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IntroductionObstructive sleep apnoea (OSA) is a multisystem, debilitating, chronic disorder of breathing during sleep, resulting in a relatively consistent pattern of cognitive deficits. More recently, it has been argued that those cognitive deficits, especially in middle-aged patients, may be driven by cardiovascular and metabolic comorbidities, rather than by distinct OSA-processes, such as are for example ensuing nocturnal intermittent hypoxaemia, oxidative stress, neuroinflammation, and sleep fragmentation.MethodsThus, we undertook to define cognitive performance in a group of 27 middle-aged male patients with untreated OSA, who had no concomitant comorbidities, compared with seven matched controls (AHI mean ± S.D.: 1.9 ± 1.4 events/h; mean age 34.0 ± 9.3 years; mean BMI 23.8 ± 2.3 kg/m2). Of the 27 patients, 16 had mild OSA (AHI mean ± S.D.:11.7 ± 4.0 events/h; mean age 42.6 ± 8.2 years; mean BMI 26.7 ± 4.1 kg/m2), and 11 severe OSA (AHI 41.8 ± 20.7 events/h; age: 46.9 ± 10.9 years, BMI: 28.0 ± 3.2 kg/m2).ResultsIn our patient cohort, we demonstrate poorer executive-functioning, visuospatial memory, and deficits in vigilance sustained attention, psychomotor and impulse control. Remarkably, we also report, for the first time, effects on social cognition in this group of male, middle-aged OSA patients.ConclusionOur findings suggest that distinct, OSA-driven processes may be sufficient for cognitive changes to occur as early as in middle age, in otherwise healthy individuals.

The uncertain, ever-changing and an ongoing nature of the COVID-19 pandemic means that it may take some time before we can fully appreciate the negative effect of the pandemic and lockdown on our sleep and mental health. It is increasingly recognised that in the aftermath of pandemic, several persistent sleep, neuropsychiatric and physical sequelae may continue long after the pandemic is over. A body of evidence to date also highlights a significant disparity in sleep and mental health difficulties in specific vulnerable groups in the community, with different temporal profiles and sleep issues that are reported. In this perspective, we argue for a possible mechanistic impact of the COVID-19 pandemic, with its imposed restrictions and social isolation on sleep quality. We similarly discuss some of the potential international differences, as well as similarities, behind reported idiosyncratic biological vulnerabilities that may have contributed to the genesis of sleep issues. Lastly, we propose some possible implementations and innovations that may be needed in restructuring of sleep disorders services in order to benefit recovering COVID-19 patients.

Aims The operating theatre is a crucial learning environment for different trainees (nurses, anaesthetists, surgeons etc.) Equity of access is essential to achieve their individual training requirements. Traditionally, opportunities within a theatre list are informally discussed between trainers and trainees at some point during the list. Furthermore, there is currently limited discussion between different members of the full team. The Theatre Training Checklist (TTC) is a simple framework that aims to facilitate coordination of training for all team members. Methods The TTC was devised as an extension of the WHO checklist. It consists of four stages: Trainer/Trainee discussion before theatre brief regarding training goals for the list, formal identification of all trainees within the theatre brief, explanation to the team of what each trainee will undertake, followed by use of theatre debrief to reprise whether training goals were met. The TTC was piloted and outcomes measured using an anonymised structured questionnaire from across the entire team. Results 27 staff participated, including 7 trainees. Individuals’ understanding of trainees’ objectives improved as a result of the TTC (25/27, 92.6%) along with perceived improved theatre list efficiency (18/27, 66.6%). All trainees agreed that the checklist improved achievement of their training objectives. Qualitative feedback included: “This is a great way to identify what students and trainees want to achieve in theatre and how we can work together to overcome any difficulties” Conclusion Initial data suggests the checklist qualitatively improves training. The TTC Toolkit is available for use and consists of the checklist tool and an instructional video.

A wide variety of diagnostic tests exist to aid the clinician in diagnosing sleep disorders. These range from simple and relatively cheap home diagnostic tests such as pulse oximetry to in-laboratory video-polysomnography, which is expensive and labour-intensive. Understanding the indications for and limitations of these diagnostic tests allows the accurate diagnosis of sleep disorders in a timely manner, whilst best managing limited resources. Diagnostic tests should be interpreted by trained suitably qualified personnel and used to compliment conventional clinical practice and decision making.

Sleep is vital for our physical and mental health. Studies have shown that there is a high prevalence of sleep disorders and sleep difficulties amongst adults with intellectual disabilities. Despite this, sleep is often overlooked or its disorders are considered to be difficult to treat in adults with intellectual disabilities. There is a significant amount of research and guidance on management of sleep disorders in the general population. However, the evidence base for sleep disorders in adults with intellectual disabilities is limited. In this review paper, we look at the current evidence base for sleep disorders in adults with an intellectual disability, discuss collaborative working between intellectual disabilities psychiatrists and sleep medicine specialists to manage sleep disorders, and provide recommendations for future directions.

Background The COVID-19 pandemic has had a significant negative impact on operative surgical training, with trainee logbook numbers reduced by more than 50% compared to 2019. The operating theatre is expensive, costing approximately £1200 per hour to run. It is a crucial learning environment for many different trainees: anaesthetists, surgeons, operation department practitioners and surgical first assistants. For individuals to achieve their training requirements, the operating theatre as a training environment must be shared between all trainees. This requires excellent teamwork and leadership. The recovery phase of the COVID-19 pandemic is a unique opportunity to adopt novel training strategies. Methods The Theatre Training Checklist is a simple framework that aims to facilitate awareness, understanding, coordination and cooperation of training for all members of the team (Figure 1). It is a practical strategy that can be adopted in any setting. Usually, trainers discuss informally with their trainees about their individual Skills, Experience, Expectationsand what is Achievable in a planned theatre list (SEEA). However, there currently is limited opportunity to discuss this between different disciplines and the wider team. This tool aims to refine communication, optimize training, manage expectations and ensure equity across the board. The checklist has been introduced and trialed locally. Results The checklist is completed at the start of the list during the theatre brief. It identifies all trainees and their specific needs within the operating theatre session to the whole team. An agreed strategy is developed on how to achieve identified training goals (figure 2). Sometimes it may not be possible to allow a trainee to perform a particular procedure. However, other opportunities for training in theatre exist, such as: patient positioning, choice of equipment, types of techniques, discussions around consenting and complications etc. Feedback undertaken from the multiprofessional team after local trialing of the checklist has been positive. Conclusions The Theatre Training Checklist aims to create dialogue and shared understanding of training needs among all parties within the operating theatre. The Theatre Training Checklist Toolkit is available for use and consists of the checklist tool and an instructional video. The Theatre Training checklist is being piloted in some centers and we hope to have the opportunity to present some early findings at AUGIS 2021.

Restless legs syndrome describes a curious need to stretch and move in response to an unpleasant feeling in the legs. For most people who have this, as they are drifting off to sleep there is a twitch of the toe, foot and ankle followed by another and then another. The limb movements are strikingly periodic and are described as such by frustrated bed partners. The pathophysiology remains debated but is likely to involve dopaminergic dysfunction and ascending arousal systems. Despite a prevalence of 5–10% in the general population, the variable nature of symptoms and difficulty describing the dysaesthesia often leads to delay in treatment. This article outlines the diagnostic criteria, medication and comorbidities that modify symptoms, the impact of restless legs syndrome on health, and symptomatic management. Several licensed therapies are effective but the dopamine agonists in particular can cause challenging side effects and paradoxically worsen symptoms over time. Case histories are reviewed to guide physicians.

SUMMARYSleep medicine is a truly multidisciplinary field that covers psychiatric, neurological and respiratory conditions. As the field has developed it has become increasingly clear that there is a great deal of overlap between sleep and psychiatric disorders and it is therefore essential for psychiatrists to have some knowledge of sleep medicine. Even those disorders, such as obstructive sleep apnoea, that may seem to be outside the remit of psychiatry can have complex and important interactions with psychiatric conditions. In this article we give a brief overview of the range of sleep disorders a psychiatrist might encounter, how they are recognised, investigated and treated, and how they relate to psychiatric conditions.LEARNING OBJECTIVES•Be aware of the range of sleep disorders that might be encountered in psychiatric practice•Understand how these sleep disorders affect mental health•Have a broad understanding of how these disorders are investigated and treatedDECLARATION OF INTERESTH.S. has accepted speaker fees from Janssen Pharmaceuticals.

Although video polysomnography (vPSG) is not routinely recommended for the evaluation of typical cases of non-rapid eye movement (NREM) parasomnias, it can aid diagnosis of unusual cases, other sleep disorders and complicated cases with REM behaviour disorder (RBD), and in differentiating parasomnias from epilepsy. In this study, we aimed to assess vPSG findings in consecutive patients with a clinical diagnosis of NREM-parasomnia covering the whole phenotypic spectrum. Five hundred and twelve patients with a final diagnosis of NREM parasomnia who had undergone vPSG were retrospectively identified. vPSGs were analysed for features of NREM parasomnia and for the presence of other sleep disorders. Two hundred and six (40.0%) patients were clinically diagnosed with sleepwalking, 72 (14.1%) with sleep terrors, 39 (7.6%) with confusional arousals, 15 (2.9%) with sexsomnia, seven (1.4%) with sleep-related eating disorder, 122 (23.8%) with mixed phenotype, and 51 (10.0%) with parasomnia overlap disorder (POD). The vPSG supported the diagnosis of NREM parasomnia in 64.4% of the patients and of POD in 98%. In 28.9% of the patients, obstructive sleep apnea (OSA) or/and periodic limb movements during sleep (PLMS) were identified, most commonly in older, male, sleepy and obese patients. vPSG has a high diagnostic yield in patients with NREM parasomnia and should be routinely performed when there is diagnostic doubt, or in patients where there is a suspicion of OSA and PLMS.

Whilst the link between insomnia and psychopathology has long been observed, our understanding of their dynamic relationship is continually evolving. The vast majority of insomnia—the most prevalent sleep disorder in the general population—exists as co-morbid insomnia (Roth and Roehrs 2003). Up to 45% of individuals with insomnia have a co-morbid psychiatric disorder (Sarsour et al. 2010), and up to 86% have a co-morbid medical illness (Taylor et al. 2007a, b). Co-morbid insomnia is therefore the rule rather than the exception. Compared to chronic medical illnesses, psychiatric disorders are more significantly associated with insomnia severity (Sarsour et al. 2010).

Acupuncture has become a popular complementary treatment in oncology, particularly as patients seek non-pharmacological alternatives to provide symptom control. A considerable body of evidence suggests that acupuncture modulates neurological processes to bring about its effects. This basic research is supported by an increasing number of positive clinical studies of varying quality. Lower quality studies have hampered the widespread acceptability of acupuncture, with some deeming the inter-personal skills of the practitioner to be more powerful than the needle or its equivalent. More recent randomised control trials (RCTs) have sought to settle this controversy, with mixed results. The literature was searched to identify, where possible, RCTs involving acupuncture and various common cancer symptoms. A potential role for acupuncture was found in the following cancer symptoms: pain, nausea and vomiting, xerostomia, hot flushes, fatigue, anxiety, depression and insomnia. Acupuncture is safe with minimal side-effects, and is clinically effective for the management of these symptoms. Continuing research using validated methodology is essential. In the interim, health professionals should be open to explore the use of acupuncture with their cancer patients.

Low birth weight in humans is predictive of hypertension in adult life. Although the mechanisms underlying this link remain unknown, fetal overexposure to glucocorticoids has been implicated. We previously showed that prenatal dexamethasone (DEX) exposure in the rat lowers birth weight and programmes adult hypertension. The current study aimed to further investigate the nature of this hypertension and to elucidate its origins. Unlike previous studies, we assessed offspring blood pressure (BP) with radiotelemetry, which is unaffected by stress artefacts of measurement. We show that prenatal DEX during the last week of pregnancy results in offspring of low birth weight (14% reduction) that have lower basal BP in adulthood (similar to 4-8 mmHg lower); with the commonly expected hypertensive phenotype only being noted when these offspring are subjected to even mild disturbance or a more severe stressor (up to 30 mmHg higher than controls). Moreover, DEX-treated offispring sustain their stress-induced hypertension for longer. Promotion of systemic catecholamine release (amphetamine) induced a significantly greater rise of BP in the DEX animals (77% increase) over that observed in the vehicle controls. Additionally, we demonstrate that the isolated mesenteric vasculature of DEX-treated offspring display greater sensitivity to noradrenaline and other vasoconstrictors. We therefore conclude that altered sympathetic responses mediate the stress-induced hypertension associated with prenatal DEX programming.

BACKGROUND AND PURPOSE The aim was to advance the understanding of Orai proteins and identify a specific inhibitor of the associated calcium entry mechanism in vascular smooth muscle cells (VSMCs). EXPERIMENTAL APPROACH Proliferating VSMCs were cultured from human saphenous veins. Intracellular calcium was measured using fura-2, whole-cell current was recorded using patch-clamp and cell migration quantified in modified Boyden chambers. Subcellular protein localization was determined by microscopy. Isometric tension was recorded from mouse aortic rings. KEY RESULTS Molecular disruption and rescue experiments indicated the importance of Orai1 in calcium entry caused by store depletion evoked passively or by platelet-derived growth factor (PDGF), suggesting the presence of Ca2+ release-activated Ca2+ (CRAC) channels like those of the immune system. The CRAC channel blocker, S66, was a potent inhibitor of the VSMC signals, IC50 26 nM, which was almost two orders of magnitude greater than with leucocytes. S66 had no effect on PDGF- and ATP-evoked calcium release, overexpressed transient receptor potential canonical (TRPC)5 channels, native TRPC1/5-containing channels, stromal interaction molecule 1 clustering, non-selective cationic current evoked by store depletion and phenylephrine-evoked aortic contraction. S66 reduced PDGF-evoked VSMC migration while having only modest effects on cell proliferation and no effect on cell viability. CONCLUSIONS AND IMPLICATIONS The data suggest that Orai1 has a role in human VSMC migration, and that a CRAC channel inhibitor has high potency and selectivity for the associated calcium entry, suggesting a distinct characteristic of vascular CRAC channels and the potential for selective chemical suppression of vascular remodelling.

Increasing epidemiological evidence supports the notion that adverse events in fetal life permanently alter the structure and physiology of the adult offspring, a phenomenon dubbed ‘fetal programming’. In particular, low weight or thinness at birth in humans is associated with an increased risk of cardiovascular and metabolic disorders as well as neuroendocrine dysfunction in adult life. Glucocorticoid administration during pregnancy is well-documented to both reduce offspring birth weight and alter the maturation of organs (hence their use to accelerate fetal lung maturation in premature labour). Here data are reviewed which show, in rodents and other models, that antenatal exposure to endogenous or exogenous glucocorticoids reduces offspring birth weight and produces permanent hypertension, hyperglycaemia, hyperinsulinaemia, altered behaviour and neuroendocrine responses throughout the lifespan. Processes underlying fetal programming include determination of the ‘set point’ of the hypothalamic-pituitary-adrenal (HPA) axis and of tissue glucocorticoid receptor (GR) expression. Similar HPA axis hyperreactivity occurs in lower birth weight humans and may be an early manifestation of the ‘low birth weight’ phenotype.

A 51-year-old Burmese woman with no family orpersonal history of psychiatric disorders was ad-mittedtotheCriticalCareUnit(CCU)followingananteriorresectionformetastatic(lungandhepatic)adenocarcinoma of the sigmoid colon. Postopera-tivelythereweretwoinitialcomplications:first,anepisode of rectal bleeding from the anastomosissite, necessitating a return to theatre for explora-tion only; second, an episode of pulmonaryoedema, during which there were no prolongedperiods of hypoxaemia, and which resolved fol-lowing non-invasive continuous positive airwaypressureventilation.OnreturntoCCU,thepatientshowed no signs of delirium, was oriented intime, place and person, and was communicatingappropriately.Subsequently, eight hours after returning fromtheatre her Glasgow Coma Scale fell from 15 to 6(E1M4V1), with no obvious focal neurologicalabnormality. Blood tests (i.e. full blood profile,liver function tests, urea and electrolytes) andarterial blood gases revealed no cause for thisdeterioration.Accordingly, she was intubated andventilated, and a head CT scan was performedwhich revealed no apparent abnormalities toexplain her deterioration. She regained a full levelof consciousness the next day. Then, however, herlevel of consciousness progressively dropped overseveral hours. On examination, she kept her eye-lids clenched, and it was impossible to assess herpupils, which rolled backwards on manual eyelidretraction. Otherwise, cranial nerve examinationwas entirely normal, including a good gag reflex.Assessment of upper and lower limb neurologywas equally unremarkable with down-goingplantar responses.A Bi-Spectral (BIS) monitor (routinely used tomonitor intra-operative conscious levels) wasemployed to assess EEG activity and level of con-sciousness, as no electroencephalogram could beimmediately arranged. This demonstrated a bi-spectral index of 85–90, which is associated withwakefulness, and not any major intra-cerebralevent or convulsive activity.