Association of Chronotype and Shiftwork with COVID-19 Infection

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.

Spatiotemporal light exposure modeling for environmental circadian misalignment and solar jetlag

Background

Light exposure is the most powerful resetting signal for circadian rhythms. The objective of this study was to develop and validate a high-resolution geospatial light exposure model that measures environmental circadian misalignment (or solar jetlag) as the mismatch between the social clock and sun clock, which occurs from geographic variation in light exposure leading to delayed circadian phase from relatively less morning light exposure and greater evening light exposure with increasing westward position within a time zone.

Methods

The light exposure model (30 m2 spatial resolution) incorporated geospatial data across the United States on time zones, elevation (using Google Earth Engine), sunrise time, and sunset time to estimate solar jetlag scores (higher values indicate higher environmental circadian misalignment). The validation study compared the light exposure model in 2022, which was linked with geocoded residential addresses of n = 20 participants in Boston, MA (eastern time zone position) and Seattle, WA (western time zone position) using a geographic information system, with illuminance values captured from wearable LYS light sensors and with sun times from the Solar Calculator.

Results

Western versus eastern positions within a time zone were associated with higher solar jetlag scores from the light exposure model (P < 0.01) and relatively larger differences in sunset time measured using light sensors (social clock) and the Solar Calculator (sun clock) (P = 0.04).

Conclusion

We developed and validated a geospatial light exposure model, enabling high spatiotemporal resolution and comprehensive characterization of geographic variation in light exposure potentially impacting circadian phase in epidemiologic studies.

Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 Infection

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.

Sleep and mental health among unpaid caregivers of children, adults, and both: United States, 2022

OBJECTIVES

We sought to characterize sleep and mental health, and their relationship, among unpaid caregivers.

METHODS

During March through August 2022, four waves of cross-sectional surveys were administered to US adults using demographic quota sampling and weighting to improve representativeness of the US adult population.

RESULTS

Among 19,767 respondents, 6260 (31.7%) identified as serving one or more unpaid caregiving roles. Compared to people without caregiving roles, caregivers more commonly reported sleep duration outside the healthy range (7-9 hours), insomnia symptoms, diagnosed sleep disorders, and more commonly screened positive for anxiety, depression, and burnout symptoms. Multivariable analyses adjusted for demographics characteristics revealed unpaid caregivers had several-fold elevated odds of adverse mental health symptoms; associations were attenuated but remained significant after adjusting for impaired and nonoptimal sleep.

CONCLUSIONS

Both sleep and mental health challenges are disproportionately experienced by and commonly co-occur among unpaid caregivers, especially those who care for both children and adults. These populations, which serve critical societal roles, may benefit from enhanced support services to address sleep and mental health.

Public opinion of resident physician work hours in 2022

OBJECTIVE

The purpose of this study was to characterize public awareness and opinion regarding resident physician work hours in the United States.

METHODS

We conducted a nationally representative cross-sectional survey among adults in the United States. Demographic quota-based sampling was conducted by Qualtrics to match 2020 United States Census estimates of age, sex, race, and ethnicity. Descriptive statistics are presented. Hypothesis testing was conducted to identify characteristics associated with agreement with current resident physician work-hour policies.

RESULTS

4763 adults in the United States participated in the study. 97.1% of the public believes that resident physicians should not work 24-hour shifts and 95.6% believe the current 80 hours resident work week is too long. 66.4% of the participants reported that the maximum shift duration should be 12 consecutive hours or fewer, including 22.9% who recommended a maximum shift length of 8 hours. Similarly, 66.4% reported that maximum weekly work hours should be 59 or fewer, including 24.9% who recommended a maximum of 40 weekly work hours.

CONCLUSIONS

Nearly all US adults disagree with current work-hour policies for resident physicians. Public opinion supports limiting shifts to no more than 12 consecutive hours and weekly work to no more than 60 hours, which is in sharp contrast to current regulations that permit of 28 hours shifts and 80 hours of work per week.

The effect of a night shift nap on post-night shift performance, sleepiness, mood, and first recovery sleep: A randomized crossover trial

OBJECTIVES

This study aimed to test the effect of a 30-minute nap versus a 2-hour nap opportunity taken during a simulated night shift on performance, fatigue, sleepiness, mood, and sleep at the end of shift and during post-night shift recovery.

METHODS

We conducted a randomized crossover trial of three nap conditions (30-minute, 2-hour, and no-nap) during 12-hour simulated night shifts. We tested for differences in performance, fatigue, sleepiness, mood, and sleep during in-lab and at-home recovery. Performance was measured with the Brief Psychomotor Vigilance Test (PVT-B). Subjective ratings were assessed with single-item surveys.

RESULTS

Twenty-eight individuals consented to participate [mean age 24.4 (standard deviation 7.2) years; 53.6% female; 85.7% Emergency Medical Services clinicians]. PVT-B false starts at the end of the 12-hour night shift (at 07:00 hours) and at the start of in-lab recovery (08:00 hours) were lower following the 2-hour nap versus other conditions (P<0.05). PVT-B response time at +0 minutes post-recovery nap was poorer compared to pre-recovery nap for the no-nap condition (P=0.003), yet not detected for other nap conditions (P>0.05). Sleepiness, fatigue, and some mood states were lower at most hourly assessments during the in-lab recovery period following the 2-hour nap condition compared to the other conditions. Sleep during recovery did not differ by duration of night shift nap.

CONCLUSIONS

A 2-hour nap opportunity versus a 30-minute or no-nap opportunity is beneficial for performance, alertness, and mood post-night shift. No differences were detected in sleep during recovery.

Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 infection (PASC)

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.

The importance of sleep regularity: a consensus statement of the National Sleep Foundation sleep timing and variability panel

OBJECTIVE

To develop and present consensus findings of the National Sleep Foundation sleep timing and variability panel regarding the impact of sleep timing variability on health and performance.

METHODS

The National Sleep Foundation assembled a panel of sleep and circadian experts to evaluate the scientific evidence and conduct a formal consensus and voting procedure. A systematic literature review was conducted using the NIH National Library of Medicine PubMed database, and panelists voted on the appropriateness of 3 questions using a modified Delphi RAND/UCLA Appropriateness Method with 2 rounds of voting.

RESULTS

The literature search and panel review identified 63 full text publications to inform consensus voting. Panelists achieved consensus on each question: (1) is daily regularity in sleep timing important for (a) health or (b) performance? and (2) when sleep is of insufficient duration during the week (or work days), is catch-up sleep on weekends (or non-work days) important for health? Based on the evidence currently available, panelists agreed to an affirmative response to all 3 questions.

CONCLUSIONS

Consistency of sleep onset and offset timing is important for health, safety, and performance. Nonetheless, when insufficient sleep is obtained during the week/work days, weekend/non-work day catch-up sleep may be beneficial.

Systematic Review of the Impact of Physician Work Schedules on Patient Safety with Meta-Analyses of Mortality Risk

Resident physician work hour limits continue to be controversial. Numerous trials have come to conflicting conclusions about the impact on patient safety of eliminating extended duration work shifts. We conducted meta-analyses to evaluate the impact of work hour policies and work schedules on patient safety. After identifying 8,362 potentially relevant studies and reviewing 688 full-text articles, 132 studies were retained and graded on quality of evidence. Of these, 68 studies provided enough information for consideration in meta-analyses. We found that patient safety improved following implementation of the Accreditation Council for Graduate Medical Education's 2003 and 2011 resident physicians work hour guidelines. Limiting all resident physicians to 80-hour work weeks and 28-hour shifts in 2003 was associated with an 11% reduction in mortality (p < 0.001). Limited shift durations and shorter work weeks were also associated with improved patient safety in clinical trials and observational studies not specifically tied to policy changes. Given the preponderance of evidence showing that patient and physician safety is negatively affected by long work hours, efforts to improve physician schedules should be prioritized. Policies that enable extended-duration shifts and long work weeks should be reexamined. Further research should expand beyond resident physicians to additional study populations, including attending physicians and other health care workers.

Are Short Duration Naps Better than Long Duration Naps for Mitigating Sleep Inertia? Brief Report of a Randomized Crossover Trial of Simulated Night Shift Work

OBJECTIVE

We sought to test the effects of different duration naps on post-nap cognitive performance during simulated night shifts.

METHODS

We used a randomized laboratory-based crossover trial design with simulated 12-hr night shifts and each participant completing three conditions of 72 hrs each (Clinicaltrials.gov; registration # NCT04469803). The three conditions tested included no-nap, a 30-min nap opportunity, and a 2-hr nap opportunity. Naps occurred at 02:00 hrs. Cognitive performance was assessed with the Brief 3-min Psychomotor Vigilance Test (PVT-B). Four PVT-B measures include: reaction time (RT in milliseconds (ms)), lapses (RT > 355 ms), false starts (reactions before stimulus or RT <100 ms), and speed (1,000/RT). The PVT-B was performed at the start of the simulated night shift (19:00), end of shift (07:00), pre-nap (02:00), and at 0 mins, 10 mins, 20 mins, and 30 mins following the 30-min and 2-hr nap conditions. Simultaneously, participants reported subjective ratings of fatigue and other constructs.

RESULTS

Twenty-eight (15 female), mostly certified emergency medical technicians or paramedics, consented to participate. For all three conditions, looking within condition, PVT-B lapse performance at the end of the 12-hr simulated night shift (at 07:00) was poorer compared to shift start (p < 0.05). Performance on PVT-B speed, RT, and false starts were poorer at shift end than shift start for the no-nap and 30-min nap conditions (p < 0.05), but not for the 2-hr nap condition (p > 0.05). Compared to pre-nap measures, performance on the PVT-B assessed at 0 mins post-nap showed significant performance declines for lapses and speed for both the 30-min and 2-hr nap conditions (p < 0.05), but not at 10, 20, or 30 mins post-nap. After waking from the 2-hr on-shift nap opportunity (at 0 mins), participants rated sleepiness, difficulty with concentration, and alertness poorer than pre-nap (p < 0.05). Participants in the 30-min nap condition rated alertness poorer immediately after the nap (at 0 mins) compared to pre-nap (p < 0.05).

CONCLUSIONS

While sleep inertia was detectable immediately following short 30-min and long 2-hr nap opportunities during simulated night shift work, deficits in cognitive performance and subjective ratings quickly dissipated and were not detectable at 10-30 mins post-nap.

Effect of Short versus Long Duration Naps on Blood Pressure during Simulated Night Shift Work: A Randomized Crossover Trial

OBJECTIVE

Blunting of the sleep-related dip in blood pressure (BP) has been linked to numerous cardiovascular outcomes including myocardial infarction. Blunting of BP dipping occurs during night shift work and previous research suggest that a 60-min or longer on-shift nap is needed to restore normal/healthy BP dipping. We sought to determine the effect of different durations of napping on BP during and following simulated night shifts. We hypothesized that the greatest benefit in terms of restoration of normal BP dipping during night shift work would be observed during a longer duration nap versus a shorter nap opportunity.

METHODS

We used a randomized crossover laboratory-based study design. Participants consented to complete three separate 72-hr conditions that included a 12-hr simulated night shift. Nap conditions included a 30-min and 2-hr nap compared to a no-nap condition. Ambulatory BP monitoring was assessed hourly and every 10-30 mins during in-lab naps. Blunted BP dipping during in-lab naps was the primary outcome. Goal enrollment of 25 (35 with attrition) provided 80% power to detect a mean difference of 5 mmHg in BP between nap conditions.

RESULTS

Of the 58 screened, 28 were consented, and 26 completed all three 72-hr conditions. More than half (53.6%) were female. Mean age was 24.4 years (SD7.2). Most (85.7%) were certified as emergency medical technicians or paramedics. The mean percentage dip in systolic BP (SBP) and diastolic BP (DBP) did not differ between the 30-min and 2-hr nap conditions (p > 0.05), yet a greater proportion of participants experienced a 10-20% dip in SBP or DBP during the 2-hr nap versus the 30-min nap (p < 0.05). For every additional minute of total sleep during the 30-min nap, the percentage of SBP dip improved by 0.60%, and the percentage of DBP dip improved by 0.68% (p < 0.05). These improvements approximate to a 6% per minute relative advancement toward normal/healthy BP dipping.

CONCLUSIONS

Restoration of a normal/healthy dip in BP is achievable during short and long duration nap opportunities during simulated night shift work. Our findings support the hypothesis that BP dipping is more common during longer 2-hr versus shorter 30-min naps.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04469803. Registered on 9 July 2020.

Association of Chronotype and Shiftwork with COVID-19 Infection

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.

Associations between obstructive sleep apnea and COVID-19 infection and hospitalization among US adults

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.

Insomnia, Poor Sleep Quality and Sleep Duration and Risk for COVID-19 Infection and Hospitalization

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.

Impact of sleep deficiency on surgical performance: a prospective assessment

STUDY OBJECTIVES

Sleep deficiency can adversely affect the performance of resident physicians, resulting in greater medical errors. However, the impact of sleep deficiency on surgical outcomes, particularly among attending surgeons, is less clear.

METHODS

Sixty attending surgeons from academic and community departments of surgery or obstetrics and gynecology were studied prospectively using direct observation and self-report to explore the effect of sleep deprivation on patient safety, operating room communication, medical errors, and adverse events while operating under 2 conditions, post-call (defined as > 2 hours of nighttime clinical duties) and non-post-call.

RESULTS

Each surgeon contributed up to 5 surgical procedures post-call and non-post-call, yielding 362 cases total (150 post-call and 210 non-post-call). Most common were caesarian section and herniorrhaphy. Hours of sleep on the night before the operative procedure were significantly less post-call (4.98 ± 1.41) vs non-post-call (6.68 ± 0.88, P < .01). Errors were infrequent and not related to hours of sleep or post-call status. However, Non-Technical Skills for Surgeons ratings demonstrated poorer performance while post-call for situational awareness, decision-making, and communication/teamwork. Fewer hours of sleep also were related to lower ratings for situational awareness and decision-making. Decreased self-reported alertness was observed to be associated with increased procedure time.

CONCLUSIONS

Sleep deficiency in attending surgeons was not associated with greater errors during procedures performed during the next day. However, procedure time was increased, suggesting that surgeons were able to compensate for sleep loss by working more slowly. Ratings on nontechnical surgical skills were adversely affected by sleep deficiency.

CITATION

Quan SF, Landrigan CP, Barger LK, et al. Impact of sleep deficiency on surgical performance: a prospective assessment. J Clin Sleep Med. 2023;19(4):673-683.

Impact of work schedules of senior resident physicians on patient and resident physician safety: nationwide, prospective cohort study

Objective

To determine whether long weekly work hours and shifts of extended duration (≥24 hours) are associated with adverse patient and physician safety outcomes in more senior resident physicians (postgraduate year 2 and above; PGY2+).

Design

Nationwide, prospective cohort study.

Setting

United States, conducted over eight academic years (2002-07, 2014-17).

Participants

4826 PGY2+ resident physicians who completed 38 702 monthly web based reports of their work hours and patient and resident safety outcomes.

Main outcome measures

Patient safety outcomes included medical errors, preventable adverse events, and fatal preventable adverse events. Resident physician health and safety outcomes included motor vehicle crashes, near miss crashes, occupational exposures to potentially contaminated blood or other bodily fluids, percutaneous injuries, and attentional failures. Data were analysed with mixed effects regression models that accounted for dependence of repeated measures and controlled for potential confounders.

Results

Working more than 48 hours per week was associated with an increased risk of self-reported medical errors, preventable adverse events, and fatal preventable adverse events as well as near miss crashes, occupational exposures, percutaneous injuries, and attentional failures (all P<0.001). Working between 60 and 70 hours per week was associated with a more than twice the risk of a medical error (odds ratio 2.36, 95% confidence interval 2.01 to 2.78) and almost three times the risk of preventable adverse events (2.93, 2.04 to 4.23) and fatal preventable adverse events (2.75, 1.23 to 6.12). Working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours was associated with an 84% increased risk of medical errors (1.84, 1.66 to 2.03), a 51% increased risk of preventable adverse events (1.51, 1.20 to 1.90), and an 85% increased risk of fatal preventable adverse events (1.85, 1.05 to 3.26). Similarly, working one or more shifts of extended duration in a month while averaging no more than 80 weekly work hours also increased the risk of near miss crashes (1.47, 1.32 to 1.63) and occupational exposures (1.17, 1.02 to 1.33).

Conclusions

These results indicate that exceeding 48 weekly work hours or working shifts of extended duration endangers even experienced (ie, PGY2+) resident physicians and their patients. These data suggest that regulatory bodies in the US and elsewhere should consider lowering weekly work hour limits, as the European Union has done, and eliminating shifts of extended duration to protect the more than 150 000 physicians training in the US and their patients.

Examining understandability, information quality, and presence of misinformation in popular YouTube videos on sleep compared to expert-led videos

The Internet is a common source of sleep information, but may be subject to commercial bias and misinformation. We compared the understandability, information quality, and presence of misinformation of popular YouTube videos on sleep to videos with credible experts. We identified the most popular YouTube videos on sleep/insomnia and 5 videos from experts. Videos were assessed for understanding and clarity using validated instruments. Misinformation and commercial bias were identified by consensus of sleep medicine experts. The most popular videos received on average 8.2 (±2.2) million views; the expert-led videos received on average 0.3 (±0.2) million views. Commercial bias was identified in 66.7% of popular videos and 0% of expert videos (p<0.012). The popular videos featured more misinformation than expert videos (p<0.001). The popular videos about sleep/insomnia on YouTube featured misinformation and commercial bias. Future research may explore methods for disseminating evidence-based sleep information.

The Emergency Medical Services Sleep Health Study: A cluster-randomized trial

BACKGROUND

Greater than half of emergency medical services (EMS) clinician shift workers report poor sleep, fatigue, and inadequate recovery between shifts. We hypothesized that EMS clinicians randomized to receive tailored sleep health education would have improved sleep quality and less fatigue compared to wait-list controls after 3 months.

METHODS

We used a cluster-randomized, 2-arm, wait-list control study design (clinicaltrials.gov identifier: NCT04218279). Recruitment of EMS agencies (clusters) was nationwide. Our study was powered at 88% to detect a 0.4 standard deviation difference in sleep quality with 20 agencies per arm and a minimum of 10 individuals per agency. The primary outcome was measured using the Pittsburgh Sleep Quality Index (PSQI) at 3-month follow-up. Our intervention was accessible in an online, asynchronous format and comprised of 10 brief education modules that address fatigue mitigation topics prescribed by the American College of Occupational Environmental Medicine.

RESULTS

In total, 36 EMS agencies and 678 individuals enrolled. Attrition at 3 months did not differ by study group (Intervention = 17.4% vs. Wait-list control = 18.2%; p = .37). Intention-to-treat analyses detected no differences in PSQI and fatigue scores at 3 months. Per protocol analyses showed the greater the number of education modules viewed, the greater the improvement in sleep quality and the greater the reduction in fatigue (p < .05).

CONCLUSIONS

While intention-to-treat analyses revealed no differences in sleep quality or fatigue at 3 months, per protocol findings identified select groups of EMS clinician shift workers who may benefit from sleep health education. Our findings may inform fatigue risk management programs.

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) enacted a policy in 2011 that restricted first-year resident physicians in the USA to work no more than 16 consecutive hours. This was rescinded in 2017.

METHODS

We conducted a nationwide prospective cohort study of resident physicians for 5 academic years (2002-2007) before and for 3 academic years (2014-2017) after implementation of the 16 hours 2011 ACGME work-hour limit. Our analyses compare trends in resident physician-reported medical errors between the two cohorts to evaluate the impact of this policy change.

RESULTS

14 796 residents provided data describing 78 101 months of direct patient care. After adjustment for potential confounders, the work-hour policy was associated with a 32% reduced risk of resident physician-reported significant medical errors (rate ratio (RR) 0.68; 95% CI 0.64 to 0.72), a 34% reduced risk of reported preventable adverse events (RR 0.66; 95% CI 0.59 to 0.74) and a 63% reduced risk of reported medical errors resulting in patient death (RR 0.37; 95% CI 0.28 to 0.49).

CONCLUSIONS

These findings have broad relevance for those who work in and receive care from academic hospitals in the USA. The decision to lift this work hour policy in 2017 may expose patients to preventable harm.

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

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.

Evaluating the impact of a sleep health education and a personalised smartphone application on sleep, productivity and healthcare utilisation among employees: results of a randomised clinical trial

OBJECTIVES

We evaluated an online Sleep Health and Wellness (SHAW) programme paired with dayzz, a personalised sleep training programme deployed via smartphone application (dayzz app) that promotes healthy sleep and treatment for sleep disorders, among employees at a large healthcare organisation.

DESIGN

Open-label, randomised, parallel-group controlled trial.

SETTING

A healthcare employer in the USA.

PARTICIPANTS

1355 daytime workers.

INTERVENTION

Participants were randomised to intervention (n=794) or control (n=561) on consent. Intervention participants received the SHAW educational programme at baseline plus access to the personalised dayzz app for up to 9 months. The control condition received the intervention at month 10.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measures were sleep-related behavioural changes (eg, consistent sleep schedule); sleep behaviour tracked on an electronic sleep diary and sleep quality. Our secondary outcome measures included employee absenteeism, performance and productivity; stress, mood, alertness and energy; and adverse health and safety outcomes (eg, accidents).

RESULTS

At follow-up, employees in the intervention condition were more likely to report increased sleep duration on work (7.20 vs 6.99, p=0.01) and on free (8.26 vs 8.04, p=0.03) nights. At follow-up, the prevalence of poor sleep quality was lower in the intervention (n=160 of 321, 50%) compared with control (n=184 of 327, 56%) (p=0.04). The mean total dollars lost per person per month due to reduced workplace performance (presenteeism) was less in the intervention condition (US$1090 vs US$1321, p=0.001). Employees in the intervention reported fewer mental health visits (RR 0.72, 95% CI 0.56 to 0.94, p=0.01) and lower healthcare utilisation over the study interval (RR 0.81, 95% CI 0.67 to 0.98, p=0.03). We did not observe differences in stress (4.7 (95% CI 4.6 to 4.8) vs 4.7 (95% CI 4.6 to 4.8)), mood (4.5 (95% CI 4.4 to 4.6) vs 4.6 (95% CI 4.5 to 4.7)), alertness (4.9 (95% CI 4.8 to 5.0) vs 5.0 (95% CI 4.9 to 5.1)) or adverse health and safety outcomes (motor vehicle crashes: OR 0.82 (95% CI 0.34 to 1.9); near-miss crashes: OR=0.89 (95% CI 0.5 to 1.5) and injuries: 0.9 (95% CI 0.6 to 1.3)); energy was higher at follow-up in the intervention group (4.3 vs 4.5; p=0.03).

CONCLUSIONS

Results from this trial demonstrate that a SHAW programme followed by access to the digital dayzz app can be beneficial to both the employee and employer.

TRIAL REGISTRATION NUMBER

NCT04224285.

A Nationally Representative Survey Assessing Restorative Sleep in US Adults

Restorative sleep is a commonly used term but a poorly defined construct. Few studies have assessed restorative sleep in nationally representative samples. We convened a panel of 7 expert physicians and researchers to evaluate and enhance available measures of restorative sleep. We then developed the revised Restorative Sleep Questionnaire (REST-Q), which comprises 9 items assessing feelings resulting from the prior sleep episode, each with 5-point Likert response scales. Finally, we assessed the prevalence of high, somewhat, and low REST-Q scores in a nationally representative sample of US adults (n= 1,055) and examined the relationship of REST-Q scores with other sleep and demographic characteristics. Pairwise correlations were performed between the REST-Q scores and other self-reported sleep measures. Weighted logistic regression analyses were conducted to compare scores on the REST-Q with demographic variables. The prevalence of higher REST-Q scores (4 or 5 on the Likert scale) was 28.1% in the nationally representative sample. REST-Q scores positively correlated with sleep quality (r=0.61) and sleep duration (r=0.32), and negatively correlated with both difficulty falling asleep (r=-0.40) and falling back asleep after waking (r=-0.41). Higher restorative sleep scores (indicating more feelings of restoration upon waking) were more common among those who were: ≥60 years of age (OR=4.20, 95%CI: 1.92-9.17); widowed (OR=2.35, 95%CI:1.01-5.42), and retired (OR=2.02, 95%CI:1.30-3.14). Higher restorative sleep scores were less frequent among those who were not working (OR=0.36, 95%CI: 0.10-1.00) and living in a household with two or more persons (OR=0.51,95%CI:0.29-0.87). Our findings suggest that the REST-Q may be useful for assessing restorative sleep.

Sleep and Alcohol Use Patterns During Federal Holidays and Daylight Saving Time Transitions in the United States

We conducted a retrospective observational study using remote wearable and mobile application data to evaluate whether US public holidays or Daylight Saving Time transitions were associated with significant changes in sleep behaviors, including sleep duration, sleep onset and offset, and the consistency of sleep timing, as well as changes in the point prevalence of alcohol use. These metrics were analyzed using objective, high resolution sleep-wake data (10,350,760 sleep episodes) and 5,777,008 survey responses of 24,250 US subscribers (74.5% male; mean age of 37.6 ± 9.8 years) to the wrist-worn biometric device platform, WHOOP (Boston, Massachusetts, United States), who were active users during 1 May 2020, through 1 May 2021. Compared to baseline, statistically significant differences in sleep and alcohol measures were found on most DST transitions, US public holidays, and their eves. For example, New Year's Eve corresponded with a sleep consistency decrease of 13.8 ± 0.3%, a sleep onset delay of 88.9 ± 3.2 min (00:01 vs. 22:33 baseline) later, a sleep offset delay of 78.1 ± 3.1 min (07:56 vs. 06:39), and an increase in the prevalence of alcohol consumption, with more than twice as many participants having reported alcohol consumption [+138.0% ± 6.7 (74.2% vs. 31.2%)] compared to baseline. In this analysis of a non-random sample of mostly male subscribers conducted during the COVID-19 pandemic, the majority of US public holidays and holiday eves were associated with sample-level increases in sleep duration, decreases in sleep consistency, later sleep onset and offset, and increases in the prevalence of alcohol consumption. Future work would be warranted to explore the generalizability of these findings and their public health implications, including in more representative samples and over longer time intervals.

Prior sleep-wake behaviors are associated with mental health outcomes during the COVID-19 pandemic among adult users of a wearable device in the United States

Objectives

To characterize objective sleep patterns among U.S. adults before and during the COVID-19 pandemic, and to assess for associations between adverse mental health symptoms and (1) sleep duration and (2) the consistency of sleep timing before and during the pandemic.

Design

Longitudinal objective sleep-wake data during January-June 2020 were linked with mental health and substance use assessments conducted during June 2020 for The COVID-19 Outbreak Public Evaluation (COPE) Initiative.

Setting

Adult users of WHOOP—a commercial, digital sleep wearable.

Participants

Adults residing in the U.S. and actively using WHOOP wearable devices, recruited by WHOOP, Inc.

Intervention

The COVID-19 pandemic and its mitigation.

Measurements

Anxiety or depression symptoms, burnout symptoms, and new or increased substance use to cope with stress or emotions.

Results

Of 4912 participants in the primary analytic sample (response rate, 14.9%), we observed acutely increased sleep duration (0.25 h or 15 m) and sleep consistency (3.51 points out of 100) and delayed sleep timing (onset, 18.7 m; offset, 36.6 m) during mid-March through mid-April 2020. Adjusting for demographic and lifestyle variables, participants with persistently insufficient sleep duration and inconsistent sleep timing had higher odds of adverse mental health symptoms and substance use in June 2020.

Conclusions

U.S. adult wearable users displayed increased sleep duration, more consistent sleep timing, and delayed sleep onset and offset times after the COVID-19 pandemic onset, with subsample heterogeneity. Associations between adverse mental health symptoms and pre- and mid-pandemic short sleep duration and inconsistent sleep timing suggest that these characteristics warrant further investigation as potential modifiable mental health and substance use risk factors.

A clinical trial to evaluate the dayzz smartphone app on employee sleep, health, and productivity at a large US employer

Sleep deficiency is a hidden cost of our 24-7 society, with 70% of adults in the US admitting that they routinely obtain insufficient sleep. Further, it is estimated that 50-70 million adults in the US have a sleep disorder. Undiagnosed and untreated sleep disorders are associated with diminished health for the individual and increased costs for the employer. Research has shown that adverse impacts on employees and employers can be mitigated through sleep health education and sleep disorder screening and treatment programs. Smartphone applications (app) are increasingly commonplace and represent promising, scalable modalities for such programs. The dayzz app is a personalized sleep training program that incorporates assessment of sleep disorders and offers a personalized comprehensive sleep improvement solution. Using a sample of day workers affiliated with a large institution of higher education, we will conduct a single-site, parallel-group, randomized, waitlist control trial. Participants will be randomly assigned to either use the dayzz app throughout the study or receive the dayzz app at the end of the study. We will collect data on feasibility and acceptability of the dayzz app; employee sleep, including sleep behavioral changes, sleep duration, regularity, and quality; employee presenteeism, absenteeism, and performance; employee mood; adverse and safety outcomes; and healthcare utilization on a monthly basis throughout the study, as well as collect more granular daily data from the employee during pre-specified intervals. Our results will illuminate whether a personalized smartphone app is a viable approach for improving employee sleep, health, and productivity. Trial registration: ClinicalTrials.gov Identifier: NCT04224285.

The Hidden Cost of Caregiving: The Association Between Self-Assessed Caregiving-Related Awakenings and Nighttime Awakenings and Workplace Productivity Impairment Among Unpaid Caregivers to Older Adults in the US

OBJECTIVE

To evaluate whether caregiving for older adults is associated with insomnia symptoms and diminished workplace productivity.

METHODS

We analyzed data collected from caregivers to older adults in the US. Participants self-reported awakenings from sleep (caregiving-related or spontaneous) and workplace measures (presenteeism, absenteeism, and productivity impairment). We conduct generalized linear modeling to examine the relationship between awakenings and workplace outcomes, controlling for confounders.

RESULTS

Two hundred fifty-eight caregivers to older adults reported current employment and met our inclusion criteria. Adjusted analyses found that reporting caregiving-related awakenings was associated with presenteeism (OR = 1.27, 95%CI: 1.16 to 1.40), absenteeism (OR = 1.10, 95%CI: 1.06 to 1.15), and productivity impairment (OR = 1.41, 95%CI: 1.25 to 1.58). Adjusted analyses found that spontaneous nighttime awakenings were associated with absenteeism (OR = 1.05, 95%CI: 1.01 to 1.08) and productivity impairment (OR = 1.12, 95%CI: 1.02 to 1.124) but not presenteeism.

CONCLUSIONS

Caregiving-related awakenings are a risk factor for workplace productivity impairment. Future studies should examine means for improving caregiver sleep.

Strategic Distractor Suppression Improves Selective Control in Human Vision

Our visual environment is complicated, and our cognitive capacity is limited. As a result, we must strategically ignore some stimuli to prioritize others. Common sense suggests that foreknowledge of distractor characteristics, like location or color, might help us ignore these objects. But empirical studies have provided mixed evidence, often showing that knowing about a distractor before it appears counterintuitively leads to its attentional selection. What has looked like strategic distractor suppression in the past is now commonly explained as a product of prior experience and implicit statistical learning, and the long-standing notion the distractor suppression is reflected in α band oscillatory brain activity has been challenged by results appearing to link α to target resolution. Can we strategically, proactively suppress distractors? And, if so, does this involve α? Here, we use the concurrent recording of human EEG and eye movements in optimized experimental designs to identify behavior and brain activity associated with proactive distractor suppression. Results from three experiments show that knowing about distractors before they appear causes a reduction in electrophysiological indices of covert attentional selection of these objects and a reduction in the overt deployment of the eyes to the location of the objects. This control is established before the distractor appears and is predicted by the power of cue-elicited α activity over the visual cortex. Foreknowledge of distractor characteristics therefore leads to improved selective control, and α oscillations in visual cortex reflect the implementation of this strategic, proactive mechanism.SIGNIFICANCE STATEMENT To behave adaptively and achieve goals we often need to ignore visual distraction. Is it easier to ignore distracting objects when we know more about them? We recorded eye movements and electrical brain activity to determine whether foreknowledge of distractor characteristics can be used to limit processing of these objects. Results show that knowing the location or color of a distractor stops us from attentionally selecting it. A neural signature of this inhibition emerges in oscillatory alpha band brain activity, and when this signal is strong, selective processing of the distractor decreases. Knowing about the characteristics of task-irrelevant distractors therefore increases our ability to focus on task-relevant information, in this way gating information processing in the brain.

Mental health, substance use, and suicidal ideation during a prolonged COVID-19-related lockdown in a region with low SARS-CoV-2 prevalence

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health consequences due to direct (i.e., SARS-CoV-2 infection, potentially due to neuronal or astrocytic infection, microvascular, or inflammatory mechanisms) and indirect (i.e., social and economic impacts of COVID-19 prevention measures) effects. Investigation of mental health in a region with one of the longest lockdowns and lowest COVID-19 prevalence globally (Victoria, Australia) allowed for evaluation of mental health in the absence of substantial direct pandemic mental health consequences. Surveys were administered during 15-24 September 2020 to Victorian residents aged ≥18 years for The COVID-19 Outbreak Public Evaluation (COPE) Initiative. Responses were compared cross-sectionally with April-2020 data, and longitudinally among respondents who completed both surveys. Multivariable Poisson regressions were used to estimate prevalence ratios for adverse mental health symptoms, substance use, and suicidal ideation adjusted for demographics, sleep, and behaviours (e.g., screen-time, outdoor-time). In September-2020, among 1157 Victorians, one-third reported anxiety or depressive disorder symptoms, one-fifth reported suicidal ideation, and one-tenth reported having seriously considered suicide in the prior 30 days. Young adults, unpaid caregivers, people with disabilities, and people with diagnosed psychiatric or sleep conditions showed increased prevalence of adverse mental health symptoms. Prevalence estimates of symptoms of burnout, anxiety, and depressive disorder were unchanged between April-2020 and September-2020. Persistently common experiences of adverse mental health symptoms despite low SARS-CoV-2 prevalence during prolonged lockdown highlight the urgent need for mental health support services.

Associations between changes in daily behaviors and self-reported feelings of depression and anxiety about the COVID-19 pandemic among older adults

Objectives

Due to the significant mortality and morbidity consequences of the coronavirus disease 2019 (COVID-19) pandemic among older adults, these individuals were urged to avoid going out in public and socializing with others, among other major disruptions to daily life. While these significant and often unavoidable disruptions have been shown to bear consequences for mental health, less attention has been devoted to behavioral changes, such as changes to sleeping or eating due to the COVID-19 pandemic, and their implications for emotional well-being.

Methods

We utilized data from a nationally representative survey of Medicare beneficiaries (aged 65 and older), which was administered between June and October 2020 (n = 3,122). We examine the relationship between self-reported changes to daily behaviors (e.g., sleep, drinking alcohol, and exercise) and emotional impacts of the COVID-19 pandemic (i.e., feelings of depression and anxiety about the COVID-19 pandemic) using stepwise hierarchical multivariable Poisson regression.

Results

We found that worse sleep quality, sleeping more or less, watching more television, and walking less were associated with more feelings of depression and anxiety about the COVID-19 pandemic.

Discussion

Previous research has shown a connection between the significant and often unavoidable disruptions to daily life due to the COVID-19 pandemic (e.g., sheltering in place) and adverse mental health symptoms. Less attention has been paid to potentially modifiable behaviors, such as sleep and exercise. Our findings highlight the behavioral changes associated with adverse emotional impacts among older adults during the COVID-19 pandemic. Future research may evaluate whether behavioral interventions may aim to attenuate the impact of pandemics on daily, modifiable behaviors to buffer against adverse emotional impacts.

Mental Health Among Parents of Children Aged <18 Years and Unpaid Caregivers of Adults During the COVID-19 Pandemic - United States, December 2020 and February-⁠March 2021

Early during the COVID-19 pandemic, nearly two thirds of unpaid caregivers of adults reported adverse mental or behavioral health symptoms, compared with approximately one third of noncaregivers^† (1). In addition, 27% of parents of children aged <18 years reported that their mental health had worsened during the pandemic (2). To examine mental health during the COVID-19 pandemic among U.S. adults on the basis of their classification as having a parenting role (i.e., unpaid persons caring for children and adolescents aged <18 years, referred to as children in this report) or being an unpaid caregiver of adults (i.e., persons caring for adults aged ≥18 years),^§ CDC analyzed data from cross-sectional surveys that were administered during December 2020 and February-March 2021 for The COVID-19 Outbreak Public Evaluation (COPE) Initiative.^¶ Respondents were categorized as parents only, caregivers of adults only, parents-caregivers (persons in both roles), or nonparents/noncaregivers (persons in neither role). Adjusted odds ratios (aORs) for any adverse mental health symptoms, particularly suicidal ideation, were higher among all respondents who were parents, caregivers of adults, or both compared with respondents who were nonparents/noncaregivers and were highest among persons in both roles (parents-caregivers) (any adverse mental health symptoms: aOR = 5.1, 95% confidence interval [CI] = 4.1-6.2; serious suicidal ideation: aOR = 8.2, 95% CI = 6.5-10.4). These findings highlight that parents and caregivers, especially those balancing roles both as parents and caregivers, experienced higher levels of adverse mental health symptoms during the COVID-19 pandemic than adults without these responsibilities. Caregivers who had someone to rely on for support had lower odds of experiencing any adverse mental health symptoms. Additional measures are needed to improve mental health among parents, caregivers, and parents-caregivers.

Interns' perspectives on impacts of the COVID-19 pandemic on the medical school to residency transition

BACKGROUND

The COVID-19 pandemic resulted in disruptions to medical school training and the transition to residency for new post-graduate year 1 resident-physicians (PGY1s). Therefore, the aim of this study was to understand the perspectives of United States PGY1s regarding the impact of the pandemic on these experiences. Our secondary aims were to understand how desire to practice medicine was impacted by the pandemic and whether PGY1s felt that they were able to meaningfully contribute to the COVID-19 response as students.

METHOD

We conducted a national, cross-sectional study of PGY1s who had recently graduated from medical school in 2020. A survey was distributed to PGY1s from across specialties, in programs distributed throughout the United States. It included questions about medical school training during the pandemic, impact on graduation timing and transition to internship, concerns about caring for patients with COVID-19, desire to practice medicine, and ability to meaningfully contribute to the pandemic. Findings are presented using descriptive statistics and univariate logistic regression models.

RESULTS

1980 PGY1s consented to participate, 1463 completed the survey (74%), and 713 met criteria for this analysis. 77% of PGY1s reported that the pandemic adversely affected their connection with their medical school communities, and 58% reported that the pandemic impeded their preparation for intern year. 4% of PGY1s reported graduating medical school and practicing as an intern earlier than their expected graduation date. While the majority of PGY1s did not have a change in desire to practice medicine, PGY1s with concerns regarding personal health or medical conditions (OR 4.92 [95% CI 3.20-7.55] p < 0.0001), the health or medical conditions of others in the home (OR 4.41 [2.87-6.77], p < 0.0001]), and PGY1s with children (OR 2.37 [1.23-4.58], p < 0.0001) were more likely to report a decreased desire.

CONCLUSIONS

The COVID pandemic disrupted the social connectedness and educational experiences of a majority of PGY1 residents in a sample of trainees in United States training programs. Those with health concerns and children had particularly challenging experiences. As the current and subsequent classes of PGY1s affected by COVID-19 proceed in their training, ongoing attention should be focused on their training needs, competencies, and well-being.

Sleep difficulties, incident dementia and all-cause mortality among older adults across 8 years: Findings from the National Health and Aging Trends Study

Sleep difficulties have been implicated in the development and progression of dementia and in all-cause mortality. This study examines the relationship between sleep difficulties, incident dementia and all-cause mortality over 8 years of follow-up among a nationally representative sample of older (≥65 years) adults in the United States. We used data collected from the National Health and Aging Trends Study (NHATS) from 2011 to 2018, a prospective cohort study of Medicare beneficiaries. At baseline, the NHATS sample comprised 6,376 older adults who were representative of 32 million older adults. Respondents reported routine difficulty initiating sleep or difficulty falling back asleep "most nights" or "every night" in each study year. In each year, dementia was determined by either self-reported diagnosis or performance on immediate and delayed recall word and clock drawing tests, whereas all-cause mortality was determined by proxy. We conducted Cox proportional hazards modelling, adjusting for age, sex, marital status and chronic conditions. In models predicting all-cause mortality, we also controlled for dementia. Among respondents at baseline, 19% were 65-75 years of age, 71% identified as non-Hispanic white and 59% were female. Difficulty initiating sleep (hazard ratio [HR], 1.49; 95% confidence interval [CI],1.25-1.77), difficulty falling back asleep (HR, = 1.39; 95% CI,1.14-1.70) and concurrent sleep difficulties (HR, 1.58; 95% CI, 1.25-1.99) were associated with greater risk of dementia. Difficulty initiating sleep (HR, 1.44; 95% CI,1.20-1.72), difficulty falling back asleep (HR, 1.56; 95% CI,1.29-1.89), and concurrent sleep difficulties (HR, 1.80; 95% CI, 1.44-2.24) were associated with greater risk of all-cause mortality. Our findings demonstrate that reported difficulties are prospectively associated with an increased risk of dementia and all-cause mortality among older people.

Adverse impact of polyphasic sleep patterns in humans: Report of the National Sleep Foundation sleep timing and variability consensus panel

Polyphasic sleep is the practice of distributing multiple short sleep episodes across the 24-hour day rather than having one major and possibly a minor ("nap") sleep episode each day. While the prevalence of polyphasic sleep is unknown, anecdotal reports suggest attempts to follow this practice are common, particularly among young adults. Polyphasic-sleep advocates claim to thrive on as little as 2 hours of total sleep per day. However, significant concerns have been raised that polyphasic sleep schedules can result in health and safety consequences. We reviewed the literature to identify the impact of polyphasic sleep schedules (excluding nap or siesta schedules) on health, safety, and performance outcomes. Of 40,672 potentially relevant publications, with 2,023 selected for full-text review, 22 relevant papers were retained. We found no evidence supporting benefits from following polyphasic sleep schedules. Based on the current evidence, the consensus opinion is that polyphasic sleep schedules, and the sleep deficiency inherent in those schedules, are associated with a variety of adverse physical health, mental health, and performance outcomes. Striving to adopt a schedule that significantly reduces the amount of sleep per 24 hours and/or fragments sleep into multiple episodes throughout the 24-hour day is not recommended.

Does the evidence support brief (≤30-mins), moderate (31-60-mins), or long duration naps (61+ mins) on the night shift? A systematic review

We performed a systematic review of four databases to determine if the evidence supports a short or long duration nap during night shifts to mitigate fatigue, and/or improve health, safety, or performance for emergency services and public safety personnel (PROSPERO CRD42020156780). We focused on experimental research and evaluated the quality of evidence with the grading of recommendations, assessment, development, and evaluation (GRADE) framework. We used the Cochrane Collaboration's risk of bias tool to assess bias and reported findings using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Our search yielded n = 10,345 records and n = 44 were reviewed in full-text. Inter-rater agreement during screening was substantial (Kappa = 0.66). We retained n = 11 publications, reporting on n = 7 experimental studies with a cumulative sample size of n = 140. We identified wide variation in study design, napping interventions (i.e., timing, placement, and duration), and outcomes. We identified mixed findings comparing brief, moderate, and long duration naps on outcomes of interest. All seven studies presented serious risk of bias and the quality of evidence was rated as low. Based on the best available evidence, decisions regarding nap duration during night shift work should be based on time (post-nap) and outcome.

Napping on the night shift and its impact on blood pressure and heart rate variability among emergency medical services workers: study protocol for a randomized crossover trial

BACKGROUND

There is an emerging body of evidence that links exposure to shift work to cardiovascular disease (CVD). The risk of coronary events, such as myocardial infarction, is greater among night shift workers compared to day workers. There is reason to believe that repeated exposure to shift work, especially night shift work, creates alterations in normal circadian patterns of blood pressure (BP) and heart rate variability (HRV) and that these alterations contribute to increased risk of CVD. Recent data suggest that allowing shift workers to nap during night shifts may help to normalize BP and HRV patterns and, over time, reduce the risk of CVD. The risk of CVD related to shift work is elevated for emergency medical services (EMS) shift workers due in part to long-duration shifts, frequent use of night shifts, and a high prevalence of multiple jobs.

METHODS

We will use a randomized crossover trial study design with three study conditions. The targeted population is comprised of EMS clinician shift workers, and our goal enrollment is 35 total participants with an estimated 10 of the 35 enrolled not completing the study protocol or classified as lost to attrition. All three conditions will involve continuous monitoring over 72 h and will begin with a 36-h at-home period, followed by 24 total hours in the lab (including a 12-h simulated night shift), ending with 12 h at home. The key difference between the three conditions is the intra-shift nap. Condition 1 will involve a simulated 12-h night shift with total sleep deprivation. Condition 2 will involve a simulated 12-h night shift and a 30-min nap opportunity. Condition 3 will involve a simulated 12-h night shift with a 2-h nap opportunity. Our primary outcomes of interest include blunted BP dipping and reduced HRV as measured by the standard deviation of the inter-beat intervals of normal sinus beats. Non-dipping status will be defined as sleep hours BP dip of less than 10%.

DISCUSSION

Our study will address two indicators of cardiovascular health and determine if shorter or longer duration naps during night shifts have a clinically meaningful impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04469803 . Registered on 9 July 2020.

Examining sleep deficiency and disturbance and their risk for incident dementia and all-cause mortality in older adults across 5 years in the United States

BACKGROUND

Sleep disturbance and deficiency are common among older adults and have been linked with dementia and all-cause mortality. Using nationally representative data, we examine the relationship between sleep disturbance and deficiency and their risk for incident dementia and all-cause mortality among older adults.

METHODS

The National Health and Aging Trends Study (NHATS) is a nationally-representative longitudinal study of Medicare beneficiaries in the US age 65 and older. Surveys that assessed sleep disturbance and duration were administered at baseline. We examined the relationship between sleep disturbance and deficiency and incident dementia and all-cause mortality over the following 5 years using Cox proportional hazards modeling, controlling for confounders.

RESULTS

Among the sample (n = 2,812), very short sleep duration (≤5 hours: HR = 2.04, 95% CI: 1.26 - 3.33) and sleep latency (>30 minutes: HR = 1.45, 95% CI: 1.03 - 2.03) were associated with incident dementia in adjusted Cox models. Difficulty maintaining alertness ("Some Days": HR = 1.49, 95% CI: 1.13 - 1.94 and "Most/Every Day": HR = 1.65, 95% CI: 1.17 - 2.32), napping ("Some days": HR = 1.38, 95% CI: 1.03 - 1.85; "Most/Every Day": HR = 1.73, 95% CI: 1.29 - 2.32), sleep quality ("Poor/Very Poor": HR = 1.75, 95% CI: 1.17 - 2.61), and very short sleep duration (≤5 hours: HR = 2.38, 95% CI: 1.44 - 3.92) were associated with all-cause mortality in adjusted Cox models.

CONCLUSIONS

Addressing sleep disturbance and deficiency may have a positive impact on risk for incident dementia and all-cause mortality among older adults.

Estimated Sleep Duration Before and During the COVID-19 Pandemic in Major Metropolitan Areas on Different Continents: Observational Study of Smartphone App Data

Background

Amid the COVID-19 pandemic, public health policies to curb the spread of SARS-CoV-2 and its associated disease, COVID-19, have resulted in significant alterations to daily routines (eg, work-from-home policies) that may have enabled longer sleep duration among the general population.

Objective

We aimed to examine changes in estimated sleep duration in 5 major metropolitan areas before and after the start of the COVID-19 pandemic.

Methods

We conducted a prospective observational study using estimated sleep duration data obtained from a smartphone app. The data were obtained from regular users of the smartphone app before and after the World Health Organization declared COVID-19 a pandemic in March 2020. We compared within-subject estimated sleep duration before and during the COVID-19 pandemic using generalized linear mixed models.

Results

Among the 2,871,037 observations, 957,022 (33.3%) were from users in London; 549,151 (19.1%) were from users in Los Angeles; 846,527 (29.5%) were from users in New York City; 251,113 (8.7%) were from users in Seoul; and 267,224 (9.3%) were from users in Stockholm. The average age of the users in the sample was 35 years (SE 11 years). Prior to the COVID-19 pandemic, people residing in Seoul had the shortest estimated sleep duration (mean 6 hours 28 minutes, SE 11.6 minutes) and those residing in Stockholm had the longest estimated sleep duration (mean 7 hours 34 minutes, SE 9.9 minutes). The onset of the COVID-19 pandemic was associated with a 13.7 minute increase in estimated sleep duration when comparing March 2019 and March 2020 (95% CI 13.1-14.3, P<.001) and an increase of 22.3 minutes when comparing April 2019 and April 2020 (95% CI 21.5-23.1, P<.001).

Conclusions

The average estimated sleep duration increased sharply in the months after the onset of the COVID-19 pandemic. This finding suggests that the implementation of COVID-19 mitigation strategies has provided people worldwide with increased opportunities to sleep, which may enhance the response of the immune system to viral pathogens.

Employee Sleep Enhancement and Fatigue Reduction Programs: Analysis of the 2017 CDC Workplace Health in America Poll

BACKGROUND

Poor sleep health, including sleep deficiency and sleep disturbance, is common among employed adults in the U.S. and is associated with undesirable workplace outcomes. Adoption of workplace health promotion programs (WHPPs) is increasing, yet few programs aim to reduce fatigue or improve sleep among employees.

OBJECTIVE

We analyzed data from the nationally representative 2017 Centers for Disease Control Workplace Health in America poll to identify the prevalence of sleep enhancement or fatigue reduction WHPPs and the characteristics of employers that offer these programs.

METHOD

A stratified random sample of nationally-representative worksites with ≥10 employees was generated. It comprised 2,843 worksites. Worksite representatives reported workplace characteristics, health promotion activities, and the likelihood of offering WHPPs relating to sleep enhancement or fatigue reduction. Logistic regression analyses were utilized to identify characteristics associated with offering a sleep enhancement or fatigue reduction WHPP, controlling for WHPP budget and size of the company, and contingent on worksites having a comprehensive workplace health plan.

RESULTS

Less than 1 in 10 worksites (10%) reported offering a sleep enhancement or fatigue reduction WHPP. Worksites most likely to offer a sleep-focused WHPP were those in retail, wholesale, or technology industries (OR = 2.71, 95%CI: 1.08-6.8) vs. those in the finance, information, technology industries; those with a large WHPP budget (>$500,000, OR = 6.85, 95%CI: 2.1-22.35) vs. those with no budget; and those that had visible support of WHPP initiatives from senior leadership (OR = 4.74, 95%CI: 1.91-11.75) vs. those without such support.

CONCLUSIONS

Our results highlight how few worksites reported offering sleep-focused programs for their employees. Those worksites that did feature such programs, were commonly well-resourced and had senior leadership support for WHPP initiatives in general. Future research should consider working directly with leaders to expand the implementation of employee sleep enhancement and fatigue reduction WHPPs.

Should public safety shift workers be allowed to nap while on duty?

Fatigue and sleep deficiency among public safety personnel are threats to wellness, public and personal safety, and workforce retention. Napping strategies may reduce work-related fatigue, improve safety and health, yet in some public safety organizations it is discouraged or prohibited. Our aim with this commentary is to define intra-shift napping, summarize arguments for and against it, and to outline potential applications of this important fatigue mitigation strategy supported by evidence. We focus our discussion on emergency medical services (EMS); a key component of the public safety system, which is comprised of police, fire, and EMS. The personnel who work in EMS stand to benefit from intra-shift napping due to frequent use of extended duration shifts, a high prevalence of personnel working multiple jobs, and evidence showing that greater than half of EMS personnel report severe fatigue, poor sleep quality, inadequate inter-shift recovery, and excessive daytime sleepiness. The benefits of intra-shift napping include decreased sleepiness and fatigue, improved recovery between shifts, decreased anxiety, and reduced feelings of burnout. Intra-shift napping also mitigates alterations in clinician blood pressure associated with disturbed sleep and shift work. The negative consequences of napping include negative public perception, acute performance deficits stemming from sleep inertia, and the potential costs associated with reduced performance. While there are valid arguments against intra-shift napping, we believe that the available scientific evidence favors it as a key component of fatigue mitigation and workplace wellness. We further believe that these arguments extend beyond EMS to all sectors of public safety.

Association of Sleep Disorders With Physician Burnout

This cross-sectional study evaluates the association between sleep disorders and burnout symptoms among faculty and staff at a large teaching hospital.

Ambulatory blood pressure monitoring among emergency medical services night shift workers

OBJECTIVES

Higher 24-hour blood pressure (BP) and blunted BP dipping during sleep and night-time hours are associated with adverse health outcomes. Night shift work may affect 24-hour BP and dipping patterns, but empirical data in emergency medical services (EMS) clinician shift workers are sparse. We implemented ambulatory blood pressure monitoring (ABPM) in EMS workers to characterise BP during night shift work versus a non-workday, and sleep versus wake.

METHODS

Participants worked night shifts. Hourly ABPM and wrist actigraphy (to measure sleep) were collected during two 24-hour periods, one scheduled night shift and one non-workday. Blunted BP dipping was defined as a BP decrease of <10%.

RESULTS

Of 56 participants, 53 (53.6% female, mean age 26.5 (SD 7.5) years) completed the study. During daytime sleep on a workday, 49.1% of participants had blunted systolic BP (SBP) or diastolic BP (DBP) dipping. During night-time sleep on a non-workday, 25% had blunted SBP dipping and 3.9% blunted DBP dipping. Blunted SBP or DBP dipping occurred among all participants who did not nap during the night shift or who napped <60 min. Blunted SBP dipping occurred in only 14.3% of participants who napped 60-120 min.

CONCLUSIONS

During night shift work, the BP dipping of EMS shift workers is blunted; however, most who nap for 60 min or longer experience a healthy dip in BP. The potential health consequences of these observations in EMS clinicians warrant further study.

Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic - United States, June 24-30, 2020

The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders.* Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April-June of 2020, compared with the same period in 2019 (1,2). To assess mental health, substance use, and suicidal ideation during the pandemic, representative panel surveys were conducted among adults aged ≥18 years across the United States during June 24-30, 2020. Overall, 40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic^† (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%). The percentage of respondents who reported having seriously considered suicide in the 30 days before completing the survey (10.7%) was significantly higher among respondents aged 18-24 years (25.5%), minority racial/ethnic groups (Hispanic respondents [18.6%], non-Hispanic black [black] respondents [15.1%]), self-reported unpaid caregivers for adults^§ (30.7%), and essential workers^¶ (21.7%). Community-level intervention and prevention efforts, including health communication strategies, designed to reach these groups could help address various mental health conditions associated with the COVID-19 pandemic.