Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

ObjectivesTo determine the number and geographical distribution of general practitioners in the NHS who qualified medically in South Asia and to project their numbers as they retire.DesignRetrospective analysis of yearly data and projection of future trends.SettingEngland and Wales.SubjectsGeneral practitioners who qualified medically in the countries of Bangladesh, India, Pakistan, and Sri Lanka and who were practising in the NHS on 1 October 1992.Results4192 of 25 333 (16.5%) of all unrestricted general practitioners practising full time on 1 October 1992 qualified in South Asian medical schools. The proportion varied by health authority from 0.007% to 56.5%. Roughly two thirds who were practising in 1992 will have retired by 2007; in some health authorities this will represent a loss of one in four general practitioners. The practices that these doctors will leave seem to be in relatively deprived areas as measured by deprivation payments and a health authority measure of population need.ConclusionMany general practitioners who qualified in South Asian medical schools will retire within the next decade. The impact will vary greatly by health authority. Those health authorities with the greatest number of such doctors are in some of the most deprived areas in the United Kingdom and have experienced the most difficulty in filling vacancies. Various responses will be required by workforce planners to mitigate the impact of these retirements.

Key messages

• Currently, one in six general practitioners practising full time in the NHS qualified medically in a South Asian medical school; two thirds are likely to retire by 2007
• It is unlikely that doctors who qualify in South Asia will be a source of general practice recruitment in the future
• The posts from which South Asian qualifiers are retiring may be more difficult to fill because they are often in practices in areas of higher need
• There is extreme variation in the proportion of total general practitioners who are South Asian qualifiers; flexibility for policy responses should be maintained

     

Ecstasy and sleep disturbance: Progress towards elucidating a role for the circadian system

MDMA (ecstasy) is an illicit drug which has pharmacological actions on the serotonin system, leading to a number of physiological and behavioral changes. Research conducted in both animals and humans has focused on how ecstasy use affects systems or functions in which serotonin has a regulatory role including mood, sleep and circadian rhythms. In this paper we review the evidence with respect to changes in sleep and circadian rhythms following ecstasy use. Studies of the subjective measurement of sleep have suggested that there are changes in sleep quality and duration following ecstasy use, while research utilizing objective measures including polysomnog-raphy has highlighted changes in sleep architecture following ecstasy use. Collectively these findings suggest that there are consequences associated with ecstasy use, and the implications of these findings for ecstasy users will be examined. Finally, preliminary evidence from the animal literature implicating ecstasy as having specific effects on the circadian system will be reviewed. A discussion of the limitations of the current evidence for such a claim is presented, and possible directions for future research are explored.

     

Prior sleep and perceptions of risk when driving

Fatigue represents a significant driving risk. One predictor of fatigue, and driving impairment, is prior sleep length. However, it is currently unknown how much sleep driver’s perceive as necessary to drive safety. This may be an important contributor to a driver’s decision about whether they are safe to drive. There is also evidence that reduced prior sleep leads to increased risk-taking. The aim of this study was to investigate community perceptions regarding sleep duration and fatigued driving, and to determine if sleep duration influences risk perception in relation to fatigued driving. 1081 participants completed a telephone survey addressing sleep history, fatigued driving, and risk perception. The majority of the sample (62.4 %) thought a minimum of 6–8 h sleep was necessary to drive safely, however a small percentage (5.6 %) felt that less was necessary or reported that they did not know. Women tended to report that individuals need more hours of sleep to drive safely. Younger age and male gender were both associated with an increased likelihood of reporting having driven despite feeling too tired, and male gender alone with being more likely to report falling asleep at the wheel. Reduced sleep duration in the prior 48 h was associated with reports of driving when too tired, and the perception that less sleep was required to drive safely. These findings imply that the Australian public may need guidance about sleep and safe driving, particularly in regards to the potential for sleep to influence risk propensity.

     

Availability of a simple self-report sleep questionnaire for 9- to 12-year-old children

Self-report questionnaires about sleep habits are useful for population-based studies because of their low cost. However, there is no valid and reliable self-report sleep questionnaire for elementary school-aged children. The aim of this study was to examine the availability of a simple self-report sleep questionnaire for 9- to 12-year-old children. Participants were 58 children aged 9–12 years from one elementary school in a rural area of Japan. Participants wore an accelerometer for 10 consecutive days and completed the sleep questionnaire twice. Sleep measures included bedtime, wake time, and assumed and actual sleep duration on weekdays and weekends. The data obtained from the accelerometer and sleep/wake scoring software were used to assess criterion validity. Pearson correlation coefficients and Bland-Altman plots were used to evaluate the relationships between objective and self-reported sleep measures. Test-retest reliability was evaluated using intraclass correlation coefficients. The correlations between the objective and questionnaire measures were moderate to high (r = 0.45 to 0.90) and significant, except girls’ wake time, assumed sleep duration, and actual sleep duration on weekends. The Bland-Altman plots indicated that bedtime and wake time obtained from the questionnaire were underestimated for both weekdays and weekends. Test-retest reliability of the questionnaire was high, with intraclass coefficients ranging from 0.71 to 0.99. Although caution should be exercised when evaluating sleep duration on weekends, this simple self-reported sleep questionnaire is a useful tool for assessing sleep habits in 9- to 12-year-old children, particularly in school-based and large-scale epidemiological studies.

     

Prevalent sleep problems in the aged.

Quality of sleep influences the level of daytime functioning, including stress levels, psychosomatic complaints, general health, and overall well-being. As people age, they complain more about disturbed sleep, insomnia, increased time in bed, and sleep fragmentation. These complaints can be related to circadian rhythm desynchronization, hypnotic or other medication use, chronic bedrest, napping, dementia, or to sleep apnea, a disorder of respiratory cessation which is quite prevalent in the elderly. We review here the results of 12 years of research on sleep in the elderly. In studies of three populations of elderly, it was found that between 24% and 42% had five or more apneas per hour of sleep and 4%-14% had 20 or more apneas per hour of sleep. Since apnea is related to dementia and even to mortality, this high prevalence of apnea is of extreme importance.     

‘I'm American,not Japanese!’: the struggle for racial citizenship among later-generation Japanese Americans

Abstract

As one of the oldest Asian American groups in the USA, most Japanese Americans are of the third and fourth generations and have become well integrated in mainstream American society. However, they are still racialized as foreigners simply because of their Asian appearance. Their Asian phenotype continues to have a foreigner connotation because of large-scale immigration from Asia and an American national identity that is racially defined as white. This paper analyses how later-generation Japanese Americans are racialized as outsiders in their daily interaction with mainstream Americans, which is often accompanied by essentialized assumptions that they are also culturally foreign. In response, they engage in everyday struggles for racial citizenship by demanding inclusion in the national community as Americans despite their racial differences. It is uncertain whether such attempts to contest their racialization will cause current mono-racial notions of American identity to be reconsidered in more inclusive and multiracial ways.     

Effects of sports training on sleep characteristics of Asian adolescent athletes

Adolescents are predisposed to poorer quality of sleep and experience shortened sleep durations, with these trends being more pronounced amongst Asians. Even though sleep is crucial for athletic recovery, there is a dearth of the literature on the sleep patterns of Asian adolescent athletes. The purpose of this study was to examine the effects of different intensities of sports training on sleep patterns in adolescent athletes, and to describe novel sleep data and daytime sleepiness amongst Asian adolescents who were high-level athletes. Those athletes (age 14.8 ± 0.9 years) in higher-intensity sports showed significantly more deep sleep, less light sleep and waketime after sleep onset. Actigraphically determined bedtimes and waketimes were significantly delayed on weekends, when mean total sleep time was also significantly longer. There was a large effect for an increased daytime sleepiness in high-intensity sport athletes. These findings highlight the phenomenon of social jet lag in Asian adolescent student-athletes.     

Uncertain call likelihood negatively affects sleep and next-day cognitive performance while on-call in a laboratory environment

ABSTRACT

On-call working arrangements are employed in a number of industries to manage unpredictable events, and often involve tasks that are safety- or time-critical. This study investigated the effects of call likelihood during an overnight on-call shift on self-reported pre-bed anxiety, sleep and next-day cognitive performance. A four-night laboratory-based protocol was employed, with an adaptation, a control and two counterbalanced on-call nights. On one on-call night, participants were instructed that they would definitely be called during the night, while on the other on-call night they were told they may be called. The State-Trait Anxiety Inventory form x-1 was used to investigate pre-bed anxiety, and sleep was assessed using polysomnography and power spectral analysis of the sleep electroencephalographic analysis. Cognitive performance was assessed four times daily using a 10-min psychomotor vigilance task. Participants felt more anxious before bed when they were definitely going to be called, compared with the control and maybe conditions. Conversely, participants experienced significantly less non-rapid eye movement and stage two sleep and poorer cognitive performance when told they may be called. Further, participants had significantly more rapid eye movement sleep in the maybe condition, which may be an adaptive response to the stress associated with this on-call condition. It appears that self-reported anxiety may not be linked with sleep outcomes while on-call. However, this research indicates that it is important to take call likelihood into consideration when constructing rosters and risk-management systems for on-call workers.     

Interaction between sleep mechanisms and orexin neurons

Orexin is a neuropeptide that plays a highly important role in mechanisms that regulate sleep/wake states. Lack of the orexin gene or orexin-producing neurons (orexin neurons) results in narcolepsy in several mammalian species, suggesting that orexin is an important factor for the maintenance of wakefulness. Constitutive, ectopic expression of orexin in transgenic mice resulted in severe fragmentation of non–rapid eye movement sleep, along with abnormal muscle tone regulation during REM sleep, suggesting that activity of orexin neurons should be appropriately decreased during sleep to maintain consolidated sleep states. This review will discuss the mechanisms by which the orexin system is regulated during sleep.

     

Prevalent sleep problems in the aged

Quality of sleep influences the level of daytime functioning, including stress levels, psychosomatic complaints, general health, and overall well-being. As people age, they complain more about disturbed sleep, insomnia, increased time in bed, and sleep fragmentation. These complaints can be related to circadian rhythm desynchronization, hypnotic or other medication use, chronic bedrest, napping, dementia, or to sleep apnea, a disorder of respiratory cessation which is quite prevalent in the elderly. We review here the results of 12 years of research on sleep in the elderly. In studies of three populations of elderly, it was found that between 24% and 42% had five or more apneas per hour of sleep and 4%–14% had 20 or more apneas per hour of sleep. Since apnea is related to dementia and even to mortality, this high prevalence of apnea is of extreme importance.Supported by grants Nos. NIA 02711, NIA 08415, NBHLI 40930, RSDA NIMH 00117 (to DFK) and by the Veterans Affairs Research Administration. Special appreciation is given to Dr. Elizabeth Barrett-Connor, Dr. Melville R. Klauber, Robert Fell, William Mason, Linda Parker, and Jennifer Bloomquist for help with these studies.     

Adenosine as a sleep factor

What puts us to sleep? This question has bothered the mankind for thousands of years, but we still have no definite answer. After abandoning philosophical and religious explanations, science has adopted this question and started to examine it with experimental methods. Two early pioneers in this field, Dr. Ishimori from Japan and Drs. Pieron and Legendre from France developed the concept of hypnotoxin — a factor that accumulates during waking and puts animals and humans to sleep. They were able to show that, indeed, during deprivation of sleep, something accumulates in body — something that can be removed and will induce sleep in another individual. Later research has identified many substances that affect sleep. One of them is adenosine, which fulfils the criteria of a physiologic sleep factor.

     

The bryophyte flora of northern Iturup (north-west Pacific): between the circumboreal and East Asian floristic regions

Introduction. The Kuril Islands Chain demarcates the boundary between the circumpolar and East Asian floras in the amphi-Pacific and is a trans-Oceanic migration route from warm-temperate insular East Asia to north-east Asia and Beringia. This paper reviews the flora of the northern part of Iturup Island in regards to its bryogeography and taxonomic diversity, as well as its relative position among other bryophyte floras of north-east and East Asia.

Methods. The paper uses morphological methods to identify the species composition and detrended correspondence analysis to identify the position of the northern Iturup Island in the system of local floras of the eastern, extra-tropical, Pacific.

Key results. The flora is closely related to the bryophyte floras of the southern Kurils and Hokkaido Island, but has been found to be distinctly distant from the ‘true’ cool-temperate East Asian floras, as well as from the boreal and hemiarctic floras of north-east Asia. Instead, the floras of the south Kurils and northern Hokkaido Island belong to a peculiar intermediate phytogeographic province that cannot be unambiguously placed in either the East Asian or circumboreal floristic regions. The hemiboreal character of the bryophyte flora of northern Iturup Island is in contrast to the general appearance of many of the dominant vegetation communities on the island, which are more characteristic of the hemiarctic.

Conclusion. There is no robust evidence to refer the bryophyte flora of northern Iturup either to the circumboreal or East Asian Floristic Region, the flora belongs to a unique intermediate province between the two regions.     

Disconjugated binocular eye movements at onset of multiple sleep latency test in childhood narcolepsy

In four of six subjects with narcolepsy, multiple sleep latency tests-examined disconjugated binocular eye movements were observed in the very beginning of multiple sleep latency test recordings. The eye movements appeared before disappearance of alpha and decrease of chin electromyography. All subjects with disconjugated eye movements had also rapid eye movement sleep without atonia and symptoms of rapid eye movement behavior disorder in their past history. Three of them (all children) had post-vaccination narcolepsy. It is not known whether such eye movements are seen in most narcoleptic subjects or whether they are more common in autoimmune/inflammatory narcolepsy with involvement of the structures that coordinate eye movements.

     

Effects of essential oil inhalation on objective and subjective sleep quality in healthy university students

Aromatherapy with essential oils is one of the most popular complementary medical tools for improving sleep quality. However, only a few reports have objectively measured the effects of essential oils on sleep. Here, we used objective and subjective measures to analyze the effects of the essential oils of lavender (Lavandula angustifolia) and sweet orange (Citrus sinensis) on the sleep quality of healthy university students. The participants were monitored for 15 consecutive nights as they inhaled lavender oil and sweet orange oil, in a crossover design. Their sleep was monitored objectively by actigraphy, and total sleep time (TST), sleep efficiency, sleep latency, and wake after sleep onset (WASO) were analyzed. Their sleep was analyzed subjectively using Oguri–Shirakawa–Azumi (OSA) sleep inventory scores. Inhalation of an essential oil improved sleep measures only in participant whose sleep quality was poor in the control condition. Lavender seemed more effective than sweet orange in objective measures, especially in improving sleep latency. In the subjective sleep analysis, the essential oils improved sleep maintenance, dreaming, and sleep length in subjects who had poor sleep quality. Sweet orange seemed more effective than lavender in the subjective sleep measures. The difference between the two oils suggests that expectancy bias had little effect on the hypnotic effect of lavender on objective sleep. Although no obvious effect was observed in good sleepers, the inhalation of lavender oil could be effective for helping poor sleepers improve objective sleep quality.

     

Actigraphic sleep and developmental progress of one-year-old infants

The aims of this study were to pilot methods to monitor the sleep of infants, as well as explore the relationships between infant sleep and physical, cognitive and motor development. Fifty-two one-year-old infants and their parents participated in the study. Infant sleep was assessed by one week’s actigraphy, sleep diaries and by the Brief Infant Sleep Questionnaire. Parents also completed a background questionnaire and the Ages and Stages Questionnaire to measure stages of development across five domains. Infant’s weight and length were measured by the researcher at study onset and Body Mass Index (BMI) scores were calculated. Sleep efficiency, and having a higher proportion of total sleep at night, were significantly correlated with age as well as stages of cognitive and motor development. However, sleep measures were not correlated with infant BMI. These findings support increasing evidence that sleep matures quickly around the age of one year and is related to other stages of development. Further research is required to confirm whether links between sleep and development are simply a marker of maturation, or if sleep per se plays a specific role in infant cognitive and motor development. Sleep and physical growth at this age need further investigation with a more representative sample including short-sleeping and overweight infants.

     

Low-dose oral risperidone lengthened sleep duration in healthy participants

We examined the effects of low-dose oral risperidone (RIS) on nocturnal sleep in healthy participants. This study was performed in a placebo-controlled manner in 10 healthy male volunteers (mean age, 23.6 years), with administration of 0.5 mg of RIS oral solution or a placebo in the morning or evening for 2 consecutive days. Each night, polysomnography (PSG) was performed, and PSG data during non-rapid-eye movement (REM) sleep were processed by power spectral analysis. An evening administration of 0.5 mg RIS significantly increased total sleep time, sleep efficiency and sleep stage 3, and significantly decreased total waking time and waking after sleep onset (P < 0.05). A morning administration of 0.5 mg RIS significantly increased sleep stage 3 (P < 0.05). According to power spectral analysis, the evening administration of RIS significantly increased the theta power (P < 0.05) and decreased the beta power (P < 0.05) during non-REM sleep. The administration of 0.5 mg oral RIS increases sleep stage 3 and increases total sleep time following evening administration.

     

Habitual sleep initiation time and metabolic syndrome in middle-aged and elderly adults

This study aimed to examine the association between habitual types of sleep initiation time and metabolic syndrome. A total of 2674 participants aged 40 to 69 years (48.73% men, mean age 48.33 ± 7.18 years), who were free of cardiovascular disease or cancer and were not shift workers, participated in this population-based cross-sectional study embedded within the Korean Genome Epidemiology Study (KoGES). Based on at baseline and the last visit, the study participants were classified into four types of sleep initiation time: persistent late sleep (PLS), persistent usual sleep (PUS), persistent early sleep (PES), and non-persistent sleep (NPS) types. Metabolic syndrome was defined as having three or more of the following five criteria: abdominal obesity, impaired glucose intolerance, high blood pressure, high triglyceride, and low high-density lipoprotein-cholesterol. Among the 2674 study participants, the prevalence of metabolic syndrome was 865 (32.35%). To estimate the association between sleep initiation time and the risk of having metabolic syndrome, we constructed multivariable logistic regression models. After adjusting for covariates including sleep duration, the participants of the PLS type were 1.87 times more likely to have metabolic syndrome (odds ratio = 1.87, 95% confidence interval 1.07–3.27) than those of the PES type. In conclusion, in this population-based cross-sectional study, we observed that the PLS type of sleep initiation time had a significantly increased risk of metabolic syndrome as compared to the PES type, even after adjusting for covariates.

     

Recent advances in obstructive sleep apnea pathophysiology and treatment

Obstructive sleep apnea (OSA) is a sleep disorder characterized by recurring collapse of the pharyngeal airway leading to restricted airflow. OSA is becoming increasingly common with at least moderate disease now evident in 17% of middle aged men and 9% of women. The list of recognized adverse health consequences associated with OSA is growing and includes daytime symptoms of sleepiness, impaired cognition and risk of motor vehicle accidents as well as associations with hypertension, cardiovascular morbidity, malignancy and all-cause mortality. In this context adequate treatment of OSA is imperative; however, there are well-recognized pitfalls in the uptake and usage of the standard treatment modality, Continuous Positive Airway Pressure (CPAP). A broad range of pathophysiological mechanisms are now recognized beyond an anatomically smaller pharyngeal airway and impaired compensatory pharyngeal muscle responsiveness. Perturbations in ventilatory control stability, low arousal threshold, sleep-related decrease in lung volume and fluid redistribution as well as upper airway surface tension have all been shown to variously contribute to sleep-disordered breathing. Many new therapies are emerging from these advances in understanding of the mechanisms of OSA. Although many may not be universally effective, the promise of phenotyping patients according to their individual pathophysiology in order to target one or more therapies may prove highly effective and allow the treatment of OSA towards a personalized medicine approach.