Melatonin use in managing insomnia in children with autism and other neurogenetic disorders - An assessment by the international pediatric sleep association (IPSA).

Though it is widely prescribed for improving sleep of children with autism and other neurogenetic disorders, there is a need for practical guidance to clinicians on the use of melatonin for managing insomnia in this population. Because data were either lacking or inconclusive, a task force was established by the International Pediatric Sleep Association (IPSA) to examine the literature based on clinical trials from 2012 onwards. A summary of evidence pertaining to melatonin's utility and potential side effects, practice-related caveats, and insights for use are published herewith.

Development of Convolutional Neural Network to Segment Ultrasound Images of Histotripsy Ablation.

OBJECTIVE: Histotripsy is a focused ultrasound therapy that ablates tissue via the action of bubble clouds. It is under investigation to treat a number of ailments, including renal tumors. Ultrasound imaging is used to monitor histotripsy, though there remains a lack of definitive imaging metrics to confirm successful treatment outcomes. In this study, a convolutional neural network (CNN) was developed to segment ablation on ultrasound images. METHODS: A transfer learning approach was used to replace classification layers of the residual network ResNet-18. Inputs to the classification layers were based on ultrasound images of ablated red blood cell phantoms. Digital photographs served as the ground truth. The efficacy of the CNN was compared to subtraction imaging, and manual segmentation of images by two board-certified radiologists. RESULTS: The CNN had a similar performance to manual segmentation, though was improved relative to segmentation with subtraction imaging. Predictions of the network improved over the course of treatment, with the Dice similarity coefficient less than 20% for fewer than 500 applied pulses, but 85% for more than 750 applied pulses. The network was also applied to ultrasound images of ex vivo kidney exposed to histotripsy, which indicated a morphological shift in the treatment profile relative to the phantoms. These findings were consistent with histology that confirmed ablation of the targeted tissue. CONCLUSION: Overall, the CNN showed promise as a rapid means to assess outcomes of histotripsy and automate treatment. SIGNIFICANCE: Data collected in this study indicate integration of CNN image segmentation to gauge outcomes for histotripsy ablation holds promise for automating treatment procedures.

Hyperactivity in patients with narcolepsy and idiopathic hypersomnia: an exploratory study.

Introduction: Patients with either Idiopathic Hypersomnia or Narcolepsy demonstrate excessive daytime somnolence (EDS) with resultant inattention mimicking Attention Deficit Hyperactivity Disorder (ADHD). Patients with ADHD also often express sleep problems including EDS. Thus, patients with ADHD and patients with idiopathic hypersomnia or narcolepsy may share inattention and daytime drowsiness as common features. However, it is not known whether EDS patients with idiopathic hypersomnia or narcolepsy also have increased movement (hyperactivity) like ADHD patients, the determination of which is the purpose of this study. Methods: We studied 12 patients (7 Narcolepsy type 2 and 5 Idiopathic Hypersomnia) with EDS as shown by Multiple Sleep Latency Test which served as the gold standard for entry into the study. Twelve subjects without symptoms of EDS served as the control group. None of the participants had a previous history of ADHD. Each participant underwent a one-hour session laying at 45 degrees with surveys about the need to move and actigraphy as an objective measure of movement. Results: Sleep-disordered patients with EDS reported more symptoms of inattention and hyperactivity on the ADHD Self-Report Scale. At each of the time points patients with EDS had a clear trend to express the need to move more than controls on the Suggested Immobilization Test (SIT). For the total 60 minutes, a large effect size for the need to move during the SIT test was found between patients and controls (Cohen's d = 0.61, p=0.01). Patients with EDS did not express a need to move more to combat drowsiness than controls, nor did actigraphy show any difference in objective movement between patients and controls during the SIT. Conclusion: Patients with EDS express inattention and a need to move more than controls. However, hyperactivity was not verified by objective measurement, nor did the EDS patients express a need to move to combat drowsiness more than controls. Thus, a hypothesis to be further tested, is whether narcolepsy and idiopathic hypersomnia may be more a model of the inattentive form of ADHD rather than the combined or inattentive/hyperactive form of ADHD. Further studies are needed to explore the relationship between EDS and hyperactivity.

A Neuro-Informatics Pipeline for Cerebrovascular Disease: Research Registry Development.

BACKGROUND: Although stroke is well recognized as a critical disease, treatment options are often limited. Inpatient stroke encounters carry critical information regarding the mechanisms of stroke and patient outcomes; however, these data are typically formatted to support administrative functions instead of research. To support improvements in the care of patients with stroke, a substantive research data platform is needed. OBJECTIVE: To advance a stroke-oriented learning health care system, we sought to establish a comprehensive research repository of stroke data using the Houston Methodist electronic health record (EHR) system. METHODS: Dedicated processes were developed to import EHR data of patients with primary acute ischemic stroke, intracerebral hemorrhage (ICH), transient ischemic attack, and subarachnoid hemorrhage under a review board-approved protocol. Relevant patients were identified from discharge diagnosis codes and assigned registry patient identification numbers. For identified patients, extract, transform, and load processes imported EHR data of primary cerebrovascular disease admissions and available data from any previous or subsequent admissions. Data were loaded into patient-focused SQL objects to enable cross-sectional and longitudinal analyses. Primary data domains (admission details, comorbidities, laboratory data, medications, imaging data, and discharge characteristics) were loaded into separate relational tables unified by patient and encounter identification numbers. Computed tomography, magnetic resonance, and angiography images were retrieved. Imaging data from patients with ICH were assessed for hemorrhage characteristics and cerebral small vessel disease markers. Patient information needed to interface with other local and national databases was retained. Prospective patient outreach was established, with patients contacted via telephone to assess functional outcomes 30, 90, 180, and 365 days after discharge. Dashboards were constructed to provide investigators with data summaries to support access. RESULTS: The Registry of Neurological Endpoint Assessments among Patients with Ischemic and Hemorrhagic Stroke (REINAH) database was constructed as a series of relational category-specific SQL objects. Encounter summaries and dashboards were constructed to draw from these objects, providing visual data summaries for investigators seeking to build studies based on REINAH data. As of June 2022, the database contains 18,061 total patients, including 1809 (10.02%) with ICH, 13,444 (74.43%) with acute ischemic stroke, 1221 (6.76%) with subarachnoid hemorrhage, and 3165 (17.52%) with transient ischemic attack. Depending on the cohort, imaging data from computed tomography are available for 85.83% (1048/1221) to 98.4% (1780/1809) of patients, with magnetic resonance imaging available for 27.85% (340/1221) to 85.54% (11,500/13,444) of patients. Outcome assessment has successfully contacted 56.1% (240/428) of patients after ICH, with 71.3% (171/240) of responders providing consent for assessment. Responders reported a median modified Rankin Scale score of 3 at 90 days after discharge. CONCLUSIONS: A highly curated and clinically focused research platform for stroke data will establish a foundation for future research that may fundamentally improve poststroke patient care and outcomes.

Social-ecological considerations informing a universal screening strategy for sleep health in the community.

"Poor sleep health" (PSH), defined as reduced amount of sleep and non-restorative sleep, affects cognitive, social and emotional development. Evidence suggests an association of sleep deprivation and mental health problems; however, there are no universal concepts allowing a first-tier screening of PSH at a community level. The focus of this narrative review is to highlight the cultural context of the current medicalized approach to PSH and to suggest social ecological strategies informing new and holistic community-based screening concepts. We present two conceptual screening frameworks; a "medical" and a merged "social emotional wellbeing framework" and combine them utilizing the concept of "ecologies." The first framework proposes the incorporation of "sleep" in the interpretation of "vigilance" and "inappropriate" labeled behaviors. In the first framework, we provide a logic model for screening the myriad of presentations and possible root causes of sleep disturbances as a tool to assess daytime behaviors in context with PSH. In the second framework, we provide evidence that informs screening for "social emotional wellbeing" in the context of predictive factors, perpetuating factors and predispositions through different cultural perspectives. The distinct goals of both frameworks are to overcome training-biased unidirectional thinking and a priori medicalization of challenging, disruptive and/or disobedient behaviors. The latter has been explicitly informed by the critical discourse on colonization and its consequences, spearheaded by First Nations. Our "transcultural, transdisciplinary and transdiagnostic screening framework" may serve as a starting point from which adaptations of medical models could be developed to suit the purposes of holistic screening, diagnosis, and treatment of complex childhood presentations in different cultural contexts.

6-, 10-, and 12-month-olds remember complex dynamic events across 2 weeks.

Whereas infants' ability to remember simple static material (e.g., pictures) has been documented extensively, we know surprisingly little about infants' memory of dynamic events (i.e., events unfolding in time) in the first year after birth. Although there is evidence to suggest that infants show some kind of sensitivity toward complex dynamic events (i.e., events involving agents and a storyline) as indicated by visual engagement in the first year after birth, 16- to 18-month-olds are hitherto the youngest infants documented to remember such material. Using a visual paired-comparison (VPC) task, in Experiment 1 we examined 6-, 10-, and 12-month-olds' (N = 108) ability to encode and remember cartoons involving complex dynamic events across 2 weeks. Results showed that all age groups remembered these cartoons. To investigate further the role of a complex storyline, in Experiment 2 we assessed the memory of 107 infants of the same age groups for similar cartoons but without coherent storyline information by scrambling the temporal presentation of the information in the cartoons. The results showed that the two youngest age groups did not remember this version. To our knowledge, this is the first experiment to document memory for such complex material in young infants using VPC.

To ask or not to ask: strategic recall, but not spontaneous recall, decreases by the passage of time in 46-month-olds' memory of a unique event.

Children's ability to intentionally recall events lessens with temporal distance to the occurrence. However, little is known about the effects of retention time on memories that emerge spontaneously. We examined spontaneous and strategic retrieval in eighty-one 46-month-olds' memory of a lab event after 1 week (the 1-week Condition) versus 43 weeks (the 43-week Condition) in a between-subjects design, using well-established procedures (Krøjgaard et al., in Consciousness and Cognition 55(91): 105, 2017). While spontaneous recall showed no significant effect of retention, the children's strategic recall was negatively affected: even though the children overall still remembered the event, the children in the 43-week Condition showed reduced voluntary recall compared to the children in the 1-week Condition. To our knowledge, this is the first study to assess spontaneous recall after such a long retention interval. The findings add to existing evidence of two modes of retrieval in early childhood and are of both theoretical and forensic relevance.

On the importance of contextual cues for spontaneous recall in 35- and 46-month-old children.

Recent evidence shows that returning to the same distinct lab setting after 1 week triggers spontaneous memories in 35- and 46-month-old children. However, it remains unclarified which specific cues are triggering spontaneous recall. We report two experiments in which distinct contextual cues were altered between encoding and test. In Experiment 1 (N = 76), the color of the box containing the event props was changed. Despite this change, the children still showed spontaneous recall. In Experiment 2 (N = 77), a more radical change was employed as the children returned to a completely differently furnished, and novel room. The children still engaged in spontaneous recall, although less frequently. Importantly, when comparing the number of children having spontaneous recollections, only about half as many children in Experiment 2 as in Experiment 1 exhibited spontaneous memories. These results underscore the importance of an encoding-retrieval match for spontaneous episodic memory in young children.

Understanding patient characteristics and medication prescriptions in children with mental health and neurodevelopmental disorders referred to a sleep clinic-A quality improvement/quality assurance analysis.

Introduction: Motivated by challenges faced in outpatient sleep services for mental health and neurodevelopmental disorders (MHNDD) during the COVID-19 clinical shutdown, a pan-Canadian/international working group of clinicians and social scientists developed a concept for capturing challenging sleep and wake behaviours already at the referral stage in the community setting. Methods: In a quality improvement/quality assurance (QIQA) project, a visual logic model was the framework for identifying the multiple causes and possible interventions for sleep disturbances. Intake forms informed clinicians about situational experiences, goals/concerns, in addition to the questions from the Sleep Disturbances Scale for Children (SDSC), the ADHD Rating Scale-IV and medication history. Descriptive statistics were used to describe the sample. Results: 66% of the pilot study patients (n = 41) scored in the SDSC red domains (highest scoring) with highest sub-scores for insomnia (falling asleep 73%; staying asleep: 51%) and daytime somnolence (27%). A total of 90% of patients were taking at least one medication; 59% sleep initiation/sleep medications, 41% in combination with further non-stimulant medications, 9% with stimulants, 27% with antidepressants and 18% with antipsychotics. Polypharmacy was observed in 62% of all patients and in 73% of the ones medicated for sleep disturbances. Qualitative information supported individualisation of assessments. Conclusion: Our intake process enabled a comprehensive understanding of patients' sleep and wake profiles prior to assessment, at the referral stage. The high prevalence of insomnia in patients, combined with polypharmacy, requires special attention in the triaging process at the community level.

Behavioral sleep medicine-The need for harmonization of clinical best practice outcome measures in children and adolescents with intellectual or developmental disabilities and restless sleep.

In behavioral medicine, sleep disorders, insomnia in particular, may be considered comorbidities and precipitating factors to intellectual or developmental disabilities (IDD). Nevertheless, sleep alterations have often been neglected in favor of daytime features and symptoms, albeit simple behavioral nighttime observations may disclose hypermotor features that characterize restless sleep. The root of most hypermotor restlessness is linked to central iron deficiency. The latter is often exacerbated by vitamin D deficiency (VDD), which interferes with both dopaminergic and serotonergic mechanisms. In this way, an imbalance affecting daytime behavior and mood is created. Several sleep-related motor disorders such as bruxism, periodic and aperiodic leg movements, Restless Legs Syndrome (RLS), and Restless Sleep Disorder (RSD) are commonly seen in Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorders (ASD). However, they are rarely diagnosed and often overlooked in affected children and adolescents. As a result, not only are these disorders not adequately addressed therapeutically, but their symptoms may be worsened by the side-effects of drugs used to contain disruptive daytime behavior, such as antipsychotics and antidepressants. In children with IDDs, obesity, inactivity and metabolic effects of antipsychotics often lead to Sleep Disordered Breathing (SDB), which is currently understood as an inflammatory state leading to "hyperactive" lethargy and further alterations of the hypoxic chain and vitamin D levels. Endorsing simple routine blood tests, including inflammatory markers such as C-reactive protein, ferritin, transferrin, and vitamin D levels, may favorably complement caregiver observations and ambulatory sleep recordings, leading to a sleep disorder diagnosis and consequent therapy. In fact, the treatment of SDB, RLS, and RSD has been copiously demonstrated to favorably impact vigilance, behavior, social competence, and academic skills in healthy and, to a greater extent, in IDD children. Thus, consulting and deliberating the root causes of functional and categorical diagnoses within a clinical framework may engender a more precise diagnosis and further benefit pediatric daytime and nighttime management of hyperactive behaviors.

Iron deficiency and common neurodevelopmental disorders-A scoping review.

BACKGROUND: A wealth of human and experimental studies document a causal and aggravating role of iron deficiency in neurodevelopmental disorders. While pre-, peri-, and early postnatal iron deficiency sets the stage for the risk of developing neurodevelopmental disorders, iron deficiency acquired at later ages aggravates pre-existing neurodevelopmental disorders. Yet, the association of iron deficiency and neurodevelopmental disorders in childhood and adolescence has not yet been explored comprehensively. In this scoping review, we investigate 1) the association of iron deficiency in children and adolescents with the most frequent neurodevelopmental disorders, ADHD, ASD, and FASD, and 2) whether iron supplementation improves outcomes in these disorders. METHOD: Scoping review of studies published between 1994 and 2021 using "iron deficiency / iron deficiency anemia" AND "ADHD" OR "autism" OR "FASD" in four biomedical databases. The main inclusion criterion was that articles needed to have quantitative determination of iron status at any postnatal age with primary iron markers such as serum ferritin being reported in association with ADHD, ASD, or FASD. RESULTS: For ADHD, 22/30 studies and 4/4 systematic reviews showed an association of ADHD occurrence or severity with iron deficiency; 6/6 treatment studies including 2 randomized controlled trials demonstrated positive effects of iron supplementation. For ASD, 3/6 studies showed an association with iron deficiency, while 3/6 and 1/1 systematic literature review did not; 4 studies showed a variety of prevalence rates of iron deficiency in ASD populations; 1 randomized controlled trial found no positive effect of iron supplementation on behavioural symptoms of ASD. For FASD, 2/2 studies showed an association of iron deficiency with growth retardation in infants and children with prenatal alcohol exposure. CONCLUSION: Evidence in favor of screening for iron deficiency and using iron supplementation for pediatric neurodevelopmental disorders comes primarily from ADHD studies and needs to be further investigated for ASD and FASD. Further analysis of study methodologies employed and populations investigated is needed to compare studies against each other and further substantiate the evidence created.

Green synthesis of silver nanoparticles reduced with Trigonella foenum-graecum and their effect on tumor necrosis factor-α in MCF7 cells.

OBJECTIVE: Silver nanoparticles (AgNPs) are known to exhibit anti-inflammatory and anticancer activities. They have been reported to reduce the levels of tumor necrosis factor (TNF) - a proinflammatory cytokine involved in cell proliferation, differentiation, and apoptosis - in cell lines. As patients with breast cancer have been reported to have higher serum TNF levels, we aimed at developing a novel treatment for breast cancer by evaluating the effect of Trigonella foenum-graecum extract (TFG)-reduced AgNPs on the MCF-7 cell line, which serves as a model of human breast cancer. MATERIALS AND METHODS: TFG-capped AgNPs were synthesized using a green reduction method, in which TFG reduced silver nitrate to generate AgNPs-TFG. The particle size, surface charge, ultraviolet (UV)-visible (VIS) spectra, surface morphology, % yield, and in vitro Ag+ release of the formulated AgNPs-TFG were evaluated. Additionally, the prepared NPs were examined for cytotoxicity using real-time polymerase chain reaction (real-time PCR), 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, and enzyme-linked immunosorbent assay (ELISA). RESULTS: The prepared AgNPs-TFG were uniform, small, discrete, and non-aggregated with a particle size of 22.5±0.75 nm and ζ-potential of -47.45±0.666 mV. The yield of AgNPs-TFG was 224.545±3.9 µM. Furthermore, the AgNP-TFG thin film exhibited a prolonged release of Ag+ in phosphate buffer for up to 11 h. AgNPs-TFG suppressed TNF-α expression at mRNA and protein levels in MCF-7 cells. Additionally, the formulated AgNPs-TFG did not exhibit any toxicity toward MCF-7 cells. CONCLUSIONS: This study showed that AgNP-TFG could effectively inhibit TNF-α. These results provide significant insights for developing new therapeutic strategies for cancer and other inflammatory illnesses.

Disruptive Behaviors and Intellectual Disability: Creating a New Script.

Background: Terms currently used to describe the so-called challenging and disruptive behaviors (CBDs) of children with intellectual disabilities (ID) have different connotations depending on guiding contextual frameworks, such as academic and cultural settings in which they are used. A non-judgmental approach, which does not attempt to establish existing categorical diagnoses, but which describes in a neutral way, is missing in the literature. Therefore, we tried to describe CDBs in youth with ID in an explorative study. Methods: Interviews with families investigated the CDBs of five youth with Down syndrome. At home, families tracked youth's sleep/wake behaviors and physical activity. Youth were observed in a summer school classroom. The collected information and suggested explanatory models for observed CDBs were reviewed with the families. Results: We grouped CDBs as challenging, if they were considered to be reactive or triggered, or unspecified, if no such explanatory model was available. A third category was created for light-hearted CDBs: goofy, acknowledging the right to laugh together with peers. We found some relationships between sleep, physical activity, and CDBs and developed an explorative approach, supporting a child-centered perspective on CDBs. Conclusion: The controversial discussions on terminology and management of CDBs in the literature demonstrate the need for a non-judgmental approach. Such an explorative approach, allowing non-professionals to not label, has been missing. The fact that, up to now, the light-hearted behaviors of an individual with ID have not been integrated in commonly-used behavioral checklists as their natural right, proves our concept and indicates that a paradigm change from judgment-based to exploratory-driven approaches is needed.

Evaluating utility and feasibility of mismatch repair testing of colorectal cancer patients in a low-middle-income country.

Molecular pathology services for colorectal cancer (CRC) in Sudan represent a significant unmet clinical need. In a retrospective cohort study involving 50 patients diagnosed with CRC at three major medical settings in Sudan, we aimed to outline the introduction of a molecular genetic service for CRC in Sudan, and to explore the CRC molecular features and their relationship to patient survival and clinicopathological characteristics. Mismatch repair (MMR) and BRAF (V600E) mutation status were determined by immunohistochemistry. A mismatch repair deficient (dMMR) subtype was demonstrated in 16% of cases, and a presumptive Lynch Syndrome (LS) diagnosis was made in up to 14% of patients. dMMR CRC in Sudan is characterized by younger age at diagnosis and a higher incidence of right-sided tumours. We report a high mortality in Sudanese CRC patients, which correlates with advanced disease stage, and MMR status. Routine MMR immunohistochemistry (with sequential BRAF mutation analysis) is a feasible CRC prognostic and predictive molecular biomarker, as well as a screening tool for LS in low-middle-income countries (LMICs).

Open abdomen technique used in complications of major gynecological oncology surgery.

OBJECTIVE: To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. METHODS: We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. RESULTS: Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. CONCLUSION: Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.

Healthcare Utilization with Drug Acquisition and Expenses at the National Health Insurance Fund in Sudan.

Background: Understanding the pattern of care use can provide valuable information for reform interventions. This study investigates the pattern of healthcare utilization and its association with drug acquisition patterns and expenses in the National Health Insurance Fund (NHIF) of Al Jazira State in Sudan. Methods: A cross-sectional survey was conducted at NHIF primary healthcare centers of Al Jazirah state in Sudan. Results: A total of 768 beneficiaries were interviewed, of which 63.2% reported using out-of-network physician care, while 36.8% receive care from the NHIF physician network only. More than half (60.8%) of NHIF-interviewed clients reported a heavy burden of medication costs. The pattern of physician utilization was significantly associated with the number and source of regular drugs, the burden of out-of-pocket payment, and monthly out-of-pocket expenditures on medications, (p < 0.001). The regression analysis revealed that gender, marital status, number of chronic diseases, and number of regular drugs were the significant predictors of the pattern of physician care utilization; these factors explained nearly 36% of the variance in respondents' pattern of physician care utilization. Conclusions: An impressive proportion of out-of-network care was found in Al Jazirah State in Sudan. The NHIF stakeholders should consider medication subsidy as a potential strategy for decreasing patient leakage to out-of-network services.

A cross-sectional survey of burnout in a sample of resident physicians in Sudan.

BACKGROUND: Resident physicians in Sudan face a variety of physical and psychological stressors. Nevertheless, the prevalence of burnout syndrome among this critical population remains unknown. The purpose of this study was to estimate the prevalence rate of burnout and its associated factors in a sample of resident physicians in Sudan. METHODS: A cross-sectional design was used to assess the burnout syndrome among resident physicians at the teaching hospitals of Wad-Medani in Gezira state, east-central Sudan. Three hundred resident physicians at the dermatology, general surgery, pediatrics, obstetrics and gynecology, psychiatry, ear, nose and throat (ENT), oncology, urology, and internal medicine departments, were approached and invited to participate in the study. The Arabic version of the Maslach Burnout Inventory was distributed to respondents from July to October 2021. RESULTS: From the 300 resident physicians, 208 (69.3%) responded. The average age of the study population was 29.99 ± 3.01 years, with more than half were females (56.7%), single (59.6%), and with more than three years of residency experience (50.5%). In total, 86.1% met the criteria for burnout in at least one dimension and 13.9% in all three dimensions. On the dimension of emotional exhaustion (EE), 70.7% reported high levels of burnout. While, 44.2% reported high levels of depersonalization (DP), and 73.1% experienced a sense of decreased professional accomplishment (PA). There were significant differences in burnout, EE, and DP levels among different specialties, with the pediatrics-specialty trainees reported higher levels. Burnout syndrome was associated with the working hours per single duty; participants who reported working for more than 24 hours had experienced higher levels of burnout, EE, and DP. CONCLUSION: Large-scale studies are required to assess the determinants of burnout syndrome among resident physicians in Sudan. In addition, Stakeholders should urgently implement effective remedies to protect the mental health of resident physicians.

Sleep as an outcome measure in ADHD randomized controlled trials: A scoping review.

Sleep disturbances are highly prevalent among children with ADHD. Yet, diagnostic and treatment regimens are primarily focused on daytime symptomatology. The goals of this scoping review are to 1) identify interventional ADHD RCTs that have used sleep as an outcome measure, 2) describe and assess the validity of tools utilized to measure sleep-specific outcomes. 40/71 RCTs used sleep as a primary outcome. Actigraphy (n = 18) and sleep log/diary (n = 16) were the most common tools to measure sleep, followed by Children's Sleep Habits Questionnaire (n = 13), and polysomnography (n = 10). Sleep was a secondary outcome in 31 RCTs. Polysomnography and actigraphy used a heterogeneous spectrum of sleep-related variables and technical algorithms, respectively. 19/23 sleep questionnaires were validated covering a spectrum of sleep-related domains. Despite the intrinsic nature of sleep disturbances in ADHD, the number of RCTs measuring sleep-specific outcomes is limited and tools to measure outcomes are not standardized. Given the potential adverse effects of ADHD medications on sleep, sleep should be included as a core outcome measure in future clinical trials.