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BACKGROUND: The services of Healthcare and Social Assistance (HCSA) workers are needed by society around the clock. As a result, these workers are exposed to shift work and long work hours. The combination of demanding work schedules and other hazards in the HCSA work environment increases the health and safety risks to these workers, as well as to their patients/clients and the public. METHODS: This paper has three aims: (1) provide an overview of the burden of shift work, long hours, and related sleep and fatigue problems in this sector; (2) suggest research priorities that would improve these ; and (3) discuss potential positive impacts of addressing these research priorities for the health and safety of workers and the public. The authors used a modified Delphi approach to anonymously rank-order priorities for improving HCSA worker health and safety and public safety. Input was also obtained from attendees at the 2019 National Institute for Occupational Safety and Health (NIOSH) Work Hours, Sleep, and Fatigue Forum. RESULTS: The highest rated research priorities were developing better designs for work schedules, and improving the HCSA culture and leadership approaches to shift work and long work hours. Additional priorities are identified. CONCLUSION: Research in these priority areas has the potential to benefit HCSA workers as well as their patients/clients, employers, and society.

For nurses, the challenges posed by demanding work environments and schedules often lead to fatigue, and this can be exacerbated during crises like the COVID-19 pandemic. In this article, the authors discuss causes and challenges of nurse fatigue and consider several evidence-based strategies and solutions for individual nurses and organizations. Barriers to implementation, including a negative workplace culture and inadequate staffing, are also described, and several resources are presented.

Introduction Sleepiness in obstructive sleep apnoea is associated with cardiovascular risk; however, the biological mechanisms are not known. This study explored whether those with subjective sleepiness have increased plasma tumour necrosis factor-related protein 1 (C1qTNF1), a novel adipose-derived hormone (adipokine), and 24-h ambulatory blood pressure (ABP) compared to those without sleepiness in newly diagnosed, treatment-naïve participants with obstructive sleep apnoea. Methods Overall, 94 participants were included in the analysis. Participants completed the Epworth Sleepiness Scale (ESS), 24-h ABP was monitored, and plasma C1qTNF1 was measured. Sleepy participants were defined as ESS≥10 and nonsleepy as ESS, Excessive sleepiness experienced by treatment-naïve patients with obstructive sleep apnoea is associated with inflammation, higher daily systolic ambulatory blood pressure and higher 24 h mean arterial pressure https://bit.ly/3goeqGD

STUDY OBJECTIVES: Intensive care unit nurses commonly work multiple consecutive 12-hour shifts that leave little time for sleep between work shifts. Working multiple consecutive shifts could compromise vigilance and patient care, especially with respect to managing high-risk medications such as insulin infusions. We hypothesized that as the number of consecutive shifts worked by nurses increases, the rate of hypoglycemia in patients who are receiving an insulin infusion would also increase. METHODS: We identified patients who had hypoglycemia (glucose ≤ 3.5 mmol/L, 63 mg/dL) between December 2008 and December 2009 in 3 intensive care units in Vancouver, British Columbia, Canada. For each hypoglycemic event, we counted the number of shifts worked on consecutive days during the previous 72 hours by the bedside nurse who was caring for the patient at the time of hypoglycemia (case shift). For each case shift, we identified up to 3 control shifts (24, 48, and 72 hours before the hypoglycemic event in the same patient when there were no hypoglycemic events) and counted the number of consecutive shifts worked by those nurses in the previous 72 hours. This analysis allowed us to control for patient-associated confounders. Conditional logistic regression was used to determine the association between number of consecutive shifts worked and occurrence of hypoglycemic events. RESULTS: A total of 282 hypoglycemic events were identified in 259 patients. For 191 events, we were able to identify 1 or more control shifts. Compared with nurses who had not worked a shift in the preceding day, the odds ratio of a hypoglycemic event was 1.68 (95% confidence interval: 1.12–2.52), 2.16 (95% confidence interval:1.25–3.73), and 2.54 (95% confidence interval: 1.28–5.06) for nurses who were working their second, third, or fourth consecutive shift, respectively. CONCLUSIONS: Working multiple consecutive nursing shifts is associated with increased risk of hypoglycemic events in patients in an intensive care unit. CITATION: Ayas NT, Jeklin A, Tholin H, et al. Consecutive nursing shifts and the risk of hypoglycemia in critically ill patients who are receiving intravenous insulin: a multicenter study. J Clin Sleep Med. 2020;16(6):949–953.

For nurses, the challenges posed by demanding work environments and schedules often lead to fatigue, and this can be exacerbated during crises like the COVID-19 pandemic. In this article, the authors discuss causes and challenges of nurse fatigue and consider several evidence-based strategies and solutions for individual nurses and organizations. Barriers to implementation, including a negative workplace culture and inadequate staffing, are also described, and several resources are presented.

Introduction There are about 15 million Americans working full-time on evening, night, or rotating shifts. Between 48% and 81.9% of those working rotating or night shifts report abdominal pain, constipation, diarrhea and other symptoms of functional bowel disorders. The basis for this high prevalence of functional bowel disorders, including irritable bowel syndrome (IBS), among shift workers is unknown. Animal studies, however, suggest that circadian disruption, similar to that in shift workers, may contribute to the development of GI complaints among shift workers by altering the composition and normal diurnal rhythmicity of the resident intestinal microbes. Methods Fifty-one full time staff nurses who worked either 12-hour day or night shifts completed demographic information, the Rome III IBS module, daily symptoms diaries for 14 days. They also collected two samples of gut microbiota before the beginning and at the end of their last work shift on day 14, using validated field-tested methods consistent with the Human Microbiome Project. After DNA extraction, 16S rRNA sequencing and assignment to the genus level was completed, samples were then compared to determine if there were 1) differences in the diversity and profile of the microbiome by shift type; 2) if there were differences in the microbiome by time of day for collection; and 3) whether there were differences in the diversity and profile of the microbiome of nurses with IBS and those without IBS. Results There were no differences in alpha or beta diversity of gut microbiota when specimens from day and night shift nurses were compared. There were however marginal differences in beta diversity when specimens collected at the beginning and end of the shifts were compared, with seven OTUs being differentially abundant when collected from day shift workers in the evening. There were also three OTUs to be differentially abundant in participants reporting IBS symptoms. Conclusion These data did not reveal strong effects of circadian alterations in gut microbiota related to shiftwork. Other factors, such as insufficient sleep and dietary intake during the data-gathering period, need to be explored Support (if any) Emory University Synergy Grant Program

Introduction A BMI increase, in men and women, is associated with an increased severity and progression of OSA. This study will examine the impact of BMI on varying levels of OSA severity and progression. Methods Participants, divided by sex, included 2728 (47%) men and 3076 (53%) women over the age of 40 that were in the Sleep Heart Health Study (SHHS). Participants were separated into 1 of 10 groups based on initial OSA levels at SHHS time point 1 (SHHS1) and ending OSA levels at SHHS time point 2 (SHHS2) as measured by RDI. A Kruskall-Wallis test examined the BMI median differences in the groups. Post-hoc tests, including pairwise comparisons and Wilcoxon rank sum test with Holm adjustment, were conducted to further examine results. Results Significant differences existed between certain groups (Men: Chi-Square=146.87, p Conclusion Although BMI is a known influential factor in OSA progression, this study demonstrated that those maintaining normal OSA levels over time have a significant BMI difference compared to those reaching even mild OSA levels over time. Additional implications were also found for men. These findings may coincide with recent research suggesting that one needs to progress only to moderate OSA levels to reach a tipping point of significantly increasing and impacting many health risks. Support Robert Wood Johnson Foundation Future of Nursing Scholars Program

The objective of the study was to determine if sleep disorder, depression or anxiety screening status was associated with safety outcomes in a diverse population of hospital workers. A sample of shift workers at four hospitals participated in a prospective cohort study. Participants were screened for five sleep disorders, depression and anxiety at baseline, then completed prospective monthly surveys for the next 6months to capture motor vehicle crashes, near-miss crashes, occupational exposures and medical errors. We tested the associations between sleep disorders, depression and anxiety and adverse safety outcomes using incidence rate ratios adjusted for potentially confounding factors in a multivariable negative binomial regression model. Of the 416 hospital workers who participated, two in five (40.9%) screened positive for a sleep disorder and 21.6% screened positive for depression or anxiety. After multivariable adjustment, screening positive for a sleep disorder was associated with 83% increased incidence of adverse safety outcomes. Screening positive for depression or anxiety increased the risk by 63%. Sleep disorders and mood disorders were independently associated with adverse outcomes and contributed additively to risk. Our findings suggest that screening for sleep disorders and mental health screening can help identify individuals who are vulnerable to adverse safety outcomes. Future research should evaluate sleep and mental health screening, evaluation and treatment programmes that may improve safety.

Aim: This pilot study examined associations between sleep quality and metabolic risk profiles, underlying hormones, inflammatory markers, and behaviors in overweight and obese young adults, aged 18–29 years. Design: Cross-sectional, descriptive, correlational study design. Method: A partial sample ( n = 29) was re-recruited from a parent study on screening for risk of early-onset diabetes. BodyMedia’s SenseWear® armband was used to assess sleep quality. Based on the percentage of consolidated sleep days during the past week, participants were classified as poor, fair, or good sleepers. Multiple multivariate general linear models were used to examine group differences in study variables after adjusting for obesity impact. Results: There were no significant differences among groups in age (mean 23.5 ± 2.9 years) or body mass index (mean 38.0 ± 8.9 kg/m2). Good sleepers ( n = 12, 41.4%) showed the longest nocturnal sleep duration (7:53 ± 1:00 hr), followed by fair ( n = 12, 41.4%, 7:23 ± 1:34 hr) and poor sleepers ( n = 5, 17.2%, 5:34 ± 0:56 hr). Poor sleepers showed the highest plasma resistin (η2 = .103) and ghrelin (η2 = .205) levels and caloric (η2 = .255) and sodium (η2 = .156) intakes. No differences in clinical metabolic markers or serum leptin or adiponectin were observed. Conclusions: Overweight/obese young adults had irregular sleep schedules and patterns, indicators of poor sleep quality, that were possibly associated with changes in dietary behaviors and underlying plasma hormones. In addition to traditional clinical cardiometabolic markers, plasma resistin and ghrelin may be good predictors of heightened vulnerability to cardiometabolic diseases in overweight/obese young adults with poor-quality sleep.

Sleep is essential for optimal health, well-being, and cognitive functioning, and yet nationwide, youth are not obtaining consistent, adequate, or high-quality sleep. In fact, more than two-thirds of US adolescents are sleeping less than 8 hours nightly on school nights. Racial and ethnic minority children and adolescents are at an increased risk of having shorter sleep duration and poorer sleep quality than their white peers. In this review, we critically examined and compared results from 23 studies that have investigated racial/ethnic sleep disparities in American school-aged children and adolescents ages 6-19 years. We found that White youth generally had more sufficient sleep than minority youth, Hispanics had more than Blacks, and there was inconclusive evidence for Asians and other minorities. Recommendations for researchers include the following: (1) explore underlying causes of the disparities of these subpopulations, with a particular interest in identifying modifiable causes; (2) examine factors that may be impacted by racial/ethnic sleep disparities; (3) use a multidimensional approach to measuring sleep disparities; and (4) examine how beliefs about sleep are patterned by race/ethnicity. Understanding sleep disparities can inform interventions, policies, and educational programs to minimize sleep disparities and their impact on health, psychological, and educational outcomes.

BACKGROUND Insomnia is a prevalent sleep disorder, and it has been increasingly associated with cardiovascular morbidity and mortality. The reasons for this relationship are not completely understood but may involve endothelial dysfunction. In this study, we hypothesized that insomnia symptoms would be associated with reduced endothelial function. METHODS Working adults (n = 496, 67.5% female, 78.6% white, mean age 48.7 [SD, 10.8] years, body mass index 28.2 [SD, 6.7] kg/m, diabetes 5.8%, hypertension 20.0%, hyperlipidemia 17.9%, heart disease 2.6%) enrolled in the Emory-Georgia Tech Predictive Health Institute study completed baseline demographic, clinical, depression (Beck Depression Inventory II), anxiety (General Anxiety Disorder 7), sleep (Pittsburg Sleep Quality Index), and noninvasive endothelial function (brachial artery flow-mediated dilation [FMD]) measures. Insomnia symptoms were defined as subjective sleep latency of 30 minutes or longer, nighttime or early morning awakenings, and/or sleep medication use occurring 3 times or more per week in the past month. RESULTS Insomnia symptoms were reported by 39.5% of participants. Multivariable regression models showed that insomnia symptoms, age, baseline artery diameter, and dyslipidemia were inversely related to FMD. After adjusting for age, baseline artery diameter, and dyslipidemia, participants reporting insomnia symptoms had lower FMD than did participants reporting better sleep (adjusted FMD mean, 6.13% [SD, 0.28%] vs 6.83% [SD, 0.26%], P = .035). CONCLUSION In this study, insomnia symptoms were associated with reduced FMD. Research examining the therapeutic benefits of treating insomnia on endothelial function and future cardiovascular risk is warranted.

BACKGROUND:: Studies indicate that extended shifts worked by hospital staff nurses are associated with higher risk of errors. Long work hours coupled with insufficient sleep and fatigue are even riskier. Although other industries have developed programs to reduce fatigue-related errors and injury, fatigue countermeasures program for nurses (FCMPN) are lacking. OBJECTIVES:: The objective of this study was to evaluate the feasibility of an FCMPN for improving sleep duration and quality while reducing daytime sleepiness and patient care errors. Selected sleep variables, errors and drowsy driving, were evaluated among hospital staff nurses (n = 47) before and after FCMPN implementation. METHOD:: A one-group pretest-posttest repeated-measures approach was used. Participants provided data 2 weeks before the FCMPN, 4 weeks after receiving the intervention, and again at 3 months after intervention. RESULTS:: Most of the nurses experienced poor sleep quality, severe daytime sleepiness, and decreased alertness at work and while operating a motor vehicle. After the FCMPN, significant improvements were noted in sleep duration, sleep quality, alertness, and error prevention. Although significant improvements were not found in daytime sleepiness scores, severity of daytime sleepiness appeared to decrease. Despite improvements in fatigue management, nurses reported feelings of guilt when engaging in FCMPN activities, especially strategic naps and relieved breaks. CONCLUSIONS:: Initial findings support the feasibility of using an FCMPN for mitigating fatigue, improving sleep, and reducing errors among hospital staff nurses. In future investigations, the acceptability, efficacy, and effectiveness of FCMPNs can be examined. Language: en

The purpose of this study was to describe the structural, organizational, and environmental factors associated with the implementation a fatigue countermeasures program for nurses (FCMPN).The industrial sector has developed fatigue management programs to improve safety for employees and customers. However, fatigue management programs have not been developed for nurses.The oral descriptions of 46 staff nurses and 8 nurse managers participating in an FCMPN were audiotaped, transcribed, and analyzed.Staff nurses identified awareness, restfulness, and lifestyle control as FCMPN benefits, whereas challenges included work culture, physical environment, and emotional turmoil. Nurse managers perceived ease of program implementation, employee-employer partnerships, and research engagement as benefits. Challenges included lack of support, nursing/organizational culture, and dissonance in staff levels and organizational policies.Although FCMPNs are feasible and sustainable in healthcare, a paradigm shift may be needed for a robust implementation of an effective FCMPN that improves patient safety.

Background: Registered nurses have a vital role in discovering and correcting medical error. Objective: To describe the type and frequency of errors detected by American critical care nurses, and to ascertain who made the errors discovered by study participants. Methods: Daily logbooks were used to collect information about errors discovered by a random sample of 502 critical care nurses during a 28-day period. Results: Although the majority of errors discovered and corrected by critical care nurses involved medications (163/367), procedural errors were common (n = 115). Charting and transcription errors were less frequently discovered. The errors discovered by participants were attributed to a wide variety of staff members including nurses, doctors, pharmacists, technicians and unit secretaries. Conclusions: Given the importance of nurses in maintaining patient safety, future studies should identify factors that enhance their effectiveness to prevent, intercept and correct healthcare errors.

Background: Steep problems are common in lung cancer survivors, yet little is known about the prevalence, determinants, and effects on quality of life (QoL) of these steep problems in tong-term Lung cancer survivors.Methods: A case-control study design comparing 76 elderly lung cancer survivors (LCS, >5 years post diagnosis with mean survival time of 8 years +/- 2.1 years) and 78 elderly non-cancer controls (NCC). Measurements included a standardized questionnaire for steep (Pittsburgh Steep Quality Index-PSQI), and analogue scales for dyspnea, pain, and other comorbid symptoms, as well as demographic factors and cancer history.Results: Overall, 56.6% of LCS had poor steep (PSQI global score > 5) as compared to only 29.5% of NCC (p Conclusions: Even 8 years after diagnosis, LCS continue to have significant steep difficulties. By asking specific questions about steep medication use, nocturnal awakenings and steep efficiency, health care providers can identify steep problems that could be treated and potentially improve the quality of life of their patients. (c) 2007 Elsevier Ireland Ltd. All rights reserved.

Recent studies have shown that extended shifts worked by hospital staff nurses are associated with significantly higher risk of errors, yet little information is available about the ability to remain alert during the nurses' commutes following the completion of an extended work shift. The purpose of this study is to describe the prevalence of drowsy driving episodes and the relationship between drowsy driving and nurse work hours, alertness on duty, working at night, and sleep duration.Data were collected from 2 national random samples of registered nurses (n=895).Full-time hospital staff nurses (n=895) completed logbooks on a daily basis for 4 weeks providing information concerning work hours, sleep duration, drowsy and sleep episodes at work, and drowsy driving occurrences. Almost 600 of the nurses (596/895) reported at least 1 episode of drowsy driving, and 30 nurses reported experiencing drowsy driving following every shift worked. Shorter sleep durations, working at night, and difficulties remaining awake at work significantly increased the likelihood of drowsy driving episodes.Given the large numbers of nurses who reported struggling to stay awake when driving home from work and the frequency with which nurses reported drowsy driving, greater attention should be paid to increasing nurse awareness of the risks and to implementing strategies to prevent drowsy driving episodes to ensure public safety. Without mitigation, fatigued nurses will continue to put the public and themselves at risk.

s. Older adults frequently complain about sleep disturbances. Although difficulties in falling asleep or staying awake are common in the older adult, this is not normal. More than half of all older adults report problems with sleep; up to two thirds of older adults living in nursing homes are also affected. 1 Unfortunately, these numbers may be an underestimation because older adults with cognitive impairments may not be able to report sleep disturbances or even realize they have not slept. Among older adults with sleep disturbances, 69% do not report this problem to their health care providers (HCPs). 2 Even when they repo sleep problems, physicians often underdiagnose or do not recognize signs and symptoms of sleep disturbances in the older adult. 3

Although most research on medical error has been conducted on adult inpatient units, the few studies conducted in pediatric settings suggest that errors occur more frequently in neonatal intensive care units (NICUs) than in other inpatient units. The effects of fatigue, due to long work hours, working at night, and insufficient sleep, are often underestimated. This article reviews basic information about fatigue and sleep and includes examples drawn from data provided by 6 NICU nurses who participated in a recent study to highlight the relationship between fatigue and error. These case studies reinforce the concept that NICU nurses need to be alert enough to provide safe care for their patients, as well as alert enough to detect and correct the errors made by others. Employing good sleep habits, minimizing shift rotations and excessive work hours, and using strategic naps can reduce the adverse effects of fatigue that could potentially put patients, especially the most vulnerable ones, at risk.

• Background To minimize the occurrence of adverse events among patients, critical care nurses must be alert to subtle changes in patients’ conditions, perform accurate clinical assessments, and respond expediently. However, little is known about the effects of the nurses’ work hours on vigilance and patients’ safety. • Objectives To describe the work patterns of critical care nurses, determine if an association exists between the occurrence of errors and the hours worked by the nurses, and explore whether these work hours have adverse effects on the nurses’ vigilance. • Methods Data were obtained from a random sample of critical care nurses in the United States. Nurses eligible for the study were mailed two 14-day logbooks to fill out. Information collected included the hours worked, the time of day worked, overtime hours, days off, and sleep-wake patterns. On days worked, the respondents completed all work-related questions and questions about difficulties in remaining awake while on duty. Space was provided for descriptions of any errors or near errors that might have occurred. On days off, the nurses completed only those questions about sleep-wake patterns, mood, and caffeine intake. • Results The 502 respondents consistently worked longer than scheduled and for extended periods. Longer work duration increased the risk of errors and near errors and decreased nurses’ vigilance. • Conclusions The findings support the Institute of Medicine recommendations to minimize the use of 12-hour shifts and to limit nurses’ work hours to no more than 12 consecutive hours during a 24-hour period.

To determine if skipping breaks and meal periods increases the risk of errors.Anecdotal data suggest that staff nurses frequently skip their breaks and/or meal periods to provide patient care. Neither the prevalence nor the impact of this practice on patient safety is known.Three hundred ninety-three nurses completed logbooks for 28 days providing information about their work hours, errors, and episodes of drowsiness and actual sleep on duty. Participants were asked if they were able to take a break or sit down for a meal during their shift, to indicate the total duration of breaks taken during the shift, and if they were relieved of patient care responsibilities during their meals and/or break periods.Nurses reported having a break or meal period free of patient care responsibilities less than half of the shifts they worked (2,429/5,211 shifts). There were no differences in the risk of errors reported by nurses who had a break free of patient care responsibilities compared with those who were unable to take a break.Although skipping breaks and/or meal periods was not associated with a higher risk of making errors, there are other compelling reasons for nurses to take breaks.

The purpose of this article is to describe the nature and prevalence of errors and near errors reported by 393 full-time hospital staff nurses. One hundred nineteen nurses (30%) reported making at least one error, and 127 nurses (33%) reported at least one near error, for a total of 199 errors and 213 near errors in the 28-day data collection period. Although the majority of errors and near errors identified in this study involved medication administration, the number of procedural, transcription, and charting errors that occurred suggests the need for further examination of the way we currently deliver health care.

The use of extended work shifts and overtime has escalated as hospitals cope with a shortage of registered nurses (RNs). Little is known, however, about the prevalence of these extended work periods and their effects on patient safety. Logbooks completed by 393 hospital staff nurses revealed that participants usually worked longer than scheduled and that approximately 40 percent of the 5,317 work shifts they logged exceeded twelve hours. The risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week.

Narcolepsy is a chronic disorder of EDS. All patients experience EDS. Other symptoms include cataplexy, sleep paralysis, hypnagogic hallucinations, and disrupted nocturnal sleep. Treatment, usually with stimulants and low-doses of antidepressant medications, can dramatically improve the patient's quality of life. Although only advanced practice nurses may be actively involved in the diagnosis and treatment of this disorder, all nurses can encourage their patients who complain of EDS to consult a specialist in sleep disorders medicine, provide emotional support after diagnosis, and educate patients and their families about narcolepsy and its treatment.

Background: Recent studies link insomnia with increased risk of hypertension. The reasons for this association are unknown but may be related, in part, to decreased levels of physical activity and cardiorespiratory fitness. Additionally, sleep medication often has multiple deleterious side effects that may impact a person’s engagement in physical activity. We hypothesized that insomnia symptoms and sleep medication use were associated with reduced cardiorespiratory fitness. Methods: Adults (n=606) enrolled in the Emory-Georgia Tech Predictive Health Institute study completed baseline demographic, clinical, depression (Beck Depression Inventory II; BDI-II), sleep (Pittsburg Sleep Quality Index , PSQI) and cardiorespiratory fitness (maximal oxygen consumption; VO2max) measures. Insomnia symptoms (sleep latency of ≥30 minutes, nighttime or early morning awakenings) and sleep medication use ≥1 times/week were derived from the PSQI. Multiple linear regression was performed to test for associations between cardiorespiratory fitness and insomnia symptoms or sleep medication use. Results: The sample was 68% female, 25% African American, 41% normotensive, 33% prehypertensive, 26% hypertensive with a mean age of 48±11 years and mean body mass index (BMI) 27.6±6.3 kg/m2. Sleep medication use was reported in 11.9% of normotensives and was inversely associated with VO2max adjusting for age, gender, ethnicity, BMI, and heart rate (β=-0.12, p=.03, adjusted R2=.36) and remained significant after further adjustment for blood pressure, HDL cholesterol, depression and smoking (β=-0.11, p=.03, adjusted R2=.41). Sleep medication use was reported in 18.4% of prehypertensives and 22.8% of hypertensives but was not significantly associated with VO2max in either group. No evidence of association between insomnia symptoms and VO2max was found. Conclusion: Sleep medication was related to reduced cardiorespiratory fitness in normotensives. People who use sleep medication may be less physically active placing them at greater cardiovascular risk which has important clinical implications for risk reduction. This relationship is attenuated in prehypertension or hypertension and may reflect the influence of pathophysiology and other variables.

Background Sleep deprivation leads to reduced vigilance and potentially impairs work performance. Nurses may work long shifts that may contribute to sleep deprivation. Objective To assess how nurses' sleep patterns are affected by work schedules and other factors. Methods Between October 2009 and June 2010, a total of 20 critical care nurses completed daily sleep and activity logs and a demographic survey and wore an actigraph to objectively measure sleep time for 14 days. Results In a multivariate model with controls for repeated measures, mean sleep time between consecutive work shifts was short: 6.79 hours between 2 day shifts and 5.68 hours between 2 night shifts (P = .01). Sleep time was much greater between days when no shifts were worked (8.53 hours), consistent with catch-up sleep during these times. Every minute of 1-way commuting time was associated with a reduction of sleep time by 0.84 minutes. Conclusion Critical care nurses obtain reduced amounts of sleep between consecutive work shifts, particularly between consecutive night shifts. Whether this degree of sleep deprivation adversely affects patients' safety needs further study.

Objective: To evaluate the burden of illness of narcolepsy and assess the health-related quality-of-life (HQL) effects of oral modafinil, a wake-promoting therapy for excessive daytime sleepiness associated with narcolepsy. Methods: Subjects with narcolepsy enrolled in a nine-week, placebo-controlled, double-blind study and were randomized to placebo, modafinil 200 mg, or modafinil 400 mg. After the study, consenting subjects received modafinil in a 40-week open-label extension. A self-administered HQL questionnaire consisting of the 36-Item Short Form Health Survey (SF-36) and supplemental narcolepsy-specific scales was given to subjects at baseline, study endpoint, and several open-label timepoints. Results: 481 subjects completed a baseline and double-blind endpoint HQL assessment. Compared to population norms, baseline HQL scores reflected substantial burden in vitality, social functioning, and performing usual activities. At study endpoint, subjects in the 400 mg modafinil group had significantly higher scores than placebo for 10 of the 17 HQL scales. The 400 mg modafinil group had more energy, fewer difficulties performing usual activities, fewer interferences with social activities, improved psychological well-being and higher productivity, attention and self-esteem compared to placebo subjects (p

Narcolepsy is considered a homogeneous clinical entity when excessive daytime sleepiness and cataplexy are present. Cataplexy is a polymorphic symptom that can be very mild and is thus subjectively defined. The Multiple Sleep Latency Test (MSLT) is widely used as a diagnostic test for narcolepsy. A short mean sleep latency and multiple sleep onset REM periods (SOREMPs) are typically observed in narcoleptic patients. The discovery of a tight association of narcolepsy with HLA class II antigens offers a unique opportunity to explore the respective value of the MSLT or of the presence of clear-cut cataplexy in defining an etiologically homogeneous group of narcoleptic patients. In this study, we carried out HLA typing for DR15(DR2) and DQB1*0602 in 188 narcoleptic patients with cataplexy in three ethnic groups (24 Asians, 61 Blacks, and 103 Caucasians). These results confirm the importance of DQB1*0602 typing rather than DR15 (DR2) typing in Black narcoleptic patients and demonstrate that the presence of clear-cut cataplexy is a better predictor for DQB1*0602 positivity than the presence of abnormal MSLT results.

The goals of this descriptive study were to determine what percentage of our treated narcoleptic subjects took their stimulant medications as prescribed and to examine the relationship between compliance and response to stimulant medications. Data obtained from a screening questionnaire, sleep diaries, and medical records showed that 22 of our 43 treated narcoleptic subjects reduced their dosage of stimulant medications or had not taken any stimulant medications during a 24-hour monitoring period during which they were expected to be on medication. Although we had expected better compliance among subjects who responded to stimulant medications (day-wake subjects), statistical testing revealed no significant differences between the two groups. Nor were there any significant differences in age, gender, or educational level when compliant and noncompliant subjects were compared. Only the type of drug prescribed (short versus long-acting stimulant) affected compliance; 39.4% of the subjects with prescriptions for dextroamphetamine or methylphenidate took the amount of medication prescribed compared to 87.5% of the subjects with prescriptions for pemoline.

Lung cancer is the second most common form of cancer but the leading cause of cancer death in both men and women (Siegel, Naishadham, & Jemal, 2013). In 2013, an estimated 228,190 individuals will be diagnosed with lung cancer and 159,480 will die from the disease (American Cancer Society [ACS], 2013). Although advances in knowledge about cancer biology and improvements in early diagnosis and treatment have increased the opportunities for long-term survival, the prognosis remains poor with a five-year survival rate of only 16% (ACS, 2013). As such, the impact of the disease and treatment on patients’ symptoms and quality of life (QOL) requires exploration. The vast majority of patients with lung cancer are diagnosed with advanced disease, a high burden of symptoms (i.e., dyspnea, hemoptysis, cough, and chest pain), poorer QOL, and shortened survival (Buchanan, Milroy, Baker, Thompson, & Levack, 2009; Hopwood & Stephens, 1995, 2000; Siegel et al., 2013; Steinberg et al., 2009). Research has demonstrated that early integration of symptom management leads to meaningful improvements in QOL, mood, and survival in patients with lung cancer (Temel et al., 2010). However, few studies have focused on sleep as a factor influencing symptom burden and QOL. Individuals with lung cancer are reported as having the highest or second highest level of sleep disturbances relative to other cancers and noncancer controls, and so may be a particularly at-risk population for sleep problems (Davidson, MacLean, Brundage, & Schulze, 2002; Palesh et al., 2010). A Canadian study using well-established diagnostic criteria and involving 982 outpatients revealed that those with lung cancer (n = 114) had a higher prevalence of sleep problems, including excessive daytime sleepiness, sleeping more than usual, severe fatigue, and using sleeping pills more often than patients with other solid tumors (Davidson et al., 2002). Only patients with breast cancer had a higher prevalence of insomnia than patients with lung cancer (Davidson et al., 2002). The authors found that patients with lung cancer were diagnosed and treated earlier than other patients with cancer. The median time from diagnosis for all cancers was 34 months, whereas the median time from diagnosis for patients with lung cancer was only 11 months. This suggests that earlier treatment interferes with sleep (Davidson et al., 2002). Palesh et al. (2010) used the Hamilton Depression Inventory, which included six questions assessing frequency and duration of sleep, to study 823 patients undergoing chemotherapy, and found that patients with lung cancer (n = 120) had the highest prevalence of insomnia syndrome when compared to patients with breast, gynecologic, hematologic, or alimentary tract cancers. Insomnia syndrome is defined as difficulty falling asleep, difficulty staying asleep (waking up in the middle of the night), and/or early morning awakenings for at least three days a week for two weeks, with each episode lasting at least 30 minutes. Patients with insomnia syndrome had significantly more fatigue and depression than patients without insomnia syndrome (Palesh et al., 2010). These previous studies provide evidence for the increased prevalence of self-reported sleep disturbances in patients during treatment for lung cancer. Disturbances of mood have an impact on sleep disturbances in patients with lung cancer. Previous estimates have suggested that 15%–40% of individuals with lung cancer have a clinically significant level of anxiety, meeting the criteria for referral (Greer, Pirl, Park, Lynch, & Temel, 2008; Savard, Villa, Ivers, Simard, & Morin, 2009), and 21%–44% are depressed (Hopwood & Stephens, 2000; Turner, Muers, Haward, & Mulley, 2007). Sleep disturbances are included in two of the six categories for anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000), suggesting that sleep disturbance and anxiety are clinically linked. Sleep requires diminished cortical arousal, whereas anxiety manifests with heightened cortical and peripheral arousal (Stein & Mellman, 2005). A review of sleep electroencephalogram (EEG) studies found that sleep homeostasis was impaired and slow wave sleep activity was reduced in depression (Armitage, 2007). Silberfarb, Hauri, Oxman, and Schnurr (1993) screened for depression and anxiety and reported that patients with lung cancer scored within normal limits, but slept as poorly as insomniacs. Only 21% of people with cancer who complained of insomnia had concurrent psychopathology (Ginsburg, Quirt, Ginsburg, & MacKillop, 1995)—a rate similar to overlap rates seen in the general older adult population (Foley et al., 1995). Still, some of the ascribed causes of severe insomnia were related to anxiety, depression, and guilt (Ginsburg et al., 1995). Sleep disturbances in patients with lung cancer have significant adverse effects on symptoms and QOL (Degner & Sloan, 1995; Gooneratne et al., 2007). Pain was significantly worse in patients with lung cancer with insomnia compared to patients without insomnia (Rumble, Keefe, Edinger, Porter, & Garst, 2005). Pain, fatigue, and dyspnea all were significantly correlated with sleep disturbance and, after controlling for all covariates, sleep disturbance was significantly associated with impaired cognitive function and poorer functional status in 115 patients receiving chemotherapy for lung cancer (Chen, Yu, & Yang, 2008). QOL in lung cancer survivors (n = 76) was not significantly different from non-cancer controls (n = 78), but lung cancer survivors with poorer sleep quality had significantly worse QOL than those with good sleep quality (Gooneratne et al., 2007). These studies suggest that newly diagnosed patients and those receiving treatment for lung cancer have increased symptoms and significantly worse QOL compared to controls. In addition, lung cancer survivors with poor quality sleep have significantly worse QOL than those with good sleep quality. Much of the previous research on sleep in patients with lung cancer has focused on self-reported sleep measures. Few studies have used both subjective and objective measures to evaluate sleep. The purpose of this study was to characterize and compare relationships among sleep, mood, and QOL using both subjective and objective measures of sleep in patients receiving treatment for lung cancer. The authors hypothesized that some discrepancies would exist between objective and subjective measures (Schlesinger, Hering-Hanit, & Dagan, 2001; Vitiello, Larsen, & Moe, 2004), but associations also would exist between objective and subjective measures and that mood disorders and poorer QOL would be highly associated with self-reported sleep disturbance. This study was guided by the Two Process Model of Sleep Regulation, one of the leading theories of sleep regulation (Borbely, 1982; Borbely & Achermann, 2005). This model suggests that sleep occurs when the homeostatic drive to sleep (Process S) approaches an upper threshold, and awakening from sleep occurs when Process S reaches a lower threshold. The need to sleep increases as the amount of prior wakefulness increases. In other words, an increase in sleep pressure occurs as wakefulness is prolonged and for a recovery process during sleep. The second process, Process C, signifies the circadian control of sleep propensity or chance for sleep. The circadian system communicates time of day (light and dark cues from the retina) and thereby regulates the change from wakefulness to sleep and the change from sleep to wakefulness. The interaction between these two processes forms the basis for a consistent period of sleep at night and a well-ordered period of wakefulness during the day.

WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Percutaneous treatment for renal stone disease is associated with a risk of significant morbidity. Our large UK series provides contemporary data on the risk of vascular complications and admission to the Intensive Care Unit (ICU) after PCNL. When compared with recent international databases, these data support the current evidence that better outcomes can be achieved in centres performing large numbers of procedures. These data add to the debate for the centralisation of specialist stone surgery.To audit the outcome of percutaneous nephrolithotomy (PCNL) at a UK stone centre over a 10-year period, and provide patients with understandable contemporary data on blood loss and vascular risk.A single centre retrospective analysis of all PCNLs undertaken between April 2000 and December 2010. The association between transfusion and patient age, operative duration and positive preoperative mid-stream urine (MSU) sample was subject to statistical analysis.Data on 568 patients was analysed. 21 were paediatric cases with a mean (range) age of 8 (2-16) years; 547 were adult cases with a mean (range) age of 55 (17-84) years. 3.8% of adult patients (21/547) received a blood transfusion; mean age 60 years (55 years in those not transfused) with a mean operative duration of 119 min (103 min in those not transfused). 23.8% of patients transfused had a confirmed preoperative urinary tract infection compared with 16.1% of those not transfused. Seven patients underwent angiography, with five having selective arterial embolisation (0.9%). There were no deaths in this series although one patient (0.2%) required an urgent nephrectomy due to cardiovascular instability from bleeding.Large UK series that provides contemporary data for consent on vascular risk at PCNL. The risk of transfusion is associated with increased patient age, operative duration and the presence of a positive preoperative MSU sample. Data compares favourably with other large published series, and supports the argument for centralisation of percutaneous stone management.

In most reported studies of treatment for narcolepsy, the efficacy of treatment has been assessed in the sleep laboratory, but not in the natural work and home settings. We therefore assessed the sleep/wake patterns of 25 subjects with narcolepsy, whose symptoms were considered under satisfactory control by the subjects and their physicians, using polygraphic recorders, and compared these with the patterns of 25 control subjects matched for age and gender. Data from one matched pair of subjects were excluded for technical reasons. There was no difference between the two groups of subjects in the total amount of sleep obtained during the 24-hour monitoring period. Narcoleptic subjects had shorter nocturnal sleep latencies and more disrupted nocturnal sleep than control subjects. Despite taking their usual medications, narcoleptic subjects averaged 44 minutes of daytime sleep compared to 4.8 minutes for controls. There was wide variation in the amount of daytime sleep among narcoleptics: 10 subjects did not sleep during the day, whereas the other 14 averaged 2.7 naps per day for an average of 76.2 minutes of daytime sleep. These findings indicate that daytime sleep episodes were common in narcoleptic patients who considered their treatment satisfactory. Wide variations in the amount of daytime sleep may reflect differences in disease severity, responsiveness to medications or willingness to tolerate daytime sleep episodes.

OBJECTIVE: To describe sleep, stress and compensatory behaviors in nurses and midwives. METHODS: The study included 41 midwives and 21 nurses working in Australian hospitals between 2005 and 2009. Participation was voluntary. All participants recorded on a daily basis their work and sleep hours, levels of stress and exhaustion, caffeine intake and use of sleep aids for a month (1,736 days, 1,002 work shifts). RESULTS: Participants reported moderate to high levels of stress and exhaustion on 20-40% of work days; experienced sleep disruption on more than 50% of work days; struggled to remain awake on 27% of work days; and suffered extreme drowsiness or experienced a near accident while travelling home on 9% of workdays. Age, perceived sleep duration and work hours were significant predictors of caffeine intake. About 60% of participants reported using sleep aids (about 20% reported taking prescription medications and 44% of nurses and 9% of midwives reported alcohol use as a sleep aid at least once during the study). Stress and workdays were significant predictors of sedative use. Overall, 22% reported being indifferent or mildly dissatisfied with their job. CONCLUSIONS: Sleep problems, high levels of stress and exhaustion and low job satisfaction are prevalent among nurses and midwives. The use of alcohol and sleeping pills as sleep aids, and the use of caffeine to help maintain alertness is also common. Nurses and midwives may use caffeine to compensate for reduced sleep, especially on workdays, and sleeping pills to cope with their daily work-related stress. OBJETIVO: Descrever sono, estresse e comportamentos compensatórios em enfermeiras e parteiras. MÉTODOS: O estudo incluiu 41 enfermeiras 21 parteiras em hospitais australianos de 2005 a 2009. A participação foi voluntária. Os participantes registraram diariamente as horas de trabalho, sono, stress e níveis de exaustão, cafeína e uso de ajuda para dormir durante um mês (1.736 dias, 1.002 turnos). RESULTADOS: Os participantes relataram de moderados a elevados níveis de stress e de exaustão em 20%-40% dos dias de trabalho; experimentaram distúrbios do sono em mais de 50% dos dias de trabalho; relataram esforço para permanecer acordado em 27% dos dias de trabalho; e sofreram sonolência extrema ou acidente perto de casa em 9% dos dias de trabalho. Idade, duração do sono percebida e jornadas foram preditores significativos da ingestão de cafeína. Aproximadamente 60% dos participantes relataram utilizar a ajuda para dormir: cerca de 20% relataram uso de medicação prescrita e 44% das enfermeiras e 9% das parteiras consumiam álcool como auxílio para dormir pelo menos uma vez durante o estudo. Estresse e dias de trabalho foram preditores significativos do uso de sedativos. Em geral, 22% relataram ser indiferente, ou ligeiramente insatisfeito com seu trabalho. CONCLUSÕES: Problemas no sono, estresse e exaustão elevados e diminuição na satisfação no trabalho são prevalentes. São comuns o uso de álcool e de medicamentos para dormir, e consumo de cafeína para se manter alerta. Enfermeiras e parteiras parecem usar a cafeína para compensar a redução do sono, especialmente em dias de trabalho, e usar soníferos para compensar o estresse diário. OBJETIVO: Describir sueño, estrés y comportamientos compensatorios en enfermeras y parteras. MÉTODOS: El estudio incluyó 41 enfermeras 21 parteras en hospitales australianos de 2005 a 2009. La participación fue voluntaria. Los participantes registraron diariamente las horas de trabajo, sueño, estrés y niveles de agotamiento, cafeína y uso de ayuda para dormir durante un mes (1.736 días, 1.002 turnos). RESULTADOS: Los participantes relataron de moderados a elevados niveles de estrés y de agotamiento en 20%-40% de los días de trabajo; experimentaron disturbios del sueño en más de 50% de los días de trabajo; relataron esfuerzo para permanecer despierto en 27% de los días de trabajo; y sofrieron somnolencia extrema o accidente cerca de casa en 9% de los días de trabajo. Edad, duración del sueño percibido y jornadas fueron predictores significativos de la ingestión de cafeína. Aproximadamente 60% de los participantes relataron utilizar la ayuda para dormir: cerca de 20% usaron de medicación prescripta y 44% de las enfermeras y 9% de las parteras consumirán alcohol como auxilio para dormir al menos una vez durante el estudio. Estrés y días de trabajo fueron predictores significativos del uso de sedativos. En general, 22% relataron ser indiferente, o ligeramente insatisfecho con su trabajo. CONCLUSIONES: Problemas en el sueño, estrés y agotamiento elevados y disminución en la satisfacción en el trabajo son prevalecientes. Uso de alcohol y de medicamentos para dormir, y consumo de cafeína para mantenerse alerta también es común. Enfermeras y parteras pueden usar la cafeína para compensar la reducción del sueño, especialmente en días de trabajo, y usar somníferos para compensar el estrés diario.

Publisher Summary Scheduled sleep periods are indicated for patients with narcolepsy who are unable to remain awake during the day. Scheduled sleep periods (naps) and good sleep hygiene have traditionally been recommended for management of excessive daytime sleepiness in narcoleptic patients. However, due to their limited efficacy, naps and good sleep hygiene are no longer recommended as the sole treatments for narcolepsy. The treatment is contraindicated in narcoleptic patients with recent increases in excessive daytime sleepiness. Since obstructive sleep apnea is common in patients with narcolepsy, all patients who report an increase in excessive daytime sleepiness need to be evaluated for obstructive sleep apnea. This intervention is suitable for narcoleptic patients who prefer not to take stimulant medications, and/or those patients whose medications do not completely relieve their excessive daytime sleepiness.

Background/objectives The International Classification of Functioning, Disability and Health (ICF) provides a comprehensive and universally accepted framework to classify changes in functioning related to health conditions. Comprehensive and Brief Core Sets have been defined for various disorders but not for sleep disorders. Such a Core Set would greatly enhance the techniques available to describe the impact of sleep disorders on patients. The overarching purpose of this paper is to report on phase 1 of the international and World Health Organization (WHO) endorsed consensus process in identifying ICF Core Sets for sleep disorders. Methods A formal decision-making and consensus process which integrated evidence gathered from preparatory studies was carried out. Relevant ICF categories were selected by a sample of international experts from different backgrounds using the nominal group technique. Results Twenty-six experts from 22 countries and different professional backgrounds attended the consensus conference. Altogether 120 second- or third-level ICF categories were included in the Comprehensive ICF Core Set with the following ICF component split: 49 categories from body functions, 8 from body structures, 31 from activities and participation and 32 from environmental factors. The Brief ICF Core Set included a total of 15 second-level categories: 5 body functions (sleep, energy and drive, attention, consciousness, respiration functions); 3 body structures (brain, respiratory system, pharynx); 4 activities and participation (focusing attention, driving, handling stress and other psychological demands, carrying out daily routine); and 3 environmental factors (immediate family; health services, systems, and policies; and health professionals). Conclusion A formal consensus process integrating evidence and expert opinion led to the first version of the ICF Core Sets for persons with sleep disorders. Further validation of the Core Set is needed.