Sleep modulates haematopoiesis and protects against atherosclerosis.

Sleep is integral to life1. Although insufficient or disrupted sleep increases the risk of multiple pathological conditions, including cardiovascular disease2, we know little about the cellular and molecular mechanisms by which sleep maintains cardiovascular health. Here we report that sleep regulates haematopoiesis and protects against atherosclerosis in mice. We show that mice subjected to sleep fragmentation produce more Ly-6Chigh monocytes, develop larger atherosclerotic lesions and produce less hypocretin-a stimulatory and wake-promoting neuropeptide-in the lateral hypothalamus. Hypocretin controls myelopoiesis by restricting the production of CSF1 by hypocretin-receptor-expressing pre-neutrophils in the bone marrow. Whereas hypocretin-null and haematopoietic hypocretin-receptor-null mice develop monocytosis and accelerated atherosclerosis, sleep-fragmented mice with either haematopoietic CSF1 deficiency or hypocretin supplementation have reduced numbers of circulating monocytes and smaller atherosclerotic lesions. Together, these results identify a neuro-immune axis that links sleep to haematopoiesis and atherosclerosis.

Using Evidence to Create a Toolkit to Enable Sleep Among Hospitalized Patients.

Studies show sleep deprivation impacts patients' ability to perform physical activities and can lead to delirium, depression, and other psychiatric impairments. One of the Choosing Wisely® recommendations is "Do not wake the patient for routine care unless the patient's condition requires it." The authors discuss the development of an evidence-based toolkit to facilitate opportunities for patients to sleep during hospitalization, exemplifying the translation of a Choosing Wisely recommendation into clinical practice.

Top 10 evidence-based countermeasures for night shift workers.

Emergency edicine providers are responsible for ensuring the emergency department is staffed 24 hours a day. As such, providers must efficiently transition between day, swing and night shift on an almost weekly basis. There is no formal education in medical school or residency on how to approach the transition to and from night shift, remain alert and productive and maximise sleep during the day. There are a multitude of blogs and online sources discussing night shift, but few, if any, provide an evidence-based approach. This article will provide the top 10 evidence-based recommendations to increase sleep, maximise performance, decrease fatigue on shift and improve quality of life outside the workplace.

Interventions to improve inpatients' sleep quality in intensive care units and acute wards: a literature review.

BACKGROUND: Sleep is essential for the physical and psychological restoration of inpatients, and lack of sleep results in sleep deprivation and poor sleep quality, with potentially harmful consequences. AIM: To summarise sleep-promoting interventions in the Intensive care unit (ICU) and acute ward setting. METHOD AND RESULTS: Six databases were searched to obtain studies for review and eight studies were selected, appraised, analysed and produced two themes: sleep-disturbing factors and sleep-promoting strategies. Sleep-disturbing factors included environmental factors (such as light and noise), illness-related factors (such as pain, anxiety and discomfort), clinical care and diagnostics. Sleep-promoting strategies included using pharmacological aids (medication) and non-pharmacological aids (reducing noise and disturbances, eye masks, earplugs and educational and behavioural changes). CONCLUSION: The literature review showed that both ICU and acute ward settings affect patients' sleep and both use similar strategies to improve this. Nevertheless, noise and sleep disturbances remain the most critical sleep-inhibiting factors in both settings. The review recommended future research should focus on behavioural changes among health professionals to reduce noise and improve patients' sleep.

Sleep Hygiene for Optimizing Recovery in Athletes: Review and Recommendations.

For elite athletes who exercise at a high level, sleep is critical to overall health. Many studies have documented the effects of sleep deprivation in the general population, but few studies exist regarding specific effects in the athlete. This review summarizes the effects of sleep deprivation and sleep extension on athletic performance, including reaction time, accuracy, strength and endurance, and cognitive function. There are clear negative effects of sleep deprivation on performance, including reaction time, accuracy, vigor, submaximal strength, and endurance. Cognitive functions such as judgment and decision-making also suffer. Sleep extension can positively affect reaction times, mood, sprint times, tennis serve accuracy, swim turns, kick stroke efficiency, and increased free throw and 3-point accuracy. Banking sleep (sleep extension prior to night of intentional sleep deprivation before sporting event) is a new concept that may also improve performance. For sports medicine providers, the negative effects of sleep deprivation cannot be overstated to athletes. To battle sleep deprivation, athletes may seek supplements with potentially serious side effects; improving sleep quality however is simple and effective, benefiting not only athlete health but also athletic performance.

Using a Sleep Protocol to Limit Sleep Interruptions on a Medical-Surgical Unit.

A quality improvement effort was designed to coordinate care in minimizing sleep interruptions to allow patients 6 or more hours of uninterrupted sleep. An interprofessional team developed a sleep protocol (HUSH) and coordinated care activities to reduce sleep interruptions on a 30-bed medical-surgical-telemetry unit. Changes in patient perceptions of noise and number of hours of restful sleep were compared before and after implementation. Results indicate a 9% improvement in quiet domain scores.

Napping on night-shifts among nursing staff: A mixed-methods systematic review.

AIMS: To synthesize research on the influence of night-shift napping on nurses. BACKGROUND: Shift work is common for hospital nurses. Various studies corroborate that shift work causes adverse health consequences for nurses. Night-shift napping is a countermeasure to address the adverse outcomes of shift work. DESIGN: A mixed-methods systematic review. DATA SOURCES: The literature search included the PubMed, Web of Science, Embase, PsycINFO and Cochrane Library electronic databases from inception to December 2017. Reference lists were hand searched. Only English articles were chosen. REVIEW METHODS: A sequential explanatory design and Cochrane's methods for integrating qualitative and implementation evidence in intervention effectiveness reviews. The Mixed Methods Assessment Tool and Cochrane Risk of Bias Tool were applied to assess the methodological quality of included studies. RESULTS: Twenty-two studies met our inclusion criteria. Many nurses experienced napping during their night-shift although no clear policy emerged. Napping is beneficial to the well-being of nurses and could improve their psychomotor vigilance and performance. However, the related studies are limited. The evidence on reducing sleepiness and fatigue was also insufficient and napping in nursing still faces challenges. CONCLUSION: Although research on this topic has just started, napping during night-shift is beneficial to nurses' health and performance. Research should further explore the long-term impact on of night-shift napping on nurses, people and organization using sound methodological designs. Managers should actively develop strategies to address night-shift napping barriers.

Historical Trajectory and Implications of Duty-Hours in Graduate Medical Education.

Duty-hours policies continue to be debated. Most know the pro and con arguments, but many may not be aware of background information preceding and intertwining the development and implementation of these policies. Interestingly, several aspects of law were involved or potentially correlated with policies enacted. This review updates new generations of physicians and scholars on the historical trajectory of duty-hour policies and highlights policy implications and the current state of evidence. In reviewing the historical and legal trajectory of duty-hours, many updates seemed to be a reaction to potential federal entanglement. Additionally, the review of the postimplementation literature revealed minimal empirical evidence. Instead, the majority of the positive findings were perception based. These summaries demonstrate a need for further outcomes evidence to validate policies.

Effect of the use of earplugs and eye mask on the quality of sleep in intensive care patients: a systematic review.

Intensive care unit (ICU) environment has a very strong and unavoidable negative impact on patients' sleep. Sleep deprivation in ICU patients has been already studied and negative effects on their outcome (prolonged ICU stay, decreased recovery) and complication rates (incidence of delirium, neuropsychological sequels of critical illness) discussed. Several interventions potentially improving the sleep disturbance in ICU (sleep-promotion strategies) have been assumed and tested for clinical practice. We present a review of recent literature focused on chosen types of non-pharmacological interventions (earplugs and eye mask) analysing their effect on sleep quality/quantity. From the total amount of 82 papers found in biomedical databases (CINAHL, PubMed and SCOPUS) we included the 19 most eligible studies meeting defined inclusion/exclusion criteria involving 1 379 participants. Both experimental and clinical trials, either ICU and non-ICU patient populations were analysed in the review. Most of the reviewed studies showed a significant improvement of subjective sleep quality when using described non-pharmacological interventions (objective parameters were not significantly validated). Measuring the sleep quality is a major concern limiting the objective comparison of the studies' results since non-standardised (and mainly individual) tools for sleep quality assessment were used. Despite the heterogeneity of analysed studies and some common methodological issues (sample size, design, outcome parameters choice and comparison) earplugs and eye mask showed potential positive effects on sleep quality and the incidence of delirium in ICU patients.

An evening milk drink can affect word recall in Indonesian children with decreased sleep efficiency: A randomized controlled trial.

STUDY OBJECTIVES: Sleep is important for memory consolidation in children. This study intended to find out whether an evening milk-based drink could influence sleep efficiency and memory recall in a group of Indonesian children (5-6 years old) with sleep deprivation. METHODS: Children were randomly allocated to one of three interventions: Reference product, satiety-stimulating product, and a relaxing product. The intervention lasted for 6 weeks and children consumed two servings per day of each 200 ml, the serving in the morning being the same for all children. All measurements took place at baseline and at the end of the intervention. Sleep parameters were studied using actigraphy and a sleep diary during three consecutive days. Memory consolidation was tested using a 20 word-pair list, which was memorized the evening before being recalled the next morning at home-base. Anthropometry was measured using standard equipment. RESULTS: The Satiety group showed a significant decrease in word recall, and a significant increase in nocturnal awakenings that was inversely associated with sleep efficiency at the end of the intervention. Sleep efficiency did not differ between the three groups being 75.5 ± 8.6% and 75.7 ± 6.3% at baseline and end of the intervention, respectively. Despite the lower energy intake in the Standard (reference) group, this condition showed the highest increase in weight. DISCUSSION: Evening growing-up milks can affect memory recall, sleep characteristics, and growth. However, to correct sleep efficiency and sleep duration, improvement of parental behavior may be the most important factor with nutrition providing a supplementary effect.

Delayed school start time is associated with better sleep, daytime functioning, and life satisfaction in residential high-school students.

The effects of a delayed school start time by one hour were examined at a boarding school in Hong Kong. Two cohorts of high school students (N = 228; 61.8% female) were recruited respectively before and after a school start time changed from 7:30am to 8:30am. Both cross-cohort and within-cohort longitudinal comparisons yielded significant increase in total sleep time. Cross-cohort comparison yielded improvement in sleep quality, insomnia, life satisfaction, and psychological distress. Longitudinal data suggested that the longer the additional sleep time, the better was sleep quality, day-time functioning, and subjective wellbeing.

A Preliminary Evaluation of a School-Based Media Education and Reduction Intervention.

While media education and reduction programs have been proposed to prevent adverse health and academic outcomes related to heavy electronic media use among school-aged children, few have been formally piloted and evaluated. We used a quasi-experimental design to evaluate the effectiveness of Take the Challenge (TtC), a school-based media education/reduction program for the primary prevention of sleep deprivation, dysfunctional social-emotional behaviors, and poor academic performance. Sixth- to eighth-grade students at a rural Midwestern U.S. middle school received the TtC program, while a similar school in the same district served as the comparison group. Health-related and academic measures were collected from students and teachers at both schools before and after the intervention. The primary outcome measure was student-reported electronic media use (television, video games, Internet). Secondary measures included student health behaviors (student-reported sleep, exercise, and outdoor play) and academic activities (teacher-reported homework and classroom performance). Compared to the comparison group, students receiving TtC slept more and reduced television viewing, background television time, after-school video gaming, and weekend Internet use. Teachers reported increases in the extent to which TtC students completed homework assignments and stayed on task in the classroom. Well-designed school-based programs such as TtC can reduce electronic media use among middle-school children and improve related health and academic outcomes.

Impact of earplugs and eye mask on sleep in critically ill patients: a prospective randomized study.

BACKGROUND: Poor sleep is common in intensive care unit (ICU) patients, where environmental factors contribute to reduce and fragment sleep. The objective of this study was to evaluate the impact of earplugs and eye mask on sleep architecture in ICU patients. METHODS: A single-center randomized controlled trial of 64 ICU patients was conducted from July 2012 to December 2013. Patients were randomly assigned to sleep with or without earplugs and an eye mask from inclusion until ICU discharge. Polysomnography was performed on the first day and night following inclusion. The primary outcome was the proportion of stage N3 sleep over total sleep time. Secondary outcomes were other descriptors of sleep and major outcome variables. RESULTS: In the intervention group, nine (30%) patients did not wear earplugs all night long. The proportion of N3 sleep was 21 [7-28]% in the intervention group and 11 [3-23]% in the control group (p = 0.09). The duration of N3 sleep was higher among the patients in the intervention group who wore earplugs all night long than in the control group (74 [32-106] vs. 31 [7-76] minutes, p = 0.039). The number of prolonged awakenings was smaller in the intervention group (21 [19-26] vs. 31 [21-47] in the control group, p = 0.02). No significant difference was observed between the two groups in terms of clinical outcome variables. CONCLUSIONS: Earplugs and eye mask reduce long awakenings and increase N3 duration when they are well tolerated. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02292134 . Registered on 21 Nov 2013.

Restoration of resident sleep and wellness with block scheduling.

CONTEXT: Block scheduling during residency is an innovative model in which in-patient and ambulatory rotations are separated. We hypothesised that this format may have a positive impact on resident sleep and wellness in comparison with a traditional format. METHODS: We performed a single-centre, cross-sectional, observational study of residents rotating in the medical intensive care unit (MICU). Residents were observed for 4 weeks at a time: internal medicine (IM) residents were observed for 3 weeks in the MICU followed by 1 week in an ambulatory context, and non-IM residents were observed for 4 weeks in the MICU. We monitored daily total sleep time (TST) utilising actigraphy, and wellness measures with weekly Epworth Sleepiness Scale (ESS) and Perceived Stress Scale (PSS) questionnaires. RESULTS: A total of 64 of 110 (58%) eligible residents participated; data for 49 of 110 (45%) were included in the final analysis. Mean ± standard deviation (SD) daily TST in the entire cohort was 6.53 ± 0.78 hours. Residents slept significantly longer during the ambulatory block than during the MICU block (mean ± SD TST 6.97 ± 1.00 hours and 6.43 ± 0.78 hours, respectively; p < 0.0005). Sleep duration during night call was significantly shorter than during day shift (mean ± SD TST 6.07 ± 1.16 hours and 6.50 ± 0.73 hours, respectively; p < 0.0005). A total of 390 of 490 (80%) ESS and PSS questionnaires were completed; scores significantly declined during rotations in the MICU. Internal medicine residents showed significant improvements in TST, and in ESS and PSS scores (p < 0.05) at the end of the ambulatory week. Non-IM residents, who remained in the MICU for a fourth week, continued a trend that showed a decline in perceived wellness. CONCLUSIONS: Despite duty hour restrictions, residents obtain inadequate sleep. As MICU days accumulate, measures of resident wellness decline. Residents in a block schedule experienced improvements in all measured parameters during the ambulatory week, whereas residents in a traditional schedule continued a downward trend. Block scheduling may have the previously unrecognised benefits of repaying sleep debt, correcting circadian misalignment and improving wellness.

A Pilot Study to Examine the Relationship Between Napping and Fatigue in Nurses Practicing on the Night Shift.

OBJECTIVE: The aim of this study is to explore the relationship of night-shift napping on fatigue. BACKGROUND: Nurses' fatigue, especially at night, interferes with quality of life and job performance and impacts safety and health. METHODS: Night-shift nurses completed the Brief Fatigue Inventory and a demographic information sheet to determine differences in fatigue between nurses who napped during their night shift as compared with nurses who did not nap. RESULTS: No statistically significant differences in global fatigue were found; differences in rotating shift, age, and, gender were identified. Rotating shifts, a 2nd job, and caring for family predicted fatigue. CONCLUSIONS: Based on this pilot study, further investigations of fatigue among night-shift nurses are needed as well as evidence-based support to promote sleep.

Effect of Changes in Sleep Quantity and Quality on Depressive Symptoms Among Korean Children.

This study aims to determine whether changes in sleep quantity and quality in childhood are associated with incidence of depressive symptoms. We used the three waves of the Korean Children & Youth Panel Survey (2011-2013). Statistical analysis using a generalized estimating equation model was performed. The 2,605 subjects analyzed included 1,453 students in 2012 and 1,152 students in 2013 without depressive symptoms in the prior year. We found that deteriorated or consistently poor sleep quality were important risk factors for depressive symptoms in children. We suggest that early detection and intervention of poor sleep quality in elementary school is required to reduce early onset depressive symptoms.

The Impact of Interventions to Improve Sleep on Delirium in the ICU: A Systematic Review and Research Framework.

OBJECTIVE: This study aimed to assess whether interventions targeted at improving sleep in the ICU were associated with reductions in ICU delirium. Secondary outcomes include duration of delirium and ICU length of stay. DATA SOURCES: MEDLINE, CINAHL, Web of Science, Scopus, WorldCat, and International Pharmaceutical Abstracts were searched from inception to January 2016. STUDY SELECTION: Studies investigating any type of sleep intervention (nonpharmacologic or pharmacologic) and assessing the impact on ICU delirium were included. Any type of study design was permitted so long as the delirium assessment was made at least daily with a validated delirium assessment tool. DATA EXTRACTION: The following data were extracted: first author, year of publication, study design, ICU type, components of sleep intervention, use of sleep assessment tool, patient age, sex, severity of illness, sleep measures, delirium assessment tool, incidence of delirium, duration of delirium, and ICU length of stay. The incidence of delirium was used to compare rates of ICU delirium across studies. Methodologic quality of included studies was evaluated using the Effective Public Health Practice Project quality assessment tool. DATA SYNTHESIS: Of 488 citations screened, 10 studies were identified for inclusion in the final review; six of which demonstrated a statistically significant reduction in the incidence of ICU delirium associated with sleep intervention. Four studies assessed duration of delirium; of which, three reported a shorter duration of delirium with sleep intervention. Two studies associated sleep intervention with a reduced ICU length of stay. In regard to quality assessment and risk of bias, only one study was assessed as strong. Multiple identified confounders and the significant qualitative assessment of heterogeneity limit both the conclusions that can be drawn from these findings and the quantitative pooling of data. CONCLUSIONS: Although sleep interventions seem to be a promising approach for improving delirium-related outcomes, studies are limited by bias issues, varying methodologies, and multiple confounders, making the evidence base for this conclusion limited at best. Future studies would benefit from a systematic approach to studying the link between sleep intervention and delirium-related outcomes, which is outlined in the context of reviewing the existing literature.

What are postpartum women doing while the rest of the world is asleep?

Large individual differences characterize maternal postpartum sleep and adjustment. Our goal was to explore aspects of mothers' nocturnal environments and behaviours that may explain differences in postpartum adjustment. A total of 201 mothers of infants aged 0-6 months completed an online survey with demographics, number and duration of nocturnal awakenings, caretaking behaviours, environment and nocturnal activities during 'one typical night during the past week'. Mothers reported 2.9 [standard deviation (SD) ± 1.7] nocturnal awakenings, each lasting 33.9 (SD ± 22.5) min. Infant age was related inversely to duration but unrelated to number of awakenings. Falling asleep while feeding was less frequent among exclusively formula-feeders. Among the entire sample, mothers used a cellphone (59%), backlit tablet (25%), TV (20%) and computer (16%) during nocturnal awakenings. Watching TV and using a computer were each associated with longer nocturnal awakenings. Eighty-nine per cent of women used ≥1 extra light source during nocturnal awakenings: night light (35%), light from a cracked door (28%), desk lamp (25%), electronic device (19%) or room light (14%). Light source(s) was unrelated to number or duration of nocturnal awakenings. These data suggest that, although supplemental light sources were not associated with awakenings, TV and computer use accounted for longer awakenings. Feeding method and technology use may help to explain individual differences in postpartum adjustments and may be targets for more effective interventions.

Social support moderates the effects of stress on sleep in adolescents.

Academic expectations and demands become primary sources of stress during adolescence, negatively affecting sleep. To cope with stress, adolescents may turn to social support figures. The present study tested the extent of main and moderating effects of various sources of social support on the association between stress and sleep. Adolescents (n = 202, meanage 14.6 years, standard deviation = 0.71) reported on academic stress, sleep, and support using questionnaires during a low- and high-stress period, defined by the absence or presence of examinations, respectively. Inquiries were made regarding social support from parents, friends, and class supervisor. During both stress periods, academic stress was associated negatively with sleep quality and positively with sleep reduction. Social support increased sleep quality and lowered sleep reduction. In addition, social support moderated the effects of academic stress on sleep, thus improving sleep quality and lowering sleep reduction. Moderating effects were stronger during a period of high stress. The present study showed that adolescents can benefit from stress moderation through social support by improvements of sleep quality and sleep reduction. Such moderating effects should be taken into account when studying stress and sleep. Implications and recommendations based on these findings are discussed.

Sleep insufficiency and the natural environment: Results from the US Behavioral Risk Factor Surveillance System survey.

BACKGROUND: Exposure to the natural environment may improve health behaviors and mental health outcomes such as increased levels of physical activity and lower levels of depression associated with sleep quality. Little is known about the relationship between insufficient sleep and the natural environment. PURPOSE: To determine whether exposure to attributes of the natural environment (e.g., greenspace) attenuates the likelihood of reporting insufficient sleep among US adults. METHODS: Multiple logistic regression models were used to explore the association between self-reported days of insufficient sleep (in the past 30days) and access to the natural environment in a multi-ethnic, nationally representative sample (n=255,171) of US adults ≥18years of age enrolled in the 2010 Behavioral Risk Factor Surveillance System. RESULTS: Using 1-to-6days of insufficient sleep as the referent group for all analyses, lower odds of exposure to natural amenities were observed for individuals reporting 21-to-29days (OR=0.843, 95% confidence interval (CI)=0.747, 0.951) of insufficient sleep. In stratified analyses, statistically significant lower odds of exposure to natural amenities were found among men reporting 7-to-13-days (OR=0.911, 95% CI=0.857, 0.968), 21-to-29-days (OR=0.838, 95% CI=0.759, 0.924), and 30-days (OR=0.860, 95% CI=0.784, 0.943) of insufficient sleep. Greenspace access was also protective against insufficient sleep for men and individuals aged 65+. CONCLUSIONS: In a representative sample of US adults, access to the natural environment attenuated the likelihood of reporting insufficient sleep, particularly among men. Additional studies are needed to examine the impact of natural environment exposure on sleep insufficiency across various socio-demographic groups.