Susan Malone

Abstract

BACKGROUND A purpose of duty-hour regulations is to reduce sleep deprivation in medical trainees, but their effects on sleep, sleepiness, and alertness are largely unknown. METHODS We randomly assigned 63 internal-medicine residency programs in the United States to follow either standard 2011 duty-hour policies or flexible policies that maintained an 80-hour workweek without limits on shift length or mandatory time off between shifts. Sleep duration and morning sleepiness and alertness were compared between the two groups by means of a noninferiority design, with outcome measures including sleep duration measured with actigraphy, the Karolinska Sleepiness Scale (with scores ranging from 1 [extremely alert] to 9 [extremely sleepy, fighting sleep]), and a brief computerized Psychomotor Vigilance Test (PVT-B), with long response times (lapses) indicating reduced alertness. RESULTS Data were obtained over a period of 14 days for 205 interns at six flexible programs and 193 interns at six standard programs. The average sleep time per 24 hours was 6.85 hours (95% confidence interval [CI], 6.61 to 7.10) among those in flexible programs and 7.03 hours (95% CI, 6.78 to 7.27) among those in standard programs. Sleep duration in flexible programs was noninferior to that in standard programs (between-group difference, −0.17 hours per 24 hours; one-sided lower limit of the 95% confidence interval, −0.45 hours; noninferiority margin, −0.5 hours; P=0.02 for noninferiority), as was the score on the Karolinska Sleepiness Scale (between-group difference, 0.12 points; one-sided upper limit of the 95% confidence interval, 0.31 points; noninferiority margin, 1 point; P<0.001). Noninferiority was not established for alertness according to the PVT-B (between-group difference, −0.3 lapses; one-sided upper limit of the 95% confidence interval, 1.6 lapses; noninferiority margin, 1 lapse; P=0.10). CONCLUSIONS This noninferiority trial showed no more chronic sleep loss or sleepiness across trial days among interns in flexible programs than among those in standard programs. Noninferiority of the flexible group for alertness was not established.

Abstract

Declining national rates of current tobacco use to an all-time low of 15.1% represents a public health victory. Undermining this progress, however, are smoking rates of up to 50% among high-risk, low-income populations. Current FDA-approved treatments for nicotine dependence are ineffective with between 70-95% of treatment-seekers relapsing within the first year of attempted abstinence. Thus, identification of novel intervention targets to optimize response to currently available treatments for nicotine dependence is a critical next step. One such target may be sleep insomnia. Insomnia is a clinically verified nicotine withdrawal symptom but, to date, addressing insomnia or other sleep disturbance symptoms as an adjunctive smoking cessation therapy has yet to be fully considered.To this end, this manuscript presents a narrative review of: (1) sleep continuity and architecture in smokers versus nonsmokers; (2) effects of nicotine abstinence on sleep; (3) possible mechanisms linking sleep with smoking cessation outcomes; (4) plausible adjunctive sleep therapies to promote smoking cessation; (5) possible treatments for unhealthy sleep in smokers; and (6) directions for future research.Taken together, this will provide conceptual support for sleep therapy as an adjunctive treatment for smoking cessation. Implications:This narrative literature review presents a comprehensive discussion of the relationship between habitual sleep and cigarette smoking.The extent to which unhealthy sleep in smokers may be a viable intervention target for promoting response to smoking cessation treatment is considered. Ultimately, this review provides conceptual support for sleep therapy as an adjunctive treatment for smoking cessation.

Abstract

The sun rises and sets over the earth in a predictable pattern. This pattern has existed for billions of years and has influenced the behavior of all living things. Behavioral rhythms have aligned with these light-dark rhythms and conferred an evolutionary advantage. Humans have adapted to the light-dark cycle so that activity occurs during the day and rest occurs during the night. Increased visibility afforded by daylight optimizes foraging and safety while being active. Reduced visibility during the night optimizes sleeping and fasting. Daily rhythms, such as light-dark, are known as circadian rhythms from the Latin words “circa,” for about, and “dias,” for a day. Physiological processes rely on predictable circadian rhythms. These processes include sleeping and waking, cardiac function, such as heart rate and blood pressure, and metabolic processes, such as glucose, lipid, and energy metabolism. Disrupting circadian rhythms can profoundly impact cardiometabolic health and well-being. Poor cardiometabolic health can also disrupt the circadian system. This chapter will briefly introduce the cardiometabolic syndrome, the circadian system, circadian disruption, and social jetlag as a form of circadian disruption.

Abstract

Social determinants of health (SDOH), the conditions in which children are born, grow, live, work or attend school, and age, impact child health and contribute to health disparities. School nurses must consider these factors as part of their clinical practice because they significantly and directly influence child well-being. We provide clinical guidance for addressing the SDOH when caring for children with three common health problems (obesity, insufficient sleep, and asthma). Given their unique role as school-based clinical experts, care coordinators, and student advocates, school nurses are well suited to serve as leaders in addressing SDOH.

Abstract

Background Sleep duration and morningness/eveningness (circadian preference) have separately been associated with cardiovascular risk factors (i.e. tobacco use, physical inactivity). Interactive effects are plausible, resulting from combinations of sleep homeostatic and circadian influences. These have not been examined in a population sample. Methods Multivariable regression models were used to test the associations between combinations of sleep duration (short [≤6 h], adequate [7-8 h], long [≥9 h]) and morning/evening preference (morning, somewhat morning, somewhat evening, evening) with the cardiovascular risk factors of tobacco use, physical inactivity, high sedentary behaviour, obesity/overweight and eating fewer than 5 daily servings of fruit and vegetables, in a cross-sectional sample of 439 933 adults enrolled in the United Kingdom Biobank project. Results Participants were 56% female, 95% white and mean age was 56.5 (SD = 8.1) years. Compared with adequate sleep with morning preference (referent group), long sleep with evening preference had a relative odds of 3.23 for tobacco use, a 2.02-fold relative odds of not meeting physical activity recommendations, a 2.19-fold relative odds of high screen-based sedentary behaviour, a 1.47-fold relative odds of being obese/overweight and a 1.62-fold relative odds of <5 fruit and vegetable daily servings. Adequate sleep with either morning or somewhat morning preference was associated with a lower prevalence and odds for all cardiovascular risk behaviours except fruit and vegetable intake. Conclusions Long sleepers with evening preference may be a sleep phenotype at high cardiovascular risk. Further work is needed to examine these relationships longitudinally and to assess the effects of chronotherapeutic interventions on cardiovascular risk behaviours.

Abstract

Fatigue, a commonly reported symptom, is defined as an overwhelming, debilitating, and sustained sense of exhaustion that decreases the ability to function and carry out daily activities. To date, cancer researchers have been in the forefront in investigating the possible biological mechanisms of fatigue, identifying inflammation, dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, and activation of the autonomic nervous system. The purpose of this systematic review is to describe fatigue and what is known about the biological mechanisms described in cancer in five chronic, noninfectious illnesses: heart failure, multiple sclerosis, chronic kidney disease, rheumatoid arthritis, and chronic obstructive pulmonary disease. We searched PubMed and EMBASE using fatigue as a major Medical subject headings (MeSH) heading with each individual disease added as a search term followed by each biological mechanism. We included only primary research articles published in English between 1996 and 2016 describing studies conducted in adult humans. We identified 26 relevant articles. While there is some evidence that the biological mechanisms causing fatigue in cancer are also associated with fatigue in other chronic illnesses, more research is needed to explore inflammation, the HPA axis, and the autonomic nervous system, and other mechanisms in relation to fatigue in a variety of chronic illnesses.

Abstract

Healthy People 2020 established a national objective to increase the proportion of 9th-to-12th-grade students reporting sufficient sleep. A salient approach for achieving this objective is to delay middle and high school start times. Despite decades of research supporting the benefits of delayed school start times on adolescent sleep, health, and well-being, progress has been slow. Accelerating progress will require new approaches incorporating strategies that influence how school policy decisions are made. In this commentary, we introduce four strategies that influence decision-making processes and demonstrate how they can be applied to efforts aimed at changing school start time policies.

Abstract

Biological evidence suggests that ethno-racial differences in morning–evening type are possible, whereby Blacks may be more likely to be morning type compared to Whites. However, population-level evidence of ethno-racial difference in morning–evening type is limited. In an earlier study, we reported that morning type was more prevalent in Blacks compared to Whites in the United Kingdom (UK) Biobank cohort (N = 439 933). This study aimed to determine if these ethno-racial differences persisted after accounting for an even broader range of social, environmental and individual characteristics and employing an analytic approach that simulates randomization in observational data, propensity score modeling. Data from UK Biobank participants whose self-identified race/ethnicity was Black/Black British or White; who did not report daytime napping, shift work or night shift work; who provided full mental health information; and who were identified using propensity score matching were used (N = 2044). Each sample was strongly matched across all social, environmental and individual characteristics as indicated by absolute standardized mean differences <0.09 for all variables. The prevalence of reporting nocturnal short, adequate and long sleep as well as morning, intermediate and evening type among Blacks (n = 1022) was compared with a matched sample of Whites (n = 1022) using multinomial logistic regression models. Blacks had a 62% greater odds of being morning type [odds ratio (OR) = 1.620, 95% confidence interval (CI): 1.336–1.964, p <.0001] and a more than threefold greater odds of reporting nocturnal short sleep (OR = 3.453, 95% CI: 2.846–4.190, p <.0001) than Whites. These data indicate that the greater prevalence of morning type and short nocturnal sleep in Blacks compared to Whites is not fully explained by a wide range of social and environmental factors. If sleep is an upstream determinant of health, these data suggest that ethno-racially targeted public health sleep intervention strategies are needed.