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Introduction: The circadian timing system regulates diurnal sleep-wake rhythm. Previously, we showed that, in patients undergoing elective surgery, sleep-wake timing is altered and post-operative sleep quality is reduced. However, how the timing of the surgical procedure affects the disturbance and what other factors affect this disturbance remain unknown., Methods: Single-centre prospective observational study investigating the influence of surgery timing on post-operative sleep in adult patients (≥18 years) undergoing elective surgery. Sleep-wake timing was measured from three nights before until seven nights after surgery with a daily sleeping log. Primary outcome was post-operative midpoint of sleep shift between patients undergoing morning and afternoon surgeries. Secondary outcomes included factors affecting sleep timing disturbance and changes in subjective sleep quality., Results: We included 259 patients: 144 patients underwent morning procedures (08:00 h-12:00 h) and 115 underwent afternoon procedures (12:00 h-17:00 h). Both groups had significant phase advance of midpoint of sleep on the night after surgery when compared with three nights before surgery (mean - 00:41 h, 95% CI -00:27 h to -00:54 h, p < .001, for morning surgery and mean - 00:28 h, 95% CI -00:09 h to -00:46 h, p = .003, for afternoon surgery). However, there was no between-group difference (mean - 00:13 h, 95% CI -00:35 h-00:09 h, p = .25). Reduction of sleep quality was also similar. Phase advance was larger for patients with an evening chronotype or with lower pre-operative sleep quality. Decline of sleep quality after surgery was larger for patients with an evening chronotype, longer procedures or better pre-operative sleep quality., Conclusion: Our results suggest that the timing of surgery between 08:00 h and 17:00 h does not modulate the effect of anaesthesia and surgery on phase of the sleep-wake rhythm in patients undergoing elective surgery with a low pre-operative risk of delirium., Editorial Comment: Timing of surgery may impact post-operative sleep. However, in this prospective cohort study of elective surgical patients, sleep-wake timing and post-operative sleep quality did not differ between those undergoing morning versus afternoon surgery., (© 2024 The Author(s). Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.)

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 ., (© 2023. Turgman et al.)

Objectives: To determine whether the statistical fragility of randomized controlled trials (RCTs) in high-impact journals has improved in the last decade and to perform an umbrella review of all published data on the Fragility Index (FI) across medical specialties., Study Design and Setting: The FI was calculated for all eligible RCTs published from 2014-2021 in the New England Journal of Medicine, The Lancet, the Journal of the American Medical Association, the British Medical Journal, and the Annals of Internal Medicine. Trials reporting dichotomous, statistically significant, superiority results were eligible. All previously published systematic reviews on the FI were included in the umbrella review and analyzed by medical (sub) specialty., Results: Of 2,544 screened RCTs, 643 were eligible for the FI analysis. These had a median sample size of 625 (interquartile range [IQR]: 265-2,056), a median FI of 12 (IQR: 3-28), and a median Fragility Quotient of 0.015 (IQR: 0.004-0.045). This is an improvement compared with the median FI of 8 (IQR: 3-18) of RCTs published a decade earlier in the same five journals (P < 0.001). The umbrella review included 57 publications across 15 different medical specialties, with a total of between 10 and 692 RCTs for each specialty. The median FI ranged between two and four for all disciplines., Conclusion: In the last decade, the median statistical robustness of RCTs published in high-impact journals has improved, yet the unchanged lower bound of the interquartile range reveals that statistical significance in 25% of trials is still dependent on three or less events. The umbrella review revealed that statistical fragility is prevalent across all medical specialties. The FI is an easy-to-understand metric that can be used to supplement reported P values and help readers look beyond merely reaching statistical significance., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)