk from a shift working mother. The aim of this study was to investigate whether maternal circadian rhythm disturbance from shift work impacts the melatonin concentration in breast milk. Materials and Methods: Breast milk and saliva samples were collected from 11 shift working mothers at four timepoints across five consecutive days. This included during their day shift or nonworkdays to act as a control, night shift, subsequent night shifts and postnight shift. Where possible, pre- and postfeed collections were also undertaken. Samples were grouped into four-time intervals: 12-6:30 am, 7-11:30 am, 12-6:30 pm, 7-11:30 pm, and melatonin levels (picogram per milliliter) in the breast milk and saliva samples were analyzed. Results: There was a significant decrease in breast milk melatonin (p = 0.026) at the 12-6:30 am time interval on subsequent night shifts, compared with control days. However, there was no overall time and shift type interaction effect (p = 0.70). In addition, no observed difference in melatonin levels was found in saliva samples, or when comparing pre- and postfeed breast milk. Breast milk melatonin however was found to be significantly higher compared with saliva (p > 0.001), at all but one time interval. Conclusion: The findings suggest that there is a potential effect of maternal circadian rhythm disruption from shift work on breast milk melatonin levels. This is an important step in exploring the role of maternal circadian timing and the effect on breast milk composition. Expansion of this research and exploration of other circadian rhythm misalignment sleep disorders on breast milk is highly recommended.
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Affiliation(s)
- Lauren A Booker
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Danielle Wilson
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Jo Spong
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Cheree Fitzgibbon
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
| | - Melissa Deacon-Crouch
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Katrin E Lenz
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
| | - Timothy C Skinner
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
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Booker LA, Fitzgerald J, Mills J, Bish M, Spong J, Deacon‐Crouch M, Skinner TC. Sleep and fatigue management strategies: How nurses, midwives and paramedics cope with their shift work schedules-a qualitative study. Nurs Open 2024; 11:e2099. [PMID: 38268269 PMCID: PMC10803889 DOI: 10.1002/nop2.2099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 12/07/2023] [Accepted: 01/05/2024] [Indexed: 01/26/2024] Open
Abstract
AIMS To understand the benefits and challenges of shift work, and the coping strategies used by nurses, midwives and paramedics to manage the impact of shift work on sleep and fatigue from shift work. DESIGN A single case study with embedded units. METHODS Twenty-seven participants were interviewed exploring their shift work experiences, coping strategies used to improve sleep, and what their recommendations are for improving shift work management. Interviews were completed between November and December 2022. RESULTS Participants enjoyed the lifestyle, flexibility and financial rewards offered by working shift work. However, fatigue and sleep deprivation undermined these benefits, as it impacted their ability to enjoy social and family events. There were also concerns of long-term health consequences of shift work and delivery of care. Changes to rostering practices and sleep and shift work education were common recommendations. CONCLUSION This study provides insights on how healthcare professionals manage sleep and fatigue due to shift work and the inadequate support. There is absence of adequate policies, processes and training at an organizational, academic and personal level on how to best manage sleep and fatigue when working shift work. Future research is needed to explore how to equip healthcare shift workers with the skills to successfully manage their schedules to mitigate the negative impact that poor sleep and fatigue has on the health and safety of themselves and their patients. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Understanding the specific challenges of shift work and how workers manage their shift work schedules is critical for improving the health and safety of themselves and their patients. This study identified that there is insufficient training regarding sleep and shift work management strategies, potentially leading to occupational health and safety concerns. Further education and training to equip staff with the necessary information, training and guidance to staff on how to reduce fatigue risk is required. PATIENT OR PUBLIC CONTRIBUTION This study involved healthcare shift workers in semi-structured interviews. Data gathered from a previous survey that participants were involved in helped shape the interview topics and the study design.
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Affiliation(s)
- Lauren A. Booker
- School of Psychology & Public HealthLa Trobe UniversityBendigoVictoriaAustralia
- Institute for Breathing and Sleep, Austin HealthMelbourneAustralia
| | - Jarrah Fitzgerald
- Department of Rural Health Sciences, La Trobe Rural Health SchoolLa Trobe UniversityBendigoVictoriaAustralia
| | - Jane Mills
- Department of Rural Health Sciences, La Trobe Rural Health SchoolLa Trobe UniversityBendigoVictoriaAustralia
| | - Melanie Bish
- Department of Rural Health Sciences, La Trobe Rural Health SchoolLa Trobe UniversityBendigoVictoriaAustralia
| | - Jo Spong
- Institute for Breathing and Sleep, Austin HealthMelbourneAustralia
- Department of Rural Health Sciences, La Trobe Rural Health SchoolLa Trobe UniversityBendigoVictoriaAustralia
| | - Melissa Deacon‐Crouch
- Department of Rural Health Sciences, La Trobe Rural Health SchoolLa Trobe UniversityBendigoVictoriaAustralia
| | - Timothy C. Skinner
- School of Psychology & Public HealthLa Trobe UniversityBendigoVictoriaAustralia
- Department of Psychology, Centre for Health and SocietyUniversity of CopenhagenCopenhagenDenmark
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane RI, McDonald CF, Ridgers A, Robbins R, Varma P, Wiley JF, Rajaratnam SM, Czeisler CA. Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 infection (PASC). medRxiv 2023:2023.12.30.23300666. [PMID: 38234859 PMCID: PMC10793517 DOI: 10.1101/2023.12.30.23300666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Background Obstructive sleep apnea (OSA) is associated with COVID-19 infection. Fewer investigations have assessed OSA as a possible risk for the development of Post-Acute Sequelae of SARS-CoV-2 infection (PASC). Research Question In a general population, is OSA associated with increased odds of PASC-related symptoms and with an overall definition of PASC? Study Design Cross-sectional survey of a general population of 24,803 U.S. adults. Results COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence rates for a wide variety of persistent (> 3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models adjusted for demographic, anthropometric, comorbid medical and socioeconomic factors, OSA was associated with all putative PASC-related symptoms with the highest adjusted odds ratios (aOR) being fever (2.053) and nervous/anxious (1.939) respectively. Elastic net regression identified the 13 of 37 symptoms most strongly associated with COVID-19 infection. Four definitions of PASC were developed using these symptoms either weighted equally or proportionally by their regression coefficients. In all 4 logistic regression models using these definitions, OSA was associated with PASC (range of aORs: 1.934-2.071); this association was mitigated in those with treated OSA. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%. Conclusion In a general population sample, OSA is associated with the development of PASC-related symptoms and a global definition of PASC. A PASC definition requiring the presence of 3 or more symptoms may be useful in identifying cases and for future research.
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Affiliation(s)
- Stuart F. Quan
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Matthew D. Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Mark É. Czeisler
- Francis Weld Peabody Society, Harvard Medical School, Boston, MA
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura K. Barger
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Lauren A. Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark E. Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melinda L. Jackson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Rashon I. Lane
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
| | - Christine F. McDonald
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Monash University, Melbourne Australia
| | - Anna Ridgers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Rebecca Robbins
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Joshua F. Wiley
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Shantha M.W. Rajaratnam
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Charles A. Czeisler
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
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Booker LA, Fitzgibbon C, Spong J, Deacon-Crouch M, Wilson DL, Skinner TC. Rapid Versus Slow Cooling Pasteurization of Donor Breast Milk: Does the Cooling Rate Effect Melatonin Reduction? Breastfeed Med 2023; 18:951-955. [PMID: 38100440 DOI: 10.1089/bfm.2023.0244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Background and Objective: There is a question as to whether melatonin levels in breast milk are impacted by the cooling rate postpasteurization. Past research that has used in the Australian donor bank's breast milk Holder Pasteurization technique has reported varying findings regarding melatonin levels postpasteurization. Where breast milk was cooled slowly, a significant reduction in breast milk melatonin levels was observed. Conversely, where a rapid cooling method was used, there was no significant reduction in melatonin levels. The aim of this study was to investigate whether the cooling process between the different pasteurization techniques impact on melatonin levels in breast milk postpasteurization. Materials and Methods: Twenty-seven nighttime breast milk samples were collected, with each sample divided into three; one remained unpasteurized, one was pasteurized and rapidly cooled to 4°C, and the other was pasteurized and cooled slowly to 4°C. Results: Melatonin levels were significantly reduced in both the rapidly cooled and slow cooled breast milk samples when compared to their unpasteurized counterpart (p < 0.001). There was no significant difference in melatonin levels between the two cooling methods (p = 0.91). Conclusion: This study showed that both the rapid and cooling pasteurization processes had a similar reduction in melatonin levels in breast milk. However, even after pasteurization melatonin was still present. Therefore, it is recommended that donor banks still take into consideration circadian timing hormones such as melatonin and the time of day breast milk is expressed.
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Affiliation(s)
- Lauren A Booker
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Cheree Fitzgibbon
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
| | - Jo Spong
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Melissa Deacon-Crouch
- Department of Rural Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Danielle L Wilson
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Timothy C Skinner
- School of Psychology and Public Health, La Trobe University, Bendigo, Australia
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Booker LA, Hodge B, Skinner TC. Rethinking the distribution of sleep services: discrepancy of obstructive sleep apnoea in rural compared with metropolitan men in Australia - a large national survey. Rural Remote Health 2023; 23:7704. [PMID: 37700451 DOI: 10.22605/rrh7704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
INTRODUCTION Geographical location is increasingly recognised as a contributor to health inequity, with barriers including travel distances and a shortage of healthcare services. Individuals living in rural areas are known to have increased illness and comorbidities. Obstructive sleep apnoea (OSA) is one such illness. OSA is a condition where a person repeatedly pauses breathing while asleep due to their airways becoming wholly or partially blocked, and it is associated with various chronic diseases. Exploration into the effects of these barriers on OSA is limited. This study explores the proportion of diagnosed and undiagnosed OSA in men living in rural compared to metropolitan areas. METHODS This was a cross-sectional, secondary analysis of the Australian Ten to Men dataset. The present study looked at men aged over 18 years diagnosed with OSA in their lifetime from wave 2 (n=10 513) and wave 3 (n=7262) of the dataset. Wave 2 data were collected between November 2015 and May 2016, and wave 3 between July 2020 and February 2021. RESULTS In wave 2, a higher proportion of rural men were diagnosed with OSA than metropolitan men (OR, 1.47, 95%CI 1.22-1.78, p<0.001), but not regional men. In addition, a significantly higher proportion of men in rural areas were at risk for OSA than metropolitan men (37.7% v 32.6%, p<0.0001). However, men living rurally were older, had higher BMI and lower socioeconomic status. Location was no longer a significant predictor of OSA after controlling for age, BMI and socioeconomic status. In wave 3, rate of diagnosis of OSA during the lifetime was no longer significantly associated with location (p=0.057) or being diagnosed with OSA in the previous 12 months (p=0.062). CONCLUSION This study highlights the need to ensure adequate services in rural areas, given the higher proportion of men diagnosed with, or at risk of, OSA in rural areas. OSA is also associated with an increase risk of comorbidities such as heart disease, hypertension and diabetes, which are diseases also seen more prevalently in rural men. Rethinking the distribution of healthcare services will go some way to addressing this problem.
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Affiliation(s)
- Lauren A Booker
- School of Psychology & Public Health, La Trobe University, Bendigo, Vic., Australia; and Institute for Breathing and Sleep, Austin Health, Melbourne, Vic., Australia
| | - Brad Hodge
- Rural Department of Community Health, La Trobe Rural Health School, La Trobe University, Bendigo, Vic., Australia
| | - Timothy C Skinner
- School of Psychology & Public Health, La Trobe University, Bendigo, Vic., Australia; and Department of Psychology, Centre for Health and Society, University of Copenhagen, Copenhagen, Denmark
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane RI, McDonald CF, Ridgers A, Robbins R, Varma P, Rajaratnam SM, Czeisler CA. Association of Chronotype and Shiftwork with COVID-19 Infection. medRxiv 2023:2023.07.06.23292337. [PMID: 37461617 PMCID: PMC10350136 DOI: 10.1101/2023.07.06.23292337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Objective This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work. Methods Cross-sectional survey of 19,821 U.S. adults. Results COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift work, sleep duration and comorbidities, morning chronotype was associated with a higher (aOR: 1.15, 95% CI 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74). Conclusion Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.
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Affiliation(s)
- Stuart F. Quan
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Matthew D. Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Mark É. Czeisler
- Francis Weld Peabody Society, Harvard Medical School, Boston, MA
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura K. Barger
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Lauren A. Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark E. Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melinda L. Jackson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Rashon I. Lane
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
| | - Christine F. McDonald
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Monash University, Melbourne Australia
| | - Anna Ridgers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Rebecca Robbins
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Shantha M.W. Rajaratnam
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Charles A. Czeisler
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA
- Division of Sleep Medicine, Harvard Medical School, Boston, MA
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11
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane R, McDonald CF, Ridgers A, Robbins R, Varma P, Rajaratnam SM, Czeisler CA. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among US adults. J Clin Sleep Med 2023; 19:1303-1311. [PMID: 37279079 PMCID: PMC10315594 DOI: 10.5664/jcsm.10588] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/30/2023]
Abstract
STUDY OBJECTIVES Medical comorbidities increase the risk of severe COVID-19 infection. In some studies, obstructive sleep apnea (OSA) has been identified as a comorbid condition that is associated with an increased prevalence of COVID-19 infection and hospitalization, but few have investigated this association in a general population. This study aimed to answer the following research question: In a general population, is OSA associated with increased odds of COVID-19 infection and hospitalization and are these altered with COVID-19 vaccination? METHODS This was a cross-sectional survey of a diverse sample of 15,057 US adults. RESULTS COVID-19 infection and hospitalization rates in the cohort were 38.9% and 2.9%, respectively. OSA or OSA symptoms were reported in 19.4%. In logistic regression models adjusted for demographic, socioeconomic, and comorbid medical conditions, OSA was positively associated with COVID-19 infection (adjusted odds ratio: 1.58, 95% CI: 1.39-1.79) and COVID-19 hospitalization (adjusted odds ratio: 1.55, 95% CI: 1.17-2.05). In fully adjusted models, boosted vaccination status was protective against both infection and hospitalization. Boosted vaccination status attenuated the association between OSA and COVID-19 related hospitalization but not infection. Participants with untreated or symptomatic OSA were at greater risk for COVID-19 infection; those with untreated but not symptomatic OSA were more likely to be hospitalized. CONCLUSIONS In a general population sample, OSA is associated with a greater likelihood of having had a COVID-19 infection and a COVID-19 hospitalization with the greatest impact observed among persons experiencing OSA symptoms or who were untreated for their OSA. Boosted vaccination status attenuated the association between OSA and COVID-19-related hospitalization. CITATION Quan SF, Weaver MD, Czeisler MÉ, et al. Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among U.S. adults. J Clin Sleep Med. 2023;19(7):1303-1311.
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Affiliation(s)
- Stuart F. Quan
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Matthew D. Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mark É. Czeisler
- Francis Weld Peabody Society, Harvard Medical School, Boston, Massachusetts
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura K. Barger
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Lauren A. Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark E. Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melinda L. Jackson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Rashon Lane
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Christine F. McDonald
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Faculty of Medicine, Monash University, Melbourne Australia
| | - Anna Ridgers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Rebecca Robbins
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Shantha M.W. Rajaratnam
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Charles A. Czeisler
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
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Booker LA, Lenz KE, Spong J, Deacon-Crouch M, Wilson DL, Nguyen TH, Skinner TC. High-Temperature Pasteurization Used at Donor Breast Milk Banks Reduces Melatonin Levels in Breast Milk. Breastfeed Med 2023. [PMID: 37257176 DOI: 10.1089/bfm.2023.0068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Background and Objective: Donor human milk banks are used when breast milk directly from mothers is unavailable or insufficient. Breast milk contains melatonin, which exhibits a 24-hour pattern. Melatonin promotes sleep onset and is barely detected in daytime milk but rises in the evening and peaks early in the morning. Melatonin supports the development of an infant's own circadian rhythm and is important for neurodevelopment. Currently, donor banks pasteurize breast milk using a Holder Pasteurization (HoP) technique where breast milk is treated at a high temperature (+62°) for 30 minutes before cooling to eliminate any pathogens before it is given to infants. It is not known how the pasteurization process affects the melatonin levels in breast milk. The aim of this study was to investigate whether the pasteurization process reduces melatonin levels in breast milk. Materials and Methods: Ten night-time breast milk samples were collected and each divided into two groups; one group remained unpasteurized and the other group was pasteurized using the HoP technique. Results: Melatonin levels between the unpasteurized and pasteurized groups were compared. Results showed that there was a significant reduction after pasteurization (mean ± standard deviation = 51.92 pg/mL ± 19.54 versus 39.66 pg/mL ± 13.05, p = 0.01). Conclusions: It is important to understand that pasteurization can reduce melatonin levels in breast milk because this hormone is considered important to support the neurodevelopment of infants, especially those born preterm. Further focus on the effect of pasteurization techniques on melatonin in donor breast milk is warranted.
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Affiliation(s)
- Lauren A Booker
- School of Psychology & Public Health, La Trobe University, Bendigo, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Katrin E Lenz
- School of Psychology & Public Health, La Trobe University, Bendigo, Victoria, Australia
| | - Jo Spong
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Rural Department of Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Melissa Deacon-Crouch
- Rural Department of Health Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Danielle L Wilson
- School of Psychology & Public Health, La Trobe University, Bendigo, Victoria, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Trang H Nguyen
- Department of Rural Clinical Sciences, La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - Timothy C Skinner
- School of Psychology & Public Health, La Trobe University, Bendigo, Victoria, Australia
- Department of Psychology, Centre for Health and Society, University of Copenhagen, Copenhagen, Denmark
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13
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Quan SF, Weaver MD, Czeisler MÉ, Barger LK, Booker LA, Howard ME, Jackson ML, Lane RI, McDonald CF, Ridgers A, Robbins R, Varma P, Wiley JF, Rajaratnam SMW, Czeisler CA. Insomnia, Poor Sleep Quality and Sleep Duration and Risk for COVID-19 Infection and Hospitalization. Am J Med 2023:S0002-9343(23)00248-6. [PMID: 37075878 PMCID: PMC10108572 DOI: 10.1016/j.amjmed.2023.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/31/2023] [Accepted: 04/02/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Medical comorbidities increase the risk of severe acute COVID-19 illness. Although sleep problems are common after COVID-19 infection, it is unclear whether insomnia, poor sleep quality and extremely long or short sleep increase risk of developing COVID-19 infection or hospitalization. METHODS Cross-sectional survey of a diverse sample of 19,926 U.S. adults RESULTS: COVID-19 infection and hospitalization prevalence rates were 40.1% and 2.9% respectively. Insomnia and poor sleep quality were reported in 19.8% and 40.1% respectively. In logistic regression models adjusted for comorbid medical conditions and sleep duration but excluding participants who reported COVID-19 associated sleep problems, poor sleep quality but not insomnia was associated with COVID-19 infection (aOR: 1.16, 95%CI: 1.07-1.26) and COVID-19 hospitalization (aOR: 1.50, 95% CI: 1.18-1.91). In comparison to habitual sleep duration of 7-8 hours, sleep durations less than 7 hours (aOR: 1.14, 95% CI: 1.06-1.23) and sleep duration of 12 hours (aOR: 1.61, 95% CI: 1.12-2.31) were associated with increased odds of COVID-19 infection. Overall, the relationship between COVID-19 infection and hours of sleep followed a quadratic (U shaped) pattern. No association between sleep duration and COVID-19 hospitalization was observed. CONCLUSION In a general population sample, poor sleep quality and extremes of sleep duration are associated with greater odds of having had a COVID-19 infection; poor sleep quality was associated with an increased requirement of hospitalization for severe COVID-19 illness. These observations suggest that inclusion of healthy sleep practices in public health messaging may reduce the impact of the COVID-19 pandemic.
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Affiliation(s)
- Stuart F Quan
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; Division of Sleep Medicine, Harvard Medical School, Boston, MA.
| | - Matthew D Weaver
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Mark É Czeisler
- Francis Weld Peabody Society, Harvard Medical School, Boston, MA; School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Laura K Barger
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Lauren A Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia; Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Melinda L Jackson
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Rashon I Lane
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA
| | - Christine F McDonald
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia; Faculty of Medicine, Monash University, Melbourne, Australia
| | - Anna Ridgers
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rebecca Robbins
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Prerna Varma
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Joshua F Wiley
- School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Shantha M W Rajaratnam
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; School of Psychological Sciences, Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia; Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Charles A Czeisler
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, MA; Division of Sleep Medicine, Harvard Medical School, Boston, MA
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Murray JM, Magee M, Giliberto ES, Booker LA, Tucker AJ, Galaska B, Sibenaller SM, Baer SA, Postnova S, Sondag TA, Phillips AJ, Sletten TL, Howard ME, Rajaratnam SM. Mobile app for personalized sleep–wake management for shift workers: A user testing trial. Digit Health 2023; 9:20552076231165972. [PMID: 37009306 PMCID: PMC10064476 DOI: 10.1177/20552076231165972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
Objective Development of personalized sleep–wake management tools is critical to improving sleep and functional outcomes for shift workers. The objective of the current study was to test the performance, engagement and usability of a mobile app ( SleepSync) for personalized sleep–wake management in shift workers that aid behavioural change and provide practical advice by providing personalized sleep scheduling recommendations and education. Methods Shift workers ( n = 27; 20 healthcare and 7 from other industries) trialled the mobile app for two weeks to determine performance, engagement and usability. Primary outcomes were self-reported total sleep time, ability to fall asleep, sleep quality and perception of overall recovery on days off. Secondary performance outcomes included sleep disturbances (insomnia and sleep hygiene symptoms, and sleep-related impairments) and mood (anxiety, stress and depression) pre- and post-app use. Satisfaction with schedule management, integration into daily routine and influence on behaviour were used to determine engagement, while the usability was assessed for functionality and ease of use of features. Results Total sleep time ( P = .04), ability to fall asleep ( P < .001), quality of sleep ( P = .001), insomnia ( P = .02), sleep hygiene ( P = .01), sleep-related impairments ( P = .001), anxiety ( P = .001), and stress ( P = .006) were all improved, with non-significant improvements in recovery on days off ( P = .19) and depression ( P = .07). All measures of engagement and usability were scored positively by the majority of users. Conclusions This pilot trial provides preliminary evidence of the positive impact of the SleepSync app in improving sleep and mood outcomes in shift workers, and warrants confirmation in a larger controlled trial.
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Affiliation(s)
- Jade M. Murray
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
| | - Michelle Magee
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
| | - Emma S. Giliberto
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
| | - Lauren A. Booker
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Australia
| | - Andrew J. Tucker
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
| | - Beth Galaska
- Philips RS North America LLC f/k/a Respironics Inc, Murrysville, USA
| | | | - Sharon A. Baer
- Philips RS North America LLC f/k/a Respironics Inc, Murrysville, USA
| | - Svetlana Postnova
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
- School of Physics, University of Sydney, Sydney, Australia
| | | | - Andrew J.K. Phillips
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
| | - Tracey L. Sletten
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
| | - Mark E. Howard
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Australia
| | - Shantha M.W. Rajaratnam
- Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Clayton, Australia
- Cooperative Research Centre for Alertness, Safety and Productivity, Clayton, Australia
- Shantha M.W. Rajaratnam, Turner Institute for Brain and Mental Health, School of Psychological Sciences, 18 Innovation Walk, Monash University, Clayton, Victoria 3800, Australia.
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Czeisler MÉ, Lane RI, Orellana RC, Lundeen K, Macomber K, Collins J, Varma P, Booker LA, Rajaratnam SM, Howard ME, Czeisler CA, Flannery B, Weaver MD. Perception of Local COVID-19 Transmission and Use of Preventive Behaviors Among Adults with Recent SARS-CoV-2 Infection - Illinois and Michigan, June 1-July 31, 2022. MMWR Morb Mortal Wkly Rep 2022; 71:1471-1478. [PMID: 36395064 PMCID: PMC9707356 DOI: 10.15585/mmwr.mm7146a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
During the early stages of the COVID-19 pandemic, use of preventive behaviors was associated with perceived risk for contracting SARS-CoV-2 infection (1,2). Over time, perceived risk has declined along with waning COVID-19-related media coverage (3,4). The extent to which communities continue to be aware of local COVID-19 transmission levels and are implementing recommended preventive behaviors is unknown. During June 1-July 31, 2022, health departments in DuPage County, Illinois and metropolitan Detroit, Michigan surveyed a combined total of 4,934 adults who had received a positive test result for SARS-CoV-2 during the preceding 3 weeks. The association between awareness of local COVID-19 transmission and use of preventive behaviors and practices was assessed, both in response to perceived local COVID-19 transmission levels and specifically during the 2 weeks preceding SARS-CoV-2 testing. Both areas had experienced sustained high COVID-19 transmission during the study interval as categorized by CDC COVID-19 transmission levels.* Overall, 702 (14%) respondents perceived local COVID-19 transmission levels as high, 987 (20%) as substantial, 1,902 (39%) as moderate, and 581 (12%) as low; 789 (16%) reported they did not know. Adjusting for geographic area, age, gender identity, and combined race and ethnicity, respondents who perceived local COVID-19 transmission levels as high were more likely to report having made behavioral changes because of the level of COVID-19 transmission in their area, including wearing a mask in public, limiting travel, and avoiding crowded places or events. Continued monitoring of public perceptions of local COVID-19 levels and developing a better understanding of their influence on the use of preventive behaviors can guide COVID-19 communication strategies and policy making during and beyond the pandemic.
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Booker LA, Spong J, Deacon-Crouch M, Skinner TC. Preliminary Exploration into the Impact of Mistimed Expressed Breast Milk Feeding on Infant Sleep Outcomes, Compared to Other Feeding Patterns. Breastfeed Med 2022; 17:853-858. [PMID: 36137055 DOI: 10.1089/bfm.2022.0125] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background and Objective: The presence and fluctuation of melatonin in breast milk during the night and day may be providing sleep timing information to infants, thereby supporting/enabling the development of their own circadian cycle. If this is the case, then it is important that infants consume breast milk according to the time of day it is produced. However, breast milk is not always consumed at the "right" time. The aim of this study was to investigate whether consuming mistimed expressed breast milk impacts infant sleep compared with other feeding types. Methods: A total of 329 mothers completed an online anonymous survey. Mothers were grouped into one of five groups; direct breastfed only, formula only, express mistimed, express-timed, and combined breastfed/formula fed. Results: Cross-sectional analysis showed mistimed expressed breast milk was significantly associated with delayed sleep onset of the infant (p < 0.001), but direct breastfed infants had significantly more awakenings at night (p < 0.001). Conclusions: The findings from this study suggest a potential effect of mistimed expressed breast milk consumption on an infant's circadian rhythm, affecting some aspects of their sleep. This is an important first step in exploring mistimed feeding on infant sleep outcomes and provides preliminary evidence that warrants future research.
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Affiliation(s)
- Lauren A Booker
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Jo Spong
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia.,Rural Department of Community Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Melissa Deacon-Crouch
- Rural Department Nursing & Midwifery, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Timothy C Skinner
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia.,Department of Psychology, Centre for Health and Society, University of Copenhagen, Copenhagen, Denmark
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17
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Booker LA, Cordon EL, Pedersen HS, Fosgerau CF, Egerton S, Chan CKY, Skinner TC. Different Behavior-Change Messaging Techniques Do Not Increase Customers' Hand Sanitization Adherence During the COVID-19 Pandemic: A Natural Behavioral Study. Front Psychol 2022; 13:876131. [PMID: 35756219 PMCID: PMC9218524 DOI: 10.3389/fpsyg.2022.876131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Hand hygiene is an integral public health strategy in reducing the transmission of COVID-19, yet the past research has shown hand hygiene practices among the public is sub-optimal. This study aimed to (1) quantify hand sanitization rates among the public to minimize the transmission of COVID-19 and (2) evaluate whether different public health messaging, based on various behavior-change theories influences hand hygiene behavior in a natural setting. Methods An observational, naturalistic study design was used with real-time customer activity data recorded against hand sanitizer usage in a regional hardware store. Primary outcome from the study was to measure the usage ratio by counting the amount of activity versus usage of hand sanitizer per hour against individual messages based on their behavioral change technique (BCT). Results There was no significant difference between the baseline message and any of the intervention messages [F(16,904) = 1.19, p = 0.279] or between BCT groups [F(3,906) = 1.33, p = 0.263]. Post hoc tests showed no significant difference between messages (social comparison, p = 0.395; information, p = 1.00; and action planning, p = 1.00). Conclusion This study showed that even during a pandemic, hand hygiene usage rates in a public setting were similar to the past studies and that compliance did not shift dependent on the public message displayed. This raises questions on whether requirements imposed on businesses to provide hand sanitizer to patrons are an ineffective and maybe an unnecessary economic burden. A measured approach to risk and behavioral analysis surrounding the use of hand sanitizer in a pandemic is suggested as a better approach to inform public policy on the value of hand sanitizer.
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Affiliation(s)
- Lauren A Booker
- La Trobe Rural Health School, La Trobe University, Melbourne, VIC, Australia
| | - Emma L Cordon
- La Trobe Rural Health School, La Trobe University, Melbourne, VIC, Australia
| | - Hanne Sæderup Pedersen
- Department of Nordic Studies and Linguistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Simon Egerton
- Department of Computer Science and Information Technology, La Trobe University, Melbourne, VIC, Australia
| | - Carina K Y Chan
- School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Timothy C Skinner
- La Trobe Rural Health School, La Trobe University, Melbourne, VIC, Australia.,Department of Psychology, Centre for Health, and Society, University of Copenhagen, Copenhagen, Denmark
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18
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Huang QF, Rolf F, Booker LA, Moore T, Thompson SC. A qualitative study of how COVID-19 impacts on Australians' hopes and dreams. BMC Public Health 2022; 22:367. [PMID: 35189875 PMCID: PMC8860267 DOI: 10.1186/s12889-022-12746-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 02/09/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although beginning in 2019, it was early in 2020 that the global community began to comprehend the significant impact that a pandemic of a new coronavirus might have on their own lives. This study was undertaken 6-9 months after significant public health restrictions were introduced within Australia and examined the impact of the COVID-19 on individuals' hopes and dreams for their future. METHODS Community members who responded to a survey about COVID-19 were invited to participate in follow up interviews if they reported living with a chronic condition. Participants across Australia who consented were interviewed between August and December in 2020 over telephone or videoconferencing. A specific question was included regarding the impact of COVID-19 on their hopes and dreams for the future. Rapid identification of themes with an audio recordings technique was used to generate themes from the data. RESULTS The 90 participants were predominantly female (77%) and ranged in age from 20 to 81 years with a mean age of 50 years and lived in several Australian states. Following immersive analysis of interviews, the identified common themes impacting people's hopes and dreams revealed: concerns for their own and others' job stability and future work; the impact on travel both for holidays, business and reconnecting with family; reassessing of personal and social values; and the intergenerational impact of such a profound pandemic, with concern for younger people particularly prominent in those concerns. Participants reflected on their loss of future dreams, with possibilities they had planned and worked towards not possible in the short term. CONCLUSIONS The responses provide a window into how people view their future goals and aspirations during a time of global and local instability and highlights the potential future impacts of the COVID-19 pandemic.
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Affiliation(s)
- Quincy F. Huang
- Western Australian Centre for Rural Health, University of Western Australia, PO Box 109, Geraldton, WA 6531 Australia
- School of Nursing and Health Studies, Georgetown University, Washington, DC USA
| | - Floraidh Rolf
- Southern Queensland Rural Health, Faculty of Health and Behavioural Sciences, The University of Queensland, Charleville, Queensland Australia
| | - Lauren A. Booker
- University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria Australia
| | - Taleah Moore
- Western Australian Centre for Rural Health, University of Western Australia, PO Box 109, Geraldton, WA 6531 Australia
| | - Sandra C. Thompson
- Western Australian Centre for Rural Health, University of Western Australia, PO Box 109, Geraldton, WA 6531 Australia
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19
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Booker LA, Sletten TL, Barnes M, Alvaro P, Collins A, Chai-Coetzer CL, McMahon M, Lockley SW, Rajaratnam SMW, Howard ME. The effectiveness of an individualized sleep and shift work education and coaching program to manage shift work disorder in nurses: a randomized controlled trial. J Clin Sleep Med 2021; 18:1035-1045. [PMID: 34870586 DOI: 10.5664/jcsm.9782] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES While insomnia and sleepiness symptoms are common in shift workers, 20-30% experience more severe symptoms and meet the criteria for shift work disorder (SWD). SWD can lead to impairments in cognitive function, physical and mental health, and reduced productivity and increased risk of workplace injury. The aim of this study was to deliver and evaluate a shift work individual management coaching program, focusing on sleep education, promoting good sleep hygiene, and providing individualized behavioral strategies to cope with shift schedules. METHODS A clustered randomized controlled trial of sleep education and sleep disorders screening was undertaken, based on hospital wards at a tertiary hospital in Melbourne, Australia. Participants identified as high risk for SWD underwent one of two 8-week programs; a shift work individualized management program (S.W.I.M.) or an active control. The primary outcome was ward-based sick leave. Secondary outcomes were SWD risk, sleep hygiene, insomnia, depression, and anxiety. A total of 149 nurses, across 16 wards (96% female, 34.66 ± 11.99 years) completed both baseline and follow-up questionnaires (23.9% were high risk SWD). RESULTS There was no significant reduction in sick leave between intervention and control wards (mean difference=1.2 days, p=.063). Improvements were seen in insomnia (p<.0001*), and depression (intervention, p=<.0001*, control, p=.023) in both groups, but were not significantly different between programs. Anxiety (p=.001. control p=.079) and FOSQ (p=.001 control p=.056) improved only for the intervention. CONCLUSIONS This SWD intervention trial did not reduce sick leave compared to the active control but there was an improvement. Improvements in sleep hygiene, insomnia, depression, and anxiety severity were seen for both groups. Future intervention trials should consider including both sleep and mental health interventions, strategies to avoid between group contamination and the duration of programs for optimal behavioral modification. CLINICAL TRIAL REGISTRATION Registry: Australian New Zealand Clinical Trials Registry; Identifier: ACTRN12616000369426.
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Affiliation(s)
- Lauren A Booker
- Turner Institute for Brain and Mental Health, School of Psychological Sciences Monash University, Clayton, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
| | - Tracey L Sletten
- Turner Institute for Brain and Mental Health, School of Psychological Sciences Monash University, Clayton, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,University of Melbourne, Parkville, Victoria Australia
| | - Pasquale Alvaro
- Flinders University, School of Psychology, Adelaide, SA, Australia
| | - Allison Collins
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, Flinders University, SA, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, SA, Australia
| | - Marcus McMahon
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Steven W Lockley
- Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Shantha M W Rajaratnam
- Turner Institute for Brain and Mental Health, School of Psychological Sciences Monash University, Clayton, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mark E Howard
- Turner Institute for Brain and Mental Health, School of Psychological Sciences Monash University, Clayton, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,University of Melbourne, Parkville, Victoria Australia
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20
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Gupta CC, Duncan MJ, Ferguson SA, Rebar A, Sprajcer M, Khalesi S, Booker LA, Binks H, Vincent GE. The Discrepancy between Knowledge of Sleep Recommendations and the Actual Sleep Behaviour of Australian Adults. Behav Sleep Med 2021; 19:828-839. [PMID: 33492169 DOI: 10.1080/15402002.2021.1876693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Inadequate sleep is a major public health concern, with large economic, health, and operational costs to Australia. Despite the implementation of public sleep health campaigns, approximately 40% of Australian adults do not obtain the recommended 7-9 hours of sleep. Thus, while people may know how much sleep is required, this knowledge may not be adequately translated to actual sleep behavior. Consequently, this study aims to examine the discrepancy between knowledge of sleep recommendations and self-reported sleep behaviors.Methods: A sample of 1265 Australian adults (54% female, aged 18-65) completed a phone interview as part of the 2017 National Social Survey and were asked questions about their knowledge of sleep guidelines and their actual sleep behavior. Binary logistic regression was used to determine the factors associated with awareness of sleep recommendations and whether this corresponded with reported sleep duration.Results: The final sample size was 998. Although 94% of the sample were aware of current sleep recommendations, 23% of participants did not self-report regularly obtaining 7-9 h sleep per night. These participants were less likely to want to obtain more sleep, less likely to view sleep as a priority before stressful events, and less likely to self-report good health.Conclusion: Although a majority of the sample were aware of sleep recommendations, almost a quarter of the participants' behavior did not align with their knowledge. Future sleep health campaigns should consider options beyond education, including emphasis on practical strategies and modifiable lifestyle factors to assist individuals to obtain the recommended amount of sleep.
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Affiliation(s)
- Charlotte C Gupta
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
| | - Mitch J Duncan
- School of Medicine & Public Health; Faculty of Health and Medicine, The University of Newcastle, University Drive, Australia.,Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, University Drive, Adelaide, Australia
| | - Sally A Ferguson
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
| | - Amanda Rebar
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
| | - Madeline Sprajcer
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
| | - Saman Khalesi
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
| | - Lauren A Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Australia.,University Department of Rural Health, La Trobe Rural Health School, La Trobe University, Victoria, Australia
| | - Hannah Binks
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
| | - Grace E Vincent
- Appleton Institute, School of Health, Medical and Applied Sciences, Central Queensland University, Adelaide, Australia
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21
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Campbell N, Thompson SC, Tynan A, Townsin L, Booker LA, Argus G. Silver Linings Reported by Australians Experiencing Public Health Restrictions during the First Phase of the COVID-19 Pandemic: A Qualitative Report. Int J Environ Res Public Health 2021; 18:11406. [PMID: 34769921 PMCID: PMC8582702 DOI: 10.3390/ijerph182111406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/25/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022]
Abstract
This national study investigated the positives reported by residents experiencing the large-scale public health measures instituted in Australia to manage the first wave of the COVID-19 pandemic in 2020. Most Australians had not previously experienced the traditional public health measures used (social distancing, hand hygiene and restriction of movement) and which could potentially impact negatively on mental well-being. The research design included qualitative semi-structured phone interviews where participants described their early pandemic experiences. Data analysis used a rapid identification of themes technique, well-suited to large-scale qualitative research. The ninety participants (mean age 48 years; 70 women) were distributed nationally. Analysis revealed five themes linked with mental well-being and the concept of silver linings: safety and security, gratitude and appreciation, social cohesion and connections, and opportunities to reset priorities and resilience. Participants demonstrated support for the public health measures and evidence of individual and community resilience. They were cognisant of positives despite personal curtailment and negative impacts of public health directives. Stories of hope, strength, and acceptance, innovative connections with others and focusing on priorities and opportunities within the hardship were important strategies that others could use in managing adversity.
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Affiliation(s)
- Narelle Campbell
- Rural and Remote Health College of Medicine and Public Health, Flinders University, Darwin 0815, Australia
| | - Sandra C. Thompson
- Western Australian Centre for Rural Health, University of Western Australia, Geraldton 6530, Australia;
| | - Anna Tynan
- Research Support Team, Darling Downs Health, Toowoomba 4350, Australia;
- Southern Queensland Rural Health, The University of Queensland, Toowoomba 4350, Australia;
| | - Louise Townsin
- Research Office, Torrens University Australia, Adelaide 5000, Australia;
| | - Lauren A. Booker
- La Trobe Rural Health School, University Department of Rural Health, La Trobe University, Bendigo 3551, Australia;
| | - Geoff Argus
- Southern Queensland Rural Health, The University of Queensland, Toowoomba 4350, Australia;
- School of Psychology and Counselling, University of Southern Queensland, Toowoomba 4350, Australia
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22
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Booker LA, Barnes M, Alvaro P, Collins A, Chai-Coetzer CL, McMahon M, Lockley SW, Rajaratnam SMW, Howard ME, Sletten TL. The role of sleep hygiene in the risk of Shift Work Disorder in nurses. Sleep 2021; 43:5602177. [PMID: 31637435 DOI: 10.1093/sleep/zsz228] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 08/21/2019] [Indexed: 12/27/2022] Open
Abstract
A high proportion (20%-30%) of shift workers experience Shift Work Disorder (SWD), characterized by chronic sleepiness and/or insomnia associated with work schedules. The reasons for individual variation in shift work tolerance are not well understood, however. The aim of this study was to identify individual factors that contribute to the risk of SWD. Nurses (n = 202) were categorized as low or high risk of SWD based on the Shift Work Disorder Questionnaire. Participants provided demographic and lifestyle information and completed the Sleep Hygiene Index (SHI) and Morningness-Eveningness Questionnaire (MEQ). High risk of SWD was associated with poorer sleep hygiene (SHI, 35.41 ± 6.19 vs. 31.49 ± 7.08, p < .0001) and greater eveningness (MEQ, 34.73 ± 6.13 vs. 37.49 ± 6.45, p = .005) compared to low risk. No other factors, including body mass index, marital status, having children, or caffeine or alcohol intake were significant. Logistic regression showed that SHI was the most significant contributing factor to SWD risk (odds ratio [OR] = 1.09, 95% confidence interval [CI] = 1.04 to 1.14). Standardized odds ratio further revealed that with every unit increase on the SHI score, the odds of being at high risk of SWD increased by 80% (OR = 1.84). Most individuals at high risk of SWD reported "always" or "frequently" going to bed at different times (79%) and waking at different times (83%; compared to 58%, p = .017, and 61%, p = .002, respectively for the low-risk group), as well as going to bed stressed/angry (67% vs. 41%, p < .0001) and/or planning/worrying in bed (54% vs. 22%, p < .0001). Interventions aimed at improving sleep hygiene practices and psychological health of shift workers may help reduce the risk of SWD.
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Affiliation(s)
- Lauren A Booker
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Cooperative Research Centre for Alertness, Safety and Productivity, University of Melbourne, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Pasquale Alvaro
- Flinders University, School of Psychology, Adelaide, South Australia, Australia
| | - Allison Collins
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - Marcus McMahon
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Steven W Lockley
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Cooperative Research Centre for Alertness, Safety and Productivity, University of Melbourne, Melbourne, Victoria, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Shantha M W Rajaratnam
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Cooperative Research Centre for Alertness, Safety and Productivity, University of Melbourne, Melbourne, Victoria, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, MA.,Division of Sleep Medicine, Harvard Medical School, Boston, MA
| | - Mark E Howard
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Cooperative Research Centre for Alertness, Safety and Productivity, University of Melbourne, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Tracey L Sletten
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Cooperative Research Centre for Alertness, Safety and Productivity, University of Melbourne, Melbourne, Victoria, Australia
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23
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Booker LA, Sletten TL, Alvaro PK, Barnes M, Collins A, Chai-Coetzer CL, Naqvi A, McMahon M, Lockley SW, Rajaratnam SMW, Howard ME. Exploring the associations between shift work disorder, depression, anxiety and sick leave taken amongst nurses. J Sleep Res 2019; 29:e12872. [PMID: 31144389 DOI: 10.1111/jsr.12872] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 03/28/2019] [Accepted: 04/21/2019] [Indexed: 11/26/2022]
Abstract
This study aimed to evaluate the association between shift work disorder and mental health in hospital-based nurses. Staff completed an online survey comprising demographic questions, the Shift Work Disorder Questionnaire, Patient Health-9 and the General Anxiety Disorder-7 scale. Sick leave data were collected from archival records from the Human Resources Department. Two hundred and two nurses (95% female; age M = 35.28 years ± SD = 12) participated (42% of eligible staff). Those at high risk of shift work disorder had higher depression (M = 7.54 ± SD = 4.28 vs. M = 3.78 ± SD = 3.24; p < 0.001) and anxiety (M = 5.66 ± SD = 3.82 vs. M = 2.83 ± SD = 3.33, p < 0.001) compared to those at low risk. Linear regression models showed that being at high risk of shift work disorder was the most significant predictor of depression, explaining 18.8% of the variance in depression (R2 = 0.188, adjusted R2 = 0.184, F(1, 200) = 46.20, p < 0.001). Shift work disorder combined with the number of night shifts and alcoholic drinks on non-work days accounted for 49.7% of the variance in anxiety scores (R2 = 0.497, adjusted R2 = 0.453, F(3, 35) = 11.51, p < 0.001). Mean sick leave in those with high risk of shift work disorder was 136.17 hr (SD = 113.11) versus 103.98 hr (SD = 94.46) in others (p = 0.057). Depression and years of shift work accounted for 18.9% of the variance in sick leave taken (R2 = 0.189, adjusted R2 = 0.180, F(2, 175) = 20.36, p < 0.001). Shift work disorder is strongly associated with depression and anxiety, providing a potential target to improve mental health in shift workers. Depression, in turn, is a significant contributing factor to sick leave.
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Affiliation(s)
- Lauren A Booker
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia
| | - Tracey L Sletten
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia
| | - Pasquale K Alvaro
- School of Psychology, Flinders University, Adelaide, South Australia, Australia
| | - Maree Barnes
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,University of Melbourne, Parkville, Victoria, Australia
| | - Allison Collins
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health: A Flinders Centre of Research Excellence, Flinders University, Adelaide, South Australia, Australia.,Respiratory and Sleep Services, Southern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - Aqsa Naqvi
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia
| | - Marcus McMahon
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - Steven W Lockley
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Shantha M W Rajaratnam
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts.,Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Mark E Howard
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia.,School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia.,Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Australia.,University of Melbourne, Parkville, Victoria, Australia
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24
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Booker LA, Magee M, Rajaratnam SMW, Sletten TL, Howard ME. Individual vulnerability to insomnia, excessive sleepiness and shift work disorder amongst healthcare shift workers. A systematic review. Sleep Med Rev 2018; 41:220-233. [PMID: 29680177 DOI: 10.1016/j.smrv.2018.03.005] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 03/16/2018] [Accepted: 03/21/2018] [Indexed: 12/21/2022]
Abstract
Shift workers often experience reduced sleep quality, duration and/or excessive sleepiness due to the imposed conflict between work and their circadian system. About 20-30% of shift workers experience prominent insomnia symptoms and excessive daytime sleepiness consistent with the circadian rhythm sleep disorder known as shift work disorder. Individual factors may influence this vulnerability to shift work disorder or sleep-related impairment associated with shift work. This paper was registered with Prospero and was conducted using recommended standards for systematic reviews and meta-analyses. Published literature that measured sleep-related impairment associated with shift work including reduced sleep quality and duration and increased daytime sleepiness amongst healthcare shift workers and explored characteristics associated with individual variability were reviewed. Fifty-eight studies were included. Older age, morning-type, circadian flexibility, being married or having children, increased caffeine intake, higher scores on neuroticism and lower on hardiness were related to a higher risk of sleep-related impairment in response to shift work, whereas physical activity was a protective factor. The review highlights the diverse range of measurement tools used to evaluate the impact of shift work on sleep. Use of standardised and validated tools would enable cross-study comparisons. Longitudinal studies are required to establish causal relationships between individual factors and the development of shift work disorder.
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Affiliation(s)
- Lauren A Booker
- Institute for Breathing and Sleep, Austin Health, Austin Hospital, Heidelberg, Victoria, Australia; School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia; Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Victoria, Australia.
| | - Michelle Magee
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia; Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Victoria, Australia
| | - Shantha M W Rajaratnam
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia; Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Victoria, Australia
| | - Tracey L Sletten
- School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia; Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Austin Health, Austin Hospital, Heidelberg, Victoria, Australia; School of Psychological Sciences and Monash Institute of Cognitive and Clinical Neurosciences, Monash University, Melbourne, Victoria, Australia; Cooperative Research Centre for Alertness, Safety and Productivity, Melbourne, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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25
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Bertino JS, Booker LA, Franck PA, Jenkins PL, Franck KR, Nafziger AN. Incidence of and significant risk factors for aminoglycoside-associated nephrotoxicity in patients dosed by using individualized pharmacokinetic monitoring. J Infect Dis 1993; 167:173-9. [PMID: 8418164 DOI: 10.1093/infdis/167.1.173] [Citation(s) in RCA: 141] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Incidence of and risk factors for aminoglycoside-associated nephrotoxicity (AAN) were evaluated in 1489 patients prospectively monitored with individualized pharmacokinetic monitoring (IPM). Incidence of AAN was 7.9% with individual (univariate) risk factors including advanced age, decreased albumin, poor nutritional status, pneumonia, concurrent furosemide, amphotericin B, vancomycin, cephalosporin, or piperacillin, intensive care unit treatment, leukemia, rapidly fatal illness, liver or renal disease, reduced aminoglycoside clearance, elevated initial steady-state trough concentration (Cminss), volume of distribution or half-life, duration of therapy, total dose, fever, male gender, shock, pleural effusion, and ascites. Multiple logistic regression revealed that Cminss, concurrent clindamycin, vancomycin, piperacillin, or cephalosporin, ascites, advanced age, male gender, decreased albumin, duration of therapy, and leukemia were significant independent risk factors for AAN. Positive predictive value of the model was 30.8%; negative predictive value was 91.7%. No identifiable risk factor alone or in combination was of sufficient sensitivity to reliably predict AAN, but use of IPM may lower the incidence of AAN.
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Affiliation(s)
- J S Bertino
- Department of Pharmacy Services, Clinical Pharmacology Research Center, Cooperstown, New York 13326
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Abstract
The pharmacokinetics of gentamicin were investigated in 880 patients with leukemia (24 patients), other malignancies (211 patients), or no malignancies (645 patients) by using data collected by our Clinical Pharmacy Service. A significant difference was seen in the initial calculated creatinine clearance between the patients with leukemia and the other two groups. No differences in gentamicin pharmacokinetics were seen in patients with other malignancies versus those with no malignancies. Patients with leukemia had significantly faster drug clearance compared with those in the other two groups. A poor predictive value was found for total body clearance of gentamicin versus the initial calculated creatinine clearance in all groups. Multiple logistic regression analysis showed that only the initial calculated creatinine clearance differed in the leukemic group compared with those in the other patients. Our data suggest that no pharmacokinetic difference exists for gentamicin in patients with malignancies.
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Affiliation(s)
- J S Bertino
- Department of Pharmacy Services, Mary Imogene Bassett Hospital, Cooperstown, New York 13326
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Windle ML, Booker LA, Rayburn WF. Postpartum pain after vaginal delivery. A review of comparative analgesic trials. J Reprod Med 1989; 34:891-5. [PMID: 2685288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Perineal tissue injury and uterine cramping within the first 24-48 hours after vaginal delivery are established models for studying pain relief. In this study, information was gathered from prospective, randomized investigations comparing the safety and efficacy of several oral analgesics. Nonsteroidal antiinflammatory drugs (NSAIDs) have been found consistently to be more useful than a placebo or acetaminophen. As compared with aspirin, the newer NSAIDs had a more delayed onset of action but required fewer doses. Mild analgesics were usually all that was necessary, and a combination with codeine was usually unnecessary. Side effects and breast milk concentrations of the drugs were negligible for this short-term therapy. Although no drug was found to be preferable to the others, aspirin and ibuprofen were the least expensive.
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Affiliation(s)
- M L Windle
- Department of Pharmaceutical Services, University of Nebraska Medical Center, Omaha 68105
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