Effects of 6/6 and 4/8 Watch Systems on Sleepiness among Bridge Officers

During the last ten years, severe sleepiness or falling asleep by watch keeping officers has been a direct or a contributing factor in a number of maritime accidents. This study examined the relationship between two watch systems and its impact on fatigue and sleepiness in bridge officers. A questionnaire and a sleep/work diary were sent to a representative sample of the Finnish Maritime Officer Association. In all, 185 bridge officers answered the questionnaire on sleep, work hours, and safety, including the Skogby Excessive Daytime Sleepiness index (SEDS); 42% of the bridge officers worked two 4 h watches (4/8) per day, while 26% worked two 6 h watches per day (6/6). Ninety‐five of the participants completed a sleep diary for seven consecutive days while at sea. The timing of the watch duties and sleep was recorded, as was subjective sleepiness every 2 h using the Karolinska Sleepiness Scale (KSS). 17.6% of the participants had fallen asleep at least once while on duty during their career. Compared to the 4/8 watch system, the officers working the 6/6 watch system reported shorter sleep durations, more frequent nodding‐off on duty (7.3% vs. 1.5%), and excessive sleepiness (32% vs. 16% with SEDS>14). Based on a logistic regression analysis, high SEDS was significantly related with probable obstructive sleep apnea (OR 5.7), the 6/6 watch system (OR 4.0), and morningness‐eveningness while controlling simultaneously several individual and sleep‐related factors. Subjective sleepiness (KSS) was highest at 04:00 and 06:00 h. In a multivariate analysis, the KSS was significantly related to time of day, time after awaking, sleep length, and interactions of the watch systems with age, morningness‐eveningness, and Epworth sleepiness scale (ESS) score. Severe sleepiness at 04:00–06:00 h was especially problematic in the 6/6 watch system among evening types and among the bridge officers with high ESS. The results suggest the 6/6 watch system is related to a higher risk of severe sleepiness during the early morning hours compared to the 4/8 and the other watch systems assessed.     

Effects of 6/6 and 4/8 watch systems on sleepiness among bridge officers

During the last ten years, severe sleepiness or falling asleep by watch keeping officers has been a direct or a contributing factor in a number of maritime accidents. This study examined the relationship between two watch systems and its impact on fatigue and sleepiness in bridge officers. A questionnaire and a sleep/work diary were sent to a representative sample of the Finnish Maritime Officer Association. In all, 185 bridge officers answered the questionnaire on sleep, work hours, and safety, including the Skogby Excessive Daytime Sleepiness index (SEDS); 42% of the bridge officers worked two 4 h watches (4/8) per day, while 26% worked two 6 h watches per day (6/6). Ninety-five of the participants completed a sleep diary for seven consecutive days while at sea. The timing of the watch duties and sleep was recorded, as was subjective sleepiness every 2 h using the Karolinska Sleepiness Scale (KSS). 17.6% of the participants had fallen asleep at least once while on duty during their career. Compared to the 4/8 watch system, the officers working the 6/6 watch system reported shorter sleep durations, more frequent nodding-off on duty (7.3% vs. 1.5%), and excessive sleepiness (32% vs. 16% with SEDS>14). Based on a logistic regression analysis, high SEDS was significantly related with probable obstructive sleep apnea (OR 5.7), the 6/6 watch system (OR 4.0), and morningness-eveningness while controlling simultaneously several individual and sleep-related factors. Subjective sleepiness (KSS) was highest at 04:00 and 06:00 h. In a multivariate analysis, the KSS was significantly related to time of day, time after awaking, sleep length, and interactions of the watch systems with age, morningness-eveningness, and Epworth sleepiness scale (ESS) score. Severe sleepiness at 04:00-06:00 h was especially problematic in the 6/6 watch system among evening types and among the bridge officers with high ESS. The results suggest the 6/6 watch system is related to a higher risk of severe sleepiness during the early morning hours compared to the 4/8 and the other watch systems assessed.     

CHRONOTYPE,SLEEP LOSS,AND DIURNAL PATTERN OF SALIVARY CORTISOL IN A SIMULATED DAYLONG DRIVING

The study focused on chronotype-related differences in subjective load assessment, sleepiness, and salivary cortisol pattern in subjects performing daylong simulated driving. Individual differences in work stress appraisal and psychobiological cost of prolonged load seem to be of importance in view of expanding compressed working time schedules. Twenty-one healthy, male volunteers (mean?±?SD: 27.9?±?4.9 yrs) were required to stay in semiconstant routine conditions. They performed four sessions (each lasting ～2.5?h) of simulated driving, i.e., completed chosen tasks from computer driving games. Saliva samples were collected after each driving session, i.e., at 10:00–11:00, 14:00–15:00, 18:00–19:00, and 22:00–23:00?h as well as 10–30?min after waking (between 05:00 and 06:00?h) and at bedtime (after 00:00?h). Two subgroups of subjects were distinguished on the basis of the Chronotype Questionnaire: morning (M)- and evening (E)-oriented types. Subjective data on sleep need, sleeping time preferences, sleeping problems, and the details of the preceding night were investigated by questionnaire. Subjective measures of task load (NASA Task Load Index [NASA-TLX]), activation (Thayer's Activation-Deactivation Adjective Check List [AD ACL]), and sleepiness (Karolinska Sleepiness Scale [KSS]) were applied at times of saliva samples collection. M- and E-oriented types differed significantly as to their ideal sleep length (6 h 54 min?±?44 versus 8 h 13 min?±?50 min), preferred sleep timing (midpoint at 03:19 versus 04:26), and sleep index, i.e., ‘real-to-ideal’ sleep ratio, before the experimental day (0.88 versus 0.67). Sleep deficit proved to be integrated with eveningness. M and E types exhibited similar diurnal profiles of energy, tiredness, tension, and calmness assessed by AD ACL, but E types estimated higher their workload (NASA-TLX) and sleepiness (KSS). M types exhibited a trend of higher mean cortisol levels than E types (F?=?4.192, p?<?.056) and distinct diurnal variation (F?=?2.950, p?<?.019), whereas E types showed a flattened diurnal curve. Cortisol values did not correlate with subjective assessments of workload, arousal, or sleepiness at any time-of-day. Diurnal cortisol pattern parameters (i.e., morning level, mean level, and range of diurnal changes) showed significant positive correlations with sleep length before the experiment (r?=?.48, .54, and .53, respectively) and with sleep index (r?=?.63, .64, and .56, respectively). The conclusions of this study are: (i) E-oriented types showed lower salivary cortisol levels and a flattened diurnal curve in comparison with M types; (ii) sleep loss was associated with lower morning cortisol and mean diurnal level, whereas higher cortisol levels were observed in rested individuals. In the context of stress theory, it may be hypothesized that rested subjects perceived the driving task as a challenge, whereas those with reduced sleep were not challenged, but bored/exhausted with the experimental situation. (Author correspondence: mmoginsk@cyf-kr.edu.pl)     

The impact of shift starting time on sleep duration,sleep quality,and alertness prior to injury in the People’s Republic of China

Early shift start time and night shifts are associated with reduced sleep duration and poor sleep quality that often lead to increased fatigue levels, performance decrements and adverse safety and health outcomes. This study investigates the impact of shift starting time on sleep patterns, including the duration and quality of sleep and alertness/sleepiness at the time of injury, in a large epidemiological field study of hospitalized adults with severe work-related hand injury in the People’s Republic of China (PRC) from multiple industries with severe work-related traumatic hand injury were recruited from 11 hospitals in three industrially-developed cities in the PRC: Ningbo, Liuzhou and Wuxi. Analysis of covariance (ANCOVA) was used to compare sleep duration, sleep quality and alertness/sleepiness across 3?h increments of shift start time, while adjusting for age, gender, work hours, shift duration, day of injury and several transient work-related factors. Effect modification by gender was also evaluated. Seven-hundred and three hospitalized adults (96.4%) completed a face-to-face interview within 4 days of injury; 527 (75.0%) were male, with a mean (±SEM) age of 31.8?±?0.4 years. Overall, these adults worked relatively long weekly (55.7?±?0.6?h) and daily hours (8.6?±?0.07?h). Average sleep duration prior to injury was 8.5?h (±0.07), and showed significant variations (p value <0.05) across shift starting time increments. Overall mean prior sleep duration was shortest for individuals starting shifts from “21:00–23:59” (5.6±0.8?h) followed by midnight “00:00–02:59” (6.1?±?0.6?h). However, a statistically significant interaction (p?<?0.05) was observed between gender and shift starting time on mean sleep duration. For males the shortest sleep duration was 5.6?h (“21:00–23:59”) and for females the shortest was 4.3?h (“24:00–02:59” and “15:00–17:59”). Sleep quality (generally quite well) and alertness/sleepiness based on the KSS (generally alert) did not vary significantly across shift starting time. Results suggest that sleep duration is shortest among injured PRC adults starting shifts late night and early morning. However, with more than 8.5?h of sleep on average work days, Chinese slept much longer than typical US day workers (Sleep in America Poll, 2012, 6:44 on workdays, 7:35 on free days), and this may help to explain higher than expected alertness/sleepiness scores at the time of injury.     

Sleepiness and Performance in Response to Repeated Sleep Restriction and Subsequent Recovery during Semi‐Laboratory Conditions

There is an ongoing debate of how best to measure the effects of sleep loss in a reliable and feasible way, partly because well controlled laboratory studies and field studies have come to different conclusions. The aims of the present study were to investigate both sleepiness and performance in response to long‐term sleep restriction and recovery in a semi‐laboratory environment, investigate order effects (i.e., whether levels return to baseline) in a study with seven days of recovery, and characterize individual differences in tolerance to restricted sleep. Nine healthy men (age 23–28 yrs) participated in the protocol, which included one habituation day (sleep 23:00–07:00 h), two baseline days (23:00–07:00 h), five days with restricted sleep (03:00–07:00 h), and seven recovery days (23:00–07:00 h). Participants went outdoors at least twice each day. Reaction‐time tests were performed at 08:00, 14:00, and 20:00 h each day in the laboratory. Sleepiness was self‐rated by the Karolinska Sleepiness Scale (KSS) after each test. The mixed‐effect regression models showed that each day of restricted sleep resulted in an increase of sleepiness by 0.64±.05 KSS units (a nine‐step scale, p<.001), increase of median reaction times of 6.6±1.6 ms (p=.003), and increase of lapses/test of 0.69±.16 ms (p<.001). Seven days of recovery allowed participants to return to the baseline for sleepiness and median reaction time, but not for lapses. The individual differences were larger for performance measures than for sleepiness; the between‐subject standard deviation for the random intercept was in the magnitude of the effects of 1.1 days of restricted sleep for sleepiness, 6.6 days of restricted sleep for median reaction time, and 3.2 days for lapses. In conclusion, the present study shows that sleepiness is closely related to sleep pressure, while performance measures, to a larger extent, appear determined by specific individual traits. Moreover, it is suggested to measure sleepiness in a standardized situation so as to minimize the influences of contextual factors.     

Mood,Alertness, and Performance in Response to Sleep Deprivation and Recovery Sleep in Experienced Shiftworkers Versus Non-Shiftworkers

Previous studies have shown increased sleepiness and mood changes in shiftworkers, which may be due to sleep deprivation or circadian disruption. Few studies, however, have compared responses of experienced shiftworkers and non-shiftworkers to sleep deprivation in an identical laboratory setting. The aim of this laboratory study, therefore, was to compare long-term shiftworkers and non-shiftworkers and to investigate the effects of one night of total sleep deprivation (30.5?h of continuous wakefulness) and recovery sleep on psychomotor vigilance, self-rated alertness, and mood. Eleven experienced male shiftworkers (shiftwork ≥5 yrs) were matched with 14 non-shiftworkers for age (mean?±?SD: 35.7?±?7.2 and 32.5?±?6.2 yrs, respectively) and body mass index (BMI) (28.7?±?3.8 and 26.6?±?3.4?kg/m², respectively). After keeping a 7-d self-selected sleep/wake cycle (7.5/8?h nocturnal sleep), both groups entered a laboratory session consisting of a night of adaptation sleep and a baseline sleep (each 7.5/8?h), a sleep deprivation night, and recovery sleep (4-h nap plus 7.5/8?h nighttime sleep). Subjective alertness and mood were assessed with the Karolinska Sleepiness Scale (KSS) and 9-digit rating scales, and vigilance was measured by the visual psychomotor vigilance test (PVT). A mixed-model regression analysis was carried out on data collected every hour during the sleep deprivation night and on all days (except for the adaptation day), at .25, 4.25, 5.25, 11.5, 12.5, and 13.5?h after habitual wake-up time. Despite similar circadian phase (melatonin onset), demographics, food intake, body posture, and environmental light, shiftworkers felt significantly more alert, more cheerful, more elated, and calmer than non-shiftworkers throughout the laboratory study. In addition, shiftworkers showed a faster median reaction time (RT) compared to non-shiftworkers, although four other PVT parameters did not differ between the groups. As expected, both groups showed a decrease in subjective alertness and PVT performance during and following the sleep deprivation night. Subjective sleepiness and most aspects of PVT performance returned to baseline levels after a nap and recovery sleep. The mechanisms underlying the observed differences between shiftworkers and non-shiftworkers require further study, but may be related to the absence of shiftwork the week prior to and during the laboratory study as well as selection into and out of shiftwork. (Author correspondence: sophie.wehrens@surrey.ac.uk)     

Evening physical activity alters wrist temperature circadian rhythmicity

The adequate time to perform physical activity (PA) to maintain optimal circadian system health has not been defined. We studied the influence of morning and evening PA on circadian rhythmicity in 16 women with wrist temperature (WT). Participants performed controlled PA (45?min continuous-running) during 7 days in the morning (MPA) and evening (EPA) and results were compared with a no-exercise-week (C). EPA was characterized by a lower amplitude (evening: 0.028?±?0.01?°C versus control: 0.038?±?0.016?°C; p?<?0.05) less pronounced second-harmonic (power) (evening: 0.41?±?0.47 versus morning: 1.04?±?0.59); and achrophase delay (evening: 06:35?±?02:14?h versus morning: 04:51?±?01:11?h; p?<?0.05) as compared to MPA and C. Performing PA in the late evening might not be as beneficial as in the morning.     

Sleepiness and Sleep in a Simulated “Six Hours On/Six Hours Off” Sea Watch System

Ships are operated around the clock using rapidly rotating shift schedules called sea watch systems. Sea watch systems may cause fatigue, in the same way as other irregular working time arrangements. The present study investigated subjective sleepiness and sleep duration in connection with a 6 h on/6 h off duty system. The study was performed in a bridge simulator, very similar to those found on ships. Twelve officers divided into two groups participated in the study that lasted 66 h. Half of the subjects started with the 06:00–12:00 h watch and the other half with the 12:00–18:00 h watch. The subjects alternated between off‐duty and on‐duty for the remainder of the experimental period. Approximately halfway through the experiment, the 12:00–18:00 h watch was divided into two 3 h watches/off‐duty periods. The effect of this was to reverse the on‐duty/off‐duty pattern between the two groups. This enabled all subjects to work the four possible watches (00:00–06:00 h, 06:00–12:00 h, 12:00–18:00 h, and 18:00–24:00 h) in an order that was essentially counterbalanced between groups. Ratings of sleepiness (Karolinska Sleepiness Scale; KSS) were obtained every 30 min during on‐duty periods and if subjects were awake during off‐duty periods. The subjectively rated duration of sleep was recorded after each off‐duty period that preceded watch periods when KSS was rated. The results showed that the average level of sleepiness was significantly higher during the 00:00–06:00 h watch compared to the 12:00–18:00 h and 18:00–24:00 h watches, but not to the 06:00–12:00 h watch. Sleepiness also progressed significantly from the start toward the end of each watch, with the exception of the 06:00‐12:00 h watch, when levels remained approximately stable. There were no differences between groups (i.e., the order between watches). Sleep duration during the 06:00–12:00 h off‐duty period (3 h 29 min) was significantly longer than during the 12:00–18:00 h period (1 h 47 min) and the 18:00–24:00 h period (2 h 7 min). Sleep during the 00:00–06:00 h period (4 h 23 min) was longer than all sleep periods except the 06:00–12:00 h period. There were no differences between groups. In spite of sufficient opportunities for sleep, sleep was on the average around 1–1 h 30 min shorter than the 7–7 h 30 min that is considered “normal” during a 24 h period. This is probably a consequence of the difficulty to sleep during daytime due to the alerting effects of the circadian rhythm. Also, sleepiness during the night and early mornings reached high levels, which may be explained by a combination of working close to or during the circadian trough of alertness and the relatively short sleep periods obtained. An initial suppression of sleepiness was observed during all watches, except for the 06:00–12:00 h watch. This suppression may be explained by the “masking effect” exerted by the relative high levels of activity required when taking over the responsibility of the ship. Toward the end of watches, the levels of sleepiness progressively increased to relatively high levels, at least during the 00:00–06:00 h watch. Presumably, initially high levels of activity are replaced by routine and even boredom.     

Stability and Fragmentation of the Activity Rhythm Across the Sleep-Wake Cycle: The Importance of Age,Lifestyle, and Mental Health

The rhythms of activity across the 24-h sleep-wake cycle, determined in part by the circadian clock, change with aging. Few large-scale studies measured the activity rhythm objectively in the general population. The present population-based study in middle-aged and elderly persons evaluated how activity rhythms change with age, and additionally investigated sociodemographics, mental health, lifestyle, and sleep characteristics as determinants of rhythms of activity. Activity rhythms were measured objectively with actigraphy. Recordings of at least 96?h (138?±?14?h, mean?±?SD) were collected from 1734 people (age: 62?±?9.4?yrs) participating in the Rotterdam Study. Activity rhythms were quantified by calculating interdaily stability, i.e., the stability of the rhythm over days, and intradaily variability, i.e., the fragmentation of the rhythm relative to its 24-h amplitude. We assessed age, gender, presence of a partner, employment, cognitive functioning, depressive symptoms, body mass index (BMI), coffee use, alcohol use, and smoking as determinants. The results indicate that older age is associated with a more stable 24-h activity profile (β?=?0.07, p?=?0.02), but also with a more fragmented distribution of periods of activity and inactivity (β?=?0.20, p?<?0.001). Having more depressive symptoms was related to less stable (β?=??0.07, p?=?0.005) and more fragmented (β?=?0.10, p?<?0.001) rhythms. A high BMI and smoking were also associated with less stable rhythms (BMI: β?=??0.11, p?<?0.001; smoking: β?=??0.11, p?<?0.001) and more fragmented rhythms (BMI: β?=?0.09, p?<?0.001; smoking: β?=?0.11, p?<?0.001). We conclude that with older age the 24-h activity rhythm becomes more rigid, whereas the ability to maintain either an active or inactive state for a longer period of time is compromised. Both characteristics appear to be important for major health issues in old age.     

An observational study on disturbed peripheral circadian rhythms in hemodialysis patients

The quality of life of hemodialysis (HD) patients is hampered by reduced nocturnal sleep quality and excessive daytime sleepiness. In addition to the sleep/wake cycle, levels of circadian biomarkers (e.g. melatonin) are disturbed in end-stage renal disease (ESRD). This suggests impaired circadian clock performance in HD patients, but the underlying mechanism is unknown. In this observational study, diurnal rhythms of sleep, serum melatonin and cortisol concentrations and clock gene mRNA expression are compared between HD patients (n?=?9) and healthy control subjects (n?=?9). In addition, the presence of circulating factors that might affect circadian rhythmicity is tested in vitro with cell culture experiments. Reduced sleep quality (median sleep onset latency [interquartile range] of 23.9 [17.3]?min for patients versus 5.0 [10] minutes for controls, p?<?0.01; mean (± SD) sleep efficiency 70.2?±?8.1% versus 82.9?±?10.9%, p?=?0.02 and mean awake minutes after sleep onset 104.8?±?27.9 versus 54.6?±?41.6 minutes, p?= 0.01) and increased daytime sleepiness (mean Epworth Sleepiness Score of 10.0?±?4.8 versus 3.9?±?2.0, p?<?0.01) were confirmed in HD patients. Reduced nocturnal melatonin concentrations (1 AM: 98.1 [122.9] pmol/L versus 12.5 [44.2] pmol/L, p?= 0.019; 5 AM: 114.0 [131.6] pmol/L versus 11.8 [86.8] pmol/L, p?= 0.031) and affected circadian control of cortisol rhythm and circadian expression of the clock gene REV-ERBα were found. HD patient serum had a higher capacity to synchronize cells in vitro, suggesting an accumulated level of clock resetting compounds in HD patients. These compounds were not cleared by hemodialysis treatment or related to frequently used medications. In conclusion, the abovementioned results strongly suggest a disturbance in circadian timekeeping in peripheral tissues of HD patients. Accumulation of clock resetting compounds possibly contributes to this. Future studies are needed for a better mechanistic understanding of the interaction between renal failure and perturbation of the circadian clock.     

Sleepiness and sleep in a simulated "six hours on/six hours off" sea watch system

Ships are operated around the clock using rapidly rotating shift schedules called sea watch systems. Sea watch systems may cause fatigue, in the same way as other irregular working time arrangements. The present study investigated subjective sleepiness and sleep duration in connection with a 6 h on/6 h off duty system. The study was performed in a bridge simulator, very similar to those found on ships. Twelve officers divided into two groups participated in the study that lasted 66 h. Half of the subjects started with the 06:00-12:00 h watch and the other half with the 12:00-18:00 h watch. The subjects alternated between off-duty and on-duty for the remainder of the experimental period. Approximately halfway through the experiment, the 12:00-18:00 h watch was divided into two 3 h watches/off-duty periods. The effect of this was to reverse the on-duty/off-duty pattern between the two groups. This enabled all subjects to work the four possible watches (00:00-06:00 h, 06:00-12:00 h, 12:00-18:00 h, and 18:00-24:00 h) in an order that was essentially counterbalanced between groups. Ratings of sleepiness (Karolinska Sleepiness Scale; KSS) were obtained every 30 min during on-duty periods and if subjects were awake during off-duty periods. The subjectively rated duration of sleep was recorded after each off-duty period that preceded watch periods when KSS was rated. The results showed that the average level of sleepiness was significantly higher during the 00:00-06:00 h watch compared to the 12:00-18:00 h and 18:00-24:00 h watches, but not to the 06:00-12:00 h watch. Sleepiness also progressed significantly from the start toward the end of each watch, with the exception of the 06:00-12:00 h watch, when levels remained approximately stable. There were no differences between groups (i.e., the order between watches). Sleep duration during the 06:00-12:00 h off-duty period (3 h 29 min) was significantly longer than during the 12:00-18:00 h period (1 h 47 min) and the 18:00-24:00 h period (2 h 7 min). Sleep during the 00:00-06:00 h period (4 h 23 min) was longer than all sleep periods except the 06:00-12:00 h period. There were no differences between groups. In spite of sufficient opportunities for sleep, sleep was on the average around 1-1 h 30 min shorter than the 7-7 h 30 min that is considered “normal” during a 24 h period. This is probably a consequence of the difficulty to sleep during daytime due to the alerting effects of the circadian rhythm. Also, sleepiness during the night and early mornings reached high levels, which may be explained by a combination of working close to or during the circadian trough of alertness and the relatively short sleep periods obtained. An initial suppression of sleepiness was observed during all watches, except for the 06:00-12:00 h watch. This suppression may be explained by the “masking effect” exerted by the relative high levels of activity required when taking over the responsibility of the ship. Toward the end of watches, the levels of sleepiness progressively increased to relatively high levels, at least during the 00:00-06:00 h watch. Presumably, initially high levels of activity are replaced by routine and even boredom.     

Circadian Phase,Sleepiness, and Light Exposure Assessment in Night Workers With and Without Shift Work Disorder

Most night workers are unable to adjust their circadian rhythms to the atypical hours of sleep and wake. Between 10% and 30% of shiftworkers report symptoms of excessive sleepiness and/or insomnia consistent with a diagnosis of shift work disorder (SWD). Difficulties in attaining appropriate shifts in circadian phase, in response to night work, may explain why some individuals develop SWD. In the present study, it was hypothesized that disturbances of sleep and wakefulness in shiftworkers are related to the degree of mismatch between their endogenous circadian rhythms and the night-work schedule of sleep during the day and wake activities at night. Five asymptomatic night workers (ANWs) (3 females; [mean?±?SD] age: 39.2?±?12.5 yrs; mean yrs on shift?=?9.3) and five night workers meeting diagnostic criteria (International Classification of Sleep Disorders [ICSD]-2) for SWD (3 females; age: 35.6?±?8.6 yrs; mean years on shift?=?8.4) participated. All participants were admitted to the sleep center at 16:00?h, where they stayed in a dim light (<10 lux) private room for the study period of 25 consecutive hours. Saliva samples for melatonin assessment were collected at 30-min intervals. Circadian phase was determined from circadian rhythms of salivary melatonin onset (dim light melatonin onset, DLMO) calculated for each individual melatonin profile. Objective sleepiness was assessed using the multiple sleep latency test (MSLT; 13 trials, 2-h intervals starting at 17:00?h). A Mann-Whitney U test was used for evaluation of differences between groups. The DLMO in ANW group was 04:42?±?3.25?h, whereas in the SWD group it was 20:42?±?2.21?h (z = 2.4; p?<?.05). Sleep did not differ between groups, except the SWD group showed an earlier bedtime on off days from work relative to that in ANW group. The MSLT corresponding to night work time (01:00–09:00?h) was significantly shorter (3.6?±?.90?min: [M?±?SEM]) in the SWD group compared with that in ANW group (6.8?±?.93?min). DLMO was significantly correlated with insomnia severity (r = ?.68; p < .03), indicating that the workers with more severe insomnia symptoms had an earlier timing of DLMO. Finally, SWD subjects were exposed to more morning light (between 05:00 and 11:00?h) as than ANW ones (798 vs. 180 lux [M?±?SD], respectively z?=??1.7; p?<?.05). These data provide evidence of an internal physiological delay of the circadian pacemaker in asymptomatic night-shift workers. In contrast, individuals with SWD maintain a circadian phase position similar to day workers, leading to a mismatch/conflict between their endogenous rhythms and their sleep-wake schedule. (Author correspondence: vgumeny1@hfhs.org)     

Cognitive functioning of female nurses during the night shift: The impact of age,clock time,time awake and subjective sleepiness

ABSTRACT

Decline in cognitive functioning in the workplace is a major concern for health care systems. Understanding factors associated with nighttime functioning is imperative for instituting organizational risk management policies and developing personalized countermeasures. The present study aims to identify individual factors associated with cognitive functioning during the night shift of hospital nurses working on irregular rotating-shift schedules. Ninety-two female nurses were recruited from 17 wards in two general hospitals, using convenience sampling by clusters. Inclusion criteria were working at least 28 h a week (75% of full time) and one night shift per week. Exclusion criteria were pregnancy, diagnosed sleep disorders or medical conditions that may affect sleep and/or function. Cognitive performance was measured during the middle (03:00 h) and at the end (07:00 h) of the night shift using the Digit Symbol Substitution Task (DSST) and the Letter Cancellation Task (LCT) over two night shifts. Subjective sleepiness was assessed by the Karolinska Sleepiness Scale (KSS) at the same time points. All participants completed a sociodemographic questionnaire, the Munich ChronoType Questionnaire for Shift-Workers (MCTQShift) and the Pittsburgh Sleep Quality Index (PSQI). Sleep duration 24 h before the night shift and time awake since last sleep opportunity were monitored by actigraphy. Univariate repeated measures ANOVA found main effects for clock time (p<0.001), age (p<0.05), time awake (p<0.05) and sleepiness (p<0.01) for DSST correct responses; main effects for clock time (p<0.001) and sleepiness (p<0.001) for LCT capacity; and main effects for clock time (p<0.001) and age (p<0.01) for LCT omission errors. All factors remained significant in a mixed-model analysis for DSST. Cognitive performance among hospital nurses is low during the middle of the night shift and increases at the end of the shift; decreased functioning is associated with increased subjective sleepiness, older age and prolonged time awake. Identifying factors contributing to performance during the night shift may provide a basis for the development of risk management policies and preventative interventions.     

Altering meal timing to improve cognitive performance during simulated nightshifts

ABSTRACT

Altering meal timing could improve cognition, alertness, and thus safety during the nightshift. This study investigated the differential impact of consuming a meal, snack, or not eating during the nightshift on cognitive performance (ANZCTR12615001107516). 39 healthy participants (59% male, age mean±SD: 24.5 ± 5.0y) completed a 7-day laboratory study and underwent four simulated nightshifts. Participants were randomly allocated to: Meal at Night (MN; n= 12), Snack at Night (SN; n = 13) or No Eating at Night (NE; n = 14). At 00:30 h, MN consumed a meal and SN consumed a snack (30% and 10% of 24 h energy intake respectively). NE did not eat during the nightshift. Macronutrient intake was constant across conditions. At 20:00 h, 22:30 h, 01:30 h, and 04:00 h, participants completed the 3-min Psychomotor Vigilance Task (PVT-B), 40-min driving simulator, post-drive PVT-B, subjective sleepiness scale, 2-choice Reaction Time task, and Running Memory task. Objective sleep was recorded for each of the day sleeps using Actigraphy and for the third day sleep, Polysomnography was used. Performance was compared between conditions using mixed model analyses. Significant two-way interactions were found. At 04:00 h, SN displayed increased time spent in the safe zone (p < .001; percentage of time spent within 10 km/h of the speed limit and 0.8 m of lane center), and decreases in speed variability (p < .001), lane variability (p < .001), post-drive PVT-B lapses (defined as RT > 355 ms; p < .001), and reaction time on the 2-choice reaction time task (p < .001) and running memory task (p < .001) compared to MN and NE. MN reported greater subjective sleepiness at 04:00 h (p < .001) compared to SN and NE. There was no difference in objective sleep between eating conditions. Eating a large meal during the nightshift impairs cognitive performance and sleepiness above the effects of time of night alone. For improved performance, shiftworkers should opt for a snack at night.     

24-hour Pattern in Lag Time of Response by Firemen to Calls for Urgent Medical Aid

The aim of the study was to assess the group 24-h pattern of lag time (LT) in response by regular and volunteer firemen (RFM and VFM) to calls for medical help (CFMH), specifically calls for out-of-hospital cardiac arrest (OHCA). LT, duration in min between a CFMH and departure of service vehicle equipped with a semiautomated defibrillator and generally staffed with four well-trained and ready-to-go FM, represents the integrated duration of several processes, each with separate reaction and decision-making times. The exact time of each CFHM (in min, h, day, month, yr) was recorded electronically, and the exact departure time from the station of the responding FM vehicle was recorded by an on-duty FM. Overall, CFMH made up 53?±?9% (SEM) of all emergencies calls for aid. To standardize the study methods, the reported findings are based on 568 CFMH specifically regarding OHCA that occurred during the 4-yr study span (January 2005 to December 2008). CFMH exhibited a 24-h pattern with a major peak at 10:00?h (mean?±?SEM: n?=?9.5?±?1.6) and major trough at 01:00?h (n?=?1.3?±?0.3; t test, p?<?.001). From year to year and season to season, a 24-h pattern was detected in the total of CFMH/h with two peaks (～10:00 and ～17:00h) and two troughs (～01:00 and ～15:00?h) (analysis of variance [ANOVA], p?<?.01; Cosinor, p?<?.05 to?<?.003), with neither season- nor year-related differences (χ², p?>?.05). In CFMH/h pooled time series, ANOVA-detected differences between the hourly means (p?<?.01), and Cosinor analysis validated a 24-h rhythm (p?<?.002). In raw data, the longest LT, indicative of poorest performance, occurred at 05:00?h (8.8?±?0.7?min) and the trough of LT, indicative of best performance, at 16:00?h (4.3?±?0.8?min (t test, p?<?.02). 24-h patterning in LT was validated both by ANOVA of hourly means (p?<?.0006) and Cosinor analysis (p?<?.05), with longest LT ～05:00?h and shortest LT ～16.00?h for data of the individual yearly time-series data. The 24-h LT rhythm was also validated in the pooled time series by Cosinor (p?<?.0001), with the 24-h mean?±?SEM?=?6?±?0.17?min and acrophase (peak) of 03:00?h?±?88?min (SD). Curve patterns of CFMH/h and LT/h differed widely. As a group phenomenon, the LT 24-h rhythm mimics the 24-h pattern of performance, as demonstrated by many laboratory and field investigations. The stability of the LT rhythm between years and seasons and its weak relationship with the CFMH 24-h pattern favors the hypothesis of an endogenous component or origin. The nighttime trough of performance is presumably linked to the elevated risk of work accidents in the same population of FM.     

Can stress act as a sleep inertia countermeasure when on-call?

The nature of on-call work is such that workers can be called and required to respond immediately after being woken. However, due to sleep inertia, impaired performance immediately upon waking is typical. We investigated the impact of a preceding stressor (an alarm/mobilisation procedure) on sleepiness and performance upon waking. Healthy, adult males (n = 16) attended the sleep laboratory for four consecutive nights which included two, counterbalanced on-call sleeps where participants were woken at 04:00 h by (a) an alarm/mobilisation procedure (Alarm) or (b) gently by a researcher (Control). Following waking was a 2-h testing session comprising the repeated administration of the Karolinska Sleepiness Scale (KSS) and 5-min Psychomotor Vigilance Task (PVT). Results from within-subjects analysis of variance in both the Control and Alarm conditions showed that for subjective sleepiness (KSS) there was a significant fixed effect of time (p = 0.012), with participants becoming less sleepy as time post-wake increased. In terms of PVT performance outcomes, in neither the Alarm or Control conditions were there measurable signs of sleep inertia with performance remaining stable across the 2-h testing period. Based on previous research measuring impact of sleep inertia when woken near the circadian nadir, performance findings in particular were unexpected. We propose that stress caused by study procedures (i.e. finger pricks using lancets) unrelated to the simulated wake-up protocols may have countered any impact of sleep inertia on performance.     

The impact of training schedules on the sleep and fatigue of elite athletes

In any sport, successful performance requires a planned approach to training and recovery. While sleep is recognized as an essential component of this approach, the amount and quality of sleep routinely obtained by elite athletes has not been systematically evaluated. Data were collected from 70 nationally ranked athletes from seven different sports. Athletes wore wrist activity monitors and completed self-report sleep/training diaries for 2 weeks during normal training. The athletes also recorded their fatigue level prior to each training session using a 7-point scale. On average, the athletes spent 08:18?±?01:12?h in bed, fell asleep at 23:06?±?01:12?h, woke at 6:48?±?01:30?h and obtained 06:30?±?01:24?h of sleep per night. There was a marked difference in the athletes’ sleep/wake behaviour on training days and rest days. Linear mixed model analyses revealed that on nights prior to training days, time spent in bed was significantly shorter (p?=?0.001), sleep onset and offset times were significantly earlier (p?<?0.001) and the amount of sleep obtained was significantly less (p?=?0.001), than on nights prior to rest days. Moreover, there was a significant effect of sleep duration on pre-training fatigue levels (p?≤?0.01). Specifically, shorter sleep durations were associated with higher levels of pre-training fatigue. Taken together, these findings suggest that the amount of sleep an elite athlete obtains is dictated by their training schedule. In particular, early morning starts reduce sleep duration and increase pre-training fatigue levels. When designing schedules, coaches should be aware of the implications of the timing of training sessions for sleep and fatigue. In cases where early morning starts are unavoidable, countermeasures for minimizing sleep loss – such as strategic napping during the day and correct sleep hygiene practices at night – should be considered.     

THERMOREGULATORY EFFECT IN HUMANS OF SUPPRESSED ENDOGENOUS MELATONIN BY PRE-SLEEP BRIGHT-LIGHT EXPOSURE IN A COLD ENVIRONMENT

This study investigated the physiological function of suppressed melatonin through thermoregulation in a cold environment. Interactions between thermoregulation directly affected by exposure to a cold environment and indirectly affected by endogenous melatonin suppression by bright-light exposure were examined. Ten male subjects were exposed to two different illumination intensities (30 and 5000 lux) for 4.5?h, and two different ambient temperatures (15 and 27°C) for 2?h before sleep under dark and thermoneutral conditions. Salivary melatonin level was suppressed by bright light (p?<?0.001), although the ambient temperature condition had no significant effect on melatonin. During sleep, significant effects of pre-sleep exposure to a cold ambient temperature (p?<?0.001) and bright light (p?<?0.01) on rectal temperature (T_re) were observed. Pre-sleep, bright-light exposure led to an attenuated fall in T_re during sleep. Moreover, T_re dropped more precipitously after cold exposure than thermoneutral conditions (cold: ?0.54?±?0.07°C/h; thermoneutral: ?0.16?±?0.03°C/h; p?<?0.001). Pre-sleep, bright-light exposure delayed the nadir time of T_re under thermoneutral conditions (p?<?0.05), while cold exposure masked the circadian rhythm with a precipitous decrease in T_re. A significant correlation between the T_re nadir and melatonin level (r?=??0.774, p?<?0.05) indicated that inter-individual differences with higher melatonin levels lead to a reduction in T_re after cold exposure. These results suggest that suppressed endogenous melatonin inhibits the downregulation of the body temperature set-point during sleep. (Author correspondence: ishibasi@design.kyushu-u.ac.jp)     

Arterial stiffness in hypertensive and type 2 diabetes patients in Ghana: comparison of the cardio-ankle vascular index and central aortic techniques

Background

Diabetes and hypertension increase arterial stiffness and cardiovascular events in all societies studied so far; sub-Saharan African studies are sparse. We investigated factors affecting arterial function in Ghanaians with diabetes, hypertension, both or neither.

Method

Testing the hypothesis that arterial stiffness would progressively increase from controls to multiply affected patients, 270 participants were stratified into those with diabetes or hypertension only, with both, or without either. Cardio-ankle vascular index (CAVI), heart–ankle pulse wave velocity (haPWV), aortic PWV (PWVao) by Arteriograph, aortic and brachial blood pressures (BP), were measured.

Results

In patients with both diabetes and hypertension compared with either alone, values were higher of CAVI (mean?±?SD, 8.3?±?1.2 vs 7.5?±?1.1 and 7.4?±?1.1 units; p?<?0.05), PWVao (9.1?±?1.4 vs 8.7?±?1.9 and 8.1?±?0.9 m/s; p?<?0.05) and haPWV (8.5?±?1 vs 7.9?±?1 and 7.2?±?0.7 m/s; p?<?0.05) respectively. In multivariate analysis, age, having diabetes or hypertension and BMI were independently associated with CAVI in all participants (β?=?0.49, 0.2, 0.17 and -0.2 units; p?<?0.01, respectively). Independent determinants of PWVao were heart rate, systolic BP and age (β?=?0.42, 0.27 and 0.22; p?<?0.01), and for haPWV were systolic BP, age, BMI, diabetes and hypertension status (β?=?0.46, 0.32, -0.2, 0.2 and 0.11; p?<?0.01).

Conclusion

In this sub-Saharan setting with lesser atherosclerosis than the western world, arterial stiffness is significantly greater in patients with coexistent diabetes and hypertension but did not differ between those with either diabetes or hypertension only. Simple, reproducibly measured PWV/CAVI may offer effective and efficient targets for intervention.