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Maintaining strict temperature control during the maintenance phase of targeted temperature management (TTM) after cardiac arrest may be an important component of clinical care. Temperature variability outside of the goal temperature range may lessen the benefit of TTM and worsen neurologic outcomes. The purpose of this retrospective study of 186 adult patients (70.4% males, mean age 53.8 ± 15.7 years) was to investigate the relationship between body temperature variability (at least one body temperature measurement outside of 36°C ± 0.5°C) during the maintenance phase of TTM at 36°C after cardiac arrest and neurologic outcome at hospital discharge. Patients with temperature variability (n = 124 [66.7%]) did not have significantly higher odds of poor neurologic outcome compared with those with no temperature variability (odds ratio [OR] = 1.01, 95% confidence interval [CI] = 0.36–2.82). Use of neuromuscular blocking agents (NMBAs) and having an initial shockable rhythm were associated with both higher odds of good neurologic outcome (shockable rhythm: OR = 10.77, 95% CI = 4.30–26.98; NMBA use: OR = 4.54, 95% CI = 1.34–15.40) and survival to hospital discharge (shockable rhythm: OR = 5.90, 95% CI = 2.65–13.13; NMBA use: OR = 3.03, 95% CI = 1.16–7.90). In this cohort of postcardiac arrest comatose survivors undergoing TTM at 36°C, having temperature variability during maintenance phase did not significantly impact neurologic outcome or survival.

Nighttime noise carries a significant disease burden. The World Health Organization (WHO) recently published guidelines for the regulation of environmental noise based on a review of evidence published up to the year 2015 on the effects of environmental noise on sleep.This systematic review and meta-analysis will update the WHO evidence review on the effects of environmental noise on sleep disturbance to include more recent studies.Investigations of self-reported sleep among residents exposed to environmental traffic noise at home were identified using Scopus, PubMed, Embase, and PsycINFO. Awakenings, falling asleep, and sleep disturbance were the three outcomes included. Extracted data were used to derive exposure-response relationships for the probability of being highly sleep disturbed by nighttime noise [average outdoor A-weighted noise level (Eleven studies (Available evidence suggests that transportation noise is negatively associated with self-reported sleep. Sleep disturbance in this updated meta-analysis was comparable to the original WHO review at low nighttime noise levels. These low levels correspond to the recent WHO noise limit recommendations for nighttime noise, and so these findings do not suggest these WHO recommendations need revisiting. Deviations from the WHO review in this updated analysis suggest that populations exposed to high levels of aircraft noise may be at greater risk of sleep disturbance than determined previously. https://doi.org/10.1289/EHP10197.

Energy expenditure (EE) is the sum of metabolic activity within the body at a given time and comprises basal EE, diet-induced thermogenesis, and physical activity. In the intensive care unit, EE is most often assessed to determine a patient’s caloric requirements. Energy expenditure also may be useful to understand disease states and the metabolic impact of interventions. Several methods for estimating EE are relevant for clinical use, including indirect calorimetry, predictive equations, exhaled carbon dioxide volume, and the Fick method. Indirect calorimetry is the preferred method for evaluating EE and is considered the gold standard for estimating EE in hospitalized patients. However, use of indirect calorimetry is not always practical or possible. Therefore, other methods of estimating EE must be considered. In this review, methods of evaluating EE in critically ill adults are examined and the benefits and limitations of each method are discussed, with practical considerations for use.

Patients undergoing targeted temperature management (TTM) after cardiac arrest are at risk for shivering, which increases energy expenditure (EE) and may attenuate TTM benefits. This article reports patterns of EE for patients with and without shivering who received TTM at 36°C after cardiac arrest. Based on 96 case assessments, there were 14 occasions when more than one 15-minute interval period was required to appropriately modify the Bedside Shivering Assessment Scale (BSAS) score. Investigators noted that although higher EE was related to higher BSAS scores, there may be opportunities for earlier detection of shivering.

Background Medical interns are at risk for sleep deprivation from long and often rotating work schedules. However, the effects of specific rotations on sleep are less clear. Objective To examine differences in sleep duration and alertness among internal medicine interns during inpatient intensive care unit (ICU) compared to general medicine (GM) rotations. Methods This secondary analysis compared interns during a GM or ICU rotation from a randomized trial (2015–2016) of 12 internal medicine residency programs assigned to different work hour limit policies (standard 16-hour shifts or no shift-length limits). The primary outcome was sleep duration/24-hour using continuous wrist actigraphy over a 13-day period. Secondary outcomes assessed each morning during the concomitant actigraphy period were sleepiness (Karolinska Sleepiness Scale [KSS]), alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses), and self-report of excessive sleepiness over past 24 hours. Linear mixed-effect models with random program intercept determined associations between each outcome by rotation, controlling for age, sex, and work hour policy followed. Results Of 398 interns, 386 were included (n = 261 GM, n = 125 ICU). Average sleep duration was 7.00±0.08h and 6.84±0.10h, and number of PVT lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU, respectively (all P > .05). KSS was 4.8±0.1 for both rotations. Compared to GM, ICU interns reported more days of excessive sleepiness from 12am–6am (2.6 vs 1.7, P < .001) and 6am–12pm (2.6 vs 1.9, P = .013) and had higher percent of days with sleep duration < 6 hours (27.6% vs 23.4%, P < .001). GM interns reported more days with no excessive sleepiness (5.3 vs 3.7, P < .001). Conclusions Despite ICU interns reporting more excessive sleepiness in morning hours and more days of insufficient sleep (

Background Continuous renal replacement therapy (CRRT) is a lifesaving intervention for critically ill patients. Delays in initiation, or an inability to resume CRRT following a temporary suspension in therapy (CRRT restart), can result in suboptimal CRRT delivery. Local problem Intensive care units across the health care system were experiencing significant delays in CRRT initiation and restarts. Approach A multimodal quality improvement initiative was implemented across 7 adult intensive care units, which allowed unit-based staff nurses to initiate and restart CRRT, a task that had previously been delegated to non-unit-based dialysis nurses. Outcomes A 75% reduction in CRRT initiation delays and a 90% reduction in CRRT restart delays were observed in the 12 months following the initiative. There were no adverse events or increased disposable CRRT circuit usage following the initiative. Conclusions Implementation of CRRT initiation and restarts by unit-based nurses were achievable and resulted in substantial improvements in timeliness of CRRT delivery.

Introduction Little is known about the impact of cumulative workdays on medical residents' alertness. The purpose of this study was to examine changes in alertness over consecutive workdays following a day off for internal medicine interns. Methods This is a secondary report of a randomized non-inferiority trial of 12 internal-medicine residency programs assigned to either standard duty-hour (80h workweek/16h shifts) or flexible (80h workweek/no shift-length limit) policies. Interns were followed for 2 weeks during inpatient rotations. Each morning, alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses) was assessed, and interns selected the type of shift worked (day-off, days, nights, beginning/ending extended overnights, or other). Sleep duration (actigraphy) was averaged each 24h day. For this analysis, interns were included if they had ≥1 day-off followed by at least 3 workdays, and had no flagged PVT-B results for non-adherence. To examine the longitudinal effect of consecutive workdays on alertness, a generalized linear mixed model with random intercept and slope, and Poisson distribution was used to determine the rate of PVT-B lapses for up to 4 work days following a day off, controlling work shift type, sleep duration, and policy, with sleep and shift type interaction, and linear spline to account for the change in slope after the 2nd workday. Results N=328 interns were included (mean age 27.8±2.2y, 49% males). Mean±SD number of PVT-B lapses were 3.4±4.5, 4.2±5.6, 5.3±6.6, 4.8±5.8, and 4.7±6.0, and mean±SD sleep duration was 9.0±1.9, 6.9±1.3, 6.5±2.1, 6.6±1.8, and 6.9±1.7 hours for a day off and workdays 1-4 respectively. Rate of lapses increased by 1.1 lapse/day from a day off to the 2nd workday (p=0.004; 95%CI: 1.03-1.18), and then significantly decreased from days 2-4 at a rate of 0.89 lapses/day (p Conclusion Both sleep and subsequent alertness were negatively impacted when returning to work following a day off for interns in this study. After two workdays, sleep duration appeared to increase again, with observed improvements in alertness. Support (If Any) Funded by the NHLBI and American Council for Graduate Medical Education. M.C. is supported by NIH/NINR (K99 NR019862).

Background Nurses working in hospital environments are at risk for burnout. Exposure to nature has psychological benefits, but the effect of hospital gardens on nurse burnout is less understood. Objective To compare the effect on nurse burnout of taking daily work breaks in a hospital-integrated garden with the effect of indoor-only breaks. Methods A prospective crossover trial was conducted of nurses assigned to either 6 weeks of a work break in an outdoor hospital garden or 6 weeks of indoor-only breaks. After a 1-week washout period, break assignments were switched for a subsequent 6 weeks. The Maslach Burnout Inventory was administered at the beginning and end of each 6-week period, and a Present Functioning Visual Analogue Scale was completed at the start and end of each break to capture immediate psychological symptoms. Change scores were analyzed by using generalized estimating equations. Results For 29 nurses, for garden compared with indoor breaks, significant improvement was apparent in scores on the Maslach Burnout Inventory subscales for emotional exhaustion (4.5 vs -0.2; P < .001) and depersonalization (1.8 vs 0.0; P = .02) but not for personal accomplishment (-0.6 vs -0.0; P = .55). Compared with indoor breaks, total symptom scores on the Present Functioning Visual Analog Scale improved significantly when nurses took a break in the garden (garden vs indoor breaks, 4.0 vs 2.4; P = .04). Conclusions Taking daily work breaks in an outdoor garden may be beneficial in mitigating burnout for nurses working in hospital environments.

Background High quality sleep of sufficient duration is vital to overall health and wellbeing. Self-reported poor quality of sleep, sleep reported as irregular in timing, marked by frequent awakenings, or shortened in duration, is common across the solid-organ transplant trajectory. Aim This Systematic Review aimed to summarize available literature on rates of self-reported poor quality of sleep among solid organ transplant candidates and recipients. Methods A systematic search of published literature was conducted in PubMed/MEDLINE, Embase, Web of Science, CINHAL, and PsychInfo databases with no date restrictions. Original articles in the English language describing self-reported quality of sleep using standardized questionnaires in adults either waitlisted for, or who received a solid organ transplant (heart, lung, kidney, liver, pancreas, or multi-solid organ) were included. Results Of a potential 2054 articles identified, 44 were included (63.6% renal transplant, 20.5% liver transplant, 11.4% lung transplant, and 4.5% included multiple organ transplant populations), with the majority (68.2%) focusing only on post-transplant populations. No included articles focused solely on heart or pancreas transplant populations. On average, the transplant population with the greatest improvement in quality of sleep (reported as poor sleep quality, insomnia, sleep disturbance, or sleep dissatisfaction) from transplant candidacy to post-transplantation were renal transplant (from 53.5% pre, to 38.9% post) followed by liver transplant patients (from 52.8% pre, to 46.3% post), while lung transplant patients remained similar pre- to post-transplantation (55.6% pre, to 52% post). Poor quality of sleep was frequently associated with anxiety and depression, poorer quality of life, restless legs syndrome, and higher comorbidity. Conclusions Reports of poor quality of sleep are highly prevalent across all solid-organ transplant populations, both pre- and post-transplantation. Future studies should assess quality of sleep longitudinally throughout all phases of the transplantation trajectory, with more research focusing on how to optimize sleep in solid organ transplant populations.

Introduction The global pandemic due to the novel coronavirus (COVID-19) has had unprecedented effects on society, in particular for those who are also working with children in the household. The aim of this analysis was to evaluate sleep amount and sleep quality during the COVID-19 pandemic compared to before COVID-19 for those working from home with minor household dependents. Methods We developed the “Anonymous Survey on Confinement during the COVID-19 Pandemic”, a national survey for individuals ≥18 years of age hosted on the Penn Medicine Clinical Research website from May 16th to November 11th, 2020. This 200 question survey captured demographics and multiple dimensions of health and well-being, including stress, sleep, eating behaviors, and coping activities. Respondents who indicated they were working from home were stratified by whether they were living with ≥1 minor dependent vs no dependents. Separate ordinal logistic regression models were used to evaluate associations between living with a minor dependent and sleep amount (less, same, more) and disturbed quality (none, less, same, more) during, compared to before, COVID-19 controlled for age, sex, ethnicity, and annual income. Results A total of 232 respondents (n=182 no dependents, n=50 dependents, 84.9% Caucasian) reported working from home, the majority of which had been in confinement (95.7%). Respondents with dependents were younger (mean age 38.9±13.5 vs 47.4±18.0, p=0.002) and mostly female (86% vs 76.9%, p=0.03). On average, reported days worked/week (3.5±2.4 days) and hours worked/day (5.5±4.17 hours) were similar regardless of dependents. Comparing those without to those with minor dependents, there were no significant differences in log odds of getting enough sleep (β=-0.38, p=0.25) or worse sleep quality (β=0.41, p=0.22) during the COVID-19 pandemic compared to before COVID-19. Respondents with dependents reported a higher log odds of taking longer to fall asleep during COVID-19 (β=0.71, p=0.045), and higher stress (β=-0.65, p=0.04). Conclusion In this mostly Caucasian female sample of people working from home, having minor dependents in the household did not significantly impact sleep amount or quality compared to no minor household dependents. However, respondents with dependents reported longer time to fall asleep and were more stressed. Support (if any) MC/CJ are supported by NHLBI (T32 HL007713).

Objectives: Measure the immediate change in intensive care unit (ICU) family members’ state stress levels from the beginning to the end of a person’s visit to a hospital garden and compare the changes produced by the garden with those associated with spending time in indoor hospital environments intended for respite and relaxation. Background: No previous research has compared the efficacy of different physical environments as interventions to foster stress reduction in family members of ICU patients, a group of hospital visitors known to experience high levels of distress. Method: A convenience sample of 42 ICU patient family (from 42 different families) completed the Present Functioning Visual Analogue Scales (PFVAS) before and after each visit (128 total visits) to a garden, an atrium/café, or ICU waiting room. Results: Stress scores significantly declined (i.e., improved) from the start to the end of a break on all PFVAS subscales ( p < .0001) in both the garden and indoors locations. However, it is noteworthy that garden breaks resulted in significantly greater improvement in the “sadness” scale than breaks in indoor locations ( p = .03), and changes in all five other PFVAS scores showed somewhat more reduction of stress for breaks spent in the garden than indoors, although these differences were not statistically significant. Conclusion: Creating an unlocked garden with abundant nature located close to an ICU can be an effective intervention for significantly mitigating state stress in family members of ICU patients and can be somewhat more effective than indoor areas expressly designed for family respite and relaxation.

Introduction As of March 2020, most U.S. states and territories issued statements advising people “stay at home” to avoid spreading the novel Coronavirus (COVID-19). This resulted in an unprecedented number of people practicing physical confinement and social distancing. This study examined self-reported changes in sleep duration, quality and timing in response to confinement and isolation. Methods We developed the “Anonymous Survey on Confinement during the COVID-19 Pandemic” to collect information on the American population practicing social distancing and some level of confinement. The survey collected information on demographics, duration and degree of confinement, and sleep-wake dynamics. The online survey was available for completion by any individual ≥18 years of age through the Penn Medicine Clinical Research page from May 16th to November 11th 2020. Descriptive statistics characterized the nature of confinement and non-parametric correlations evaluated the relationships between confinement and sleep-wake dynamics. Results N=226 participants completed the survey (n=176 female [77.8%]; n=47 male [20.8%]). The average age was 44.9±17.4 years. N=215[95.1%] reported confinement since March 2020 for an average of 89.3±41.7 days in confinement. Surveyed participants in confinement reported sleeping more than before confinement [40.0%], taking the same amount of time to fall asleep [56.6%], and felt that they were getting enough sleep [66.3%]. However, 36.3% of participants reported going to bed earlier and waking up earlier. Participants that engaged in naps prior to confinement reported taking more naps in confinement [50.8%]. Participants reported more daytime sleepiness [42.9%] and more disturbed sleep quality during confinement relative to before confinement [42.5%]. There were no significant correlations between time in confinement and sleep outcomes. Conclusion During the confinement amid the COVID-19 pandemic, participants responded by sleeping more and at different times, which could reflect circadian disruption of sleep. Changes in sleep amount and sleeping timing were accompanied by increased daytime sleepiness and a reduction in sleep quality. These changes may have been due to age, stressors experienced during the pandemic, social isolation, and/or a change in behavioral routines in response to changing demands and schedules. Our findings suggest that attention to changes in sleep-wake dynamics due to prolonged confinement is likely important to maintain healthy behaviors. Support (if any)

Introduction In March 2020, an unprecedented number of individuals were confined to their homes in an effort to stem the spread of the novel Coronavirus (Covid-19), however the impact of this confinement on health and behavior is unknown. Long-duration confinement studies have found effects on homeostatic biology and neurobehavioral functions, including reduced sleep durations. This study evaluated how confinement due to Covid-19 has impacted health and stress through changes in sleep. Methods The Anonymous Survey on Confinement during the COVID-19 Pandemic was available online to any individual ≥18 years of age through the Penn Medicine Clinical Research webpage on May 14, 2020 and the data presented are through October 24, 2020. The survey collected self-reported information on demographics, the amount and quality of sleep, as well as ratings of health and stress. To determine the impact of confinement on these domains, participants were asked to answer questions relative to pre-confinement levels. To test associations between sleep amounts and sleep quality on health and stress, generalized linear models were used and adjusted for age, sex, and race. Results N=228 participants (n=180 female [79.0%]) were on average 45.0±17.1 years of age. During confinement relative to pre-confinement, 41.7% of participants reported sleeping more, 37.3% reported sleeping the same amount, and 21.0% reported less sleep, while 14.0% reported better sleep quality, 47.4% the same, and 38.6% worse quality of sleep relative to pre-confinement. Ratings of worse health during confinement were associated with both reduced sleep amount (β=0.695; P Conclusion The confinement resulting from the COVID-19 pandemic has impacted the amount and quality of sleep and good sleep may help to reduce stress and maintain health. These findings highlight the need to further examine how long-term confinement influences human health and behavior and warrant examining what factors or life-style behaviors promote resilience to the negative effects of confinement. Support (if any) CWJ supported by NHLBI NRSA (T32 HL007713).

Introduction Little is known about the impact of specific rotations on medical residents’ sleep. The purpose of this analysis was to examine the difference in sleep duration and alertness among internal-medicine resident interns during intensive care unit (ICU) compared to general medicine (GM) rotations. Methods This is a secondary report of a randomized non-inferiority trial of 63 United States internal-medicine residency programs. Programs were assigned to either standard duty-hour (80h workweek/16h shifts) or flexible (80h workweek/no shift-length limit) policies. Interns were followed for 2 weeks during either a GM or ICU rotation. The primary outcome was sleep duration/24h (actigraphy). Secondary outcomes were sleepiness (Karolinska Sleepiness Scale [KSS]) and alertness (number of Brief Psychomotor Vigilance Test [PVT-B] lapses). Data were averaged across days (thirteen 24-hour periods). Linear mixed-effect models with random program intercept were used to determine the association between each outcome by rotation, controlling for age, sex, and policy followed. Results N=386 interns were included (mean age 27.9±2.1y, 194 (50.3%) males), with n=261 (67.6%) in GM, and n=125 (32.4%) in ICU. Average sleep duration was 7.00±0.08h and 6.84±0.10h for GM and ICU respectively (p=.09; 95%CI -0.02;0.33h). Percent of days with self-reports of excessive sleepiness were significantly more likely for ICU vs GM from 12am-6am (ICU: 20.2%; GM: 12.5%) and 6am-12pm (ICU: 20.5%; GM: 14.3%). GM had significantly more days with no excessive sleepiness (GM: 40.5%; ICU: 28.1%). Average KSS was 4.8±0.1 for both GM and ICU (p=.60; 95%CI -0.18;0.32). Average number of PVT-B lapses were 5.5±0.5 and 5.7±0.7 for GM and ICU respectively (p=.83; 95%CI -1.48;1.18 lapses). There were no significant differences in PVT-B response speed or false starts between rotations. Conclusion Interns in ICU may experience more excessive sleepiness compared to GM interns, especially in early morning hours. However, sleep duration and alertness were not significantly different between rotations. Support Funded by the National Heart, Lung, and Blood Institute and American Council for Graduate Medical Education

Introduction American nurses report sleeping an average of 6.8 hours per night on workdays, which is less than the recommended 7-9 hours. Burnout, which is comprised of emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA), is common among nurses and may contribute to insufficient sleep quantity and sleep disruption. We aimed to investigate if burnout, measured using the Maslach Burnout Inventory (MBI), predicted self-report of trouble sleeping for nurses working in the hospital. Methods This is a secondary report of a prospective crossover trial of nurses assigned to either 6 weeks of daily work-breaks in an outdoor hospital garden or 6 weeks of indoor-only breaks. After a 1-week washout period, break assignments were switched for an additional 6 weeks. Nurses completed the MBI at the beginning and end of each 6-week period. Each workday, nurses completed a visual analog scale reporting no trouble sleeping to much trouble sleeping immediately following a break. For this analysis, we used initial MBI subscale score (EE, DP, PA) as a predictor of mean trouble sleeping over the subsequent 6-week period regardless of break location using generalized estimating equations. Results A total of 29 nurses (27 females, mean age 42.8 years) participated. Most (n=20) worked dayshift, and 9 worked night shift. Initial MBI subscale score, regardless of break location, was predictive of mean self-report of trouble sleeping over the subsequent 6-week period for EE (p