Good morning, everyone. So my name is Nathan Nowak. I'm a sleep medicine fellow at University of Chicago. I'm going to introduce our panelists for this session entitled Shifting to Hawaii, Jetlag, Shift Workers, and Sleep for Healthcare Providers. Thank you all so much for joining us. I would say early in the morning, but I don't know if that's true of all of you, where you're coming from. More than likely, this is the afternoon, especially on our first day. But we know that there's many other good talks that you could be at, because this is a great conference. And so thank you for joining ours. So the panelists that I'll be presenting today are Paul Chung, Ritwik Agarwal, and Mary-Anne Louise, and myself. And so we'll get started with, if you would please reserve your questions until the end of our session, that way we keep pace, and we'd be happy to answer as many as we can. And if we don't get to all of them, we'll also be available after the session for at least 15 minutes before the next one starts to discuss anything that you have. Thank you so much. All right, good morning, everyone. So my name is Paul Chung. I'm a clinical instructor at Northwestern University. I have nothing to disclose, but I do want to give a shout out to my mentor, Dr. Phil Z. So originally, she was scheduled to give this talk, but unfortunately, she wasn't able to make this conference. So she provided the resources and guidance for me to give this talk. These are the lesson objectives. So we'll go through some of the physiology of the circadian system, as well as circadian disruption, and then kind of look at how this impacts the development and expression of disease, as well as look at the potential of developing therapeutics for how we can manage patients based on their circadian rhythms. And to begin, I have to start with this because this was a game changer in how we looked at sleep and wake. And this model, to orient you at the bottom, is time. So it starts at 7 a.m., and then it's a 48-hour period from there. Process S is seen at the top. I don't know if I can, okay. Process S is seen at the top, and to remember this is that it represents sleep. In a very simple way, it depends on the duration of your sleep or the duration of your wakefulness, or in other words, how much. And if you look, it starts at the bottom, and as you stay awake, the longer you stay awake, the more your need or drive for sleep is. And we call this the homeostatic sleep drive. Once you sleep, that drive dissipates and then starts over again when you wake up. Process C is shown at the bottom, and C stands for circadian. And what it represents is actually somewhat different. It is all about our arousal or alertness. And so just before 7 a.m., you start having these alerting signals that continue to increase until it reaches its peak around midday and then goes back down. Now, both these processes are related in terms of when we sleep and when we're awake, but the difference is that, again, process S kind of is dependent on your sleep duration and your wake duration, whereas the circadian rhythm, in many ways, is regulated genetically. And this is expressed through our core clock chains. And I'll show you kind of what I'm talking about at a molecular mechanism level. So this is a cell. The yellow portion is a cytoplasm, and the white portion is a nucleus. And so within the nucleus, you have transcription of CLOCK and BMEL1, which are then translated and then retranslocated back into the nucleus, where they activate the transcription of PER and CRY. PER and CRY are then translated, and then in a rate-limiting step, they are dimerized by CK1. And after enough of this builds up, they're retranslocated back into the cell, where they inhibit further transcription of PER and CRY, so negative feedback loop. And in general, for most of us, most humans, this whole process takes roughly a little longer than 24 hours. And as I do more research into this, it's actually quite amazing how our biological clock affects our daily rhythms in terms of our physiologic processes. And so I'm just showing you some of this just to give you an idea of the breadth of what is being regulated. And even sleep itself has a rhythm to it, such that when we look at our sleep cycles, you see more non-REM sleep in the beginning portion of the night, and more REM sleep at the end of the night. Now, it's come to be known that we have a master clock, or you may see this as a master circadian pacemaker, found in the suprachiasmatic nucleus, the SCN, and this conducts its rhythmicity to all other parts of our body, and some of the outputs that we can measure include like melatonin, core body temperature, and then with advanced techniques, we can also look at gene expression. But most importantly, and I'll talk about this even more later, is the factors that affect our rhythms. So I kind of put them into three broad categories. So the first factor is the environment, the most important of which is light. Light works on our melanopsin cells in the eyes, which then innervate different parts of the brain to modulate sleep onset and other things. And this helps us to kind of entrain or reset to our light-dark environment, which is Earth. The other factor is, kind of put them all together as behavioral, but include like social things, daytime activity, even meal timing that affect our rhythms. And then what's very cool is that actually, we've been finding that there are other clocks in different brain regions, as well as in all of our tissues. So these peripheral tissue clocks are semi-autonomous and work and regulate the local tissue physiology, which has some outputs to also affect our master clock. So all of this works together in the sense that the SCN is like a master synchronizer. So then what happens when something goes wrong? We call this circadian disruption, and frankly, this is kind of a nonspecific term that essentially describes a negative effect on circadian function at multiple different levels. You may see this in the literature as circadian dysregulation, circadian disturbance, circadian dysfunction, all kind of relatively the same thing. But what's happening is that there's a problem in the circadian timekeeping system and also the entrainment mechanism. So our ability to take these cues that I talked about and cause alignment within ourselves. And this leads to misalignment. So what does that look like? All the way on the left, you have the environmental cues, social behavior cues. And when there's a misalignment, it then causes a circadian disruption. And clinically, we can also see circadian disorders. This then causes a misalignment among all of our tissues and organs that then has a negative effect. I think for sleep physicians, we see this most often in sleep-wake disorders, but it has a negative effect on all of our systems throughout our body. And it's good to say that it actually is a bidirectional relationship. And so what I'm gonna do is I'm gonna show you a couple of examples of studies that have looked at this, how factors affect our circadian rhythms and cause us disruption and health problems. If you don't get anything else from what I'm talking about, this is probably the most important thing. It's not only how much, but when. So in other words, I'm not saying that how much is not important. It is important. But also, we should think about the timing as an important factor as well. And this is becoming more prominent as we've increased our artificial light exposure, particularly at all hours of the day. And in addition, we can also see this depending on when we actually sleep, as well as certain behaviors such as meal timing. So the first study I'm gonna show you was from the New Moms to Be group. And what they did is they looked at sleep duration and sleep timing in pregnant women to see if there was an association with gestational diabetes. And so kind of obviously, the timing that I'm showing here is that the women who slept less than seven hours compared to those who slept seven or more hours had an increased crude odds ratio of 2.24 for gestational diabetes. So there's that. But they also looked at the timing. So and how they did that is through the sleep midpoint. So a sleep midpoint is basically just the clock time of the middle of when you went to sleep and when you woke up. So as an example, a sleep midpoint of 5 a.m. is essentially someone who sleeps at 1 a.m. and wakes up at 9 a.m. So what they found was that those people who had a sleep midpoint past 5 a.m. had an increased crude odds ratio of 2.58 for gestational diabetes. So again, not only is how much important, but when is important. Now looking at meal timing, this study, what they did is they calculated the total calorie intake based on time and also what percentage that you did it. And then their outcome that they looked at was insulin sensitivity, particularly using the Matsuda Index. And so just to orient you, higher is actually better for the Matsuda Index. For the first figure you're seeing here, they looked at what time it took for people to reach at least 25% of their total energy intake. And as you can see, the earlier tickets, so closer to 8 a.m., they had a higher Matsuda Index for insulin sensitivity compared to those who reached that point past 4 p.m. And then this is somewhat looking at proportions, but also timing. Those who took most of their energy intake in the morning, so up to 60%, had a higher Matsuda Index for insulin sensitivity. Whereas those who took it later in the evening, it's not statistically significant, so I will just say there was a trend to decrease in the insulin sensitivity. And then finally, when we're looking at light now, this study looked at older community-dwelling adults. And what they did was they looked at the group that had light at night and then compared to those who didn't have any light at night. And they looked at CVD risk factors. And what they found was that the adults who had light at night had a higher prevalence for obesity, increases in their BMI, diabetes, and hypertension. So all of this to show you that, again, timing is very important. Now if we switch gears a little bit, we talked a little bit about what factors cause disruption and disease. There's also a lot of evidence now showing that when you give therapies also matters very much. In this review, they looked at over 100 studies that did different timings of therapies. And they found that at least 75% of them definitely showed that there was a time-of-day effect. And I think, or not I think, but it wasn't only in hypertension, but also in cancer and various other disorders. And just to give you an example of this, because we are in vaccination season right now, this group did an observational study looking at COVID-19 vaccine effectiveness. And what they found was that those people who got vaccines in the late morning or early afternoon tended to have decreased breakthrough infections, ER visits, and hospitalizations, compared to those who received the vaccines past 4 p.m. All right, so in summary, just wanted to kind of give you an idea that circadian disruption definitely has broad implications for diseases, both in terms of the severity as well as across the lifespan. But as we get to know this, especially our circadian rhythms more and more, I think there's a lot of hope and also a lot of studies now that have looked at applying some of these ideas in order to improve and enhance our health. Some of the examples are shown here all the way on the right. And that's it, so thank you for your attention. We'll take, again, we'll take questions after everyone has spoken. Okay, good morning, everybody. Thank you for your attention. This one is going to be an interactive session, so if you would like to participate in the audience response system, by all means, take out your devices right now. All right, so my name's Maryam Lewis, and today I'm gonna talk to you about adjusting to jet lag strategies for patients and for you. So although I said I have no relevant disclosures, I need to kind of clarify, I do write questions for the ABIM, for the sleep board. However, with that said, nothing that appears here in terms of questions is part of the ABIM. So this is the information, if you would like to participate in the audience response system. I'll just give you a few seconds. All right, looks like most of you got it. Okay. So the objectives for today are to just provide an overview of jet lag and then discuss specific strategies that may help with jet lag symptoms for eastward travel as well as for westward travel. Oops. All right, so we'll start with a case. So your patient who lives in Atlanta, Georgia will be traveling for a two-week holiday to Paris, France. He is asking at what time should he consider maximizing light exposure to help minimize the effect of jet lag? Is it A, noon Paris time, B, 8 a.m. Paris time, C, midnight Atlanta time, or D, not enough information to determine? Okay, looks like it's pretty steady, so let's see what everybody said. Okay, so most of you got it wrong, which is good because I hope that by the end of this talk you'll understand what vital piece of information was not provided in this question so that you can answer it correctly. The correct answer was, I didn't give you enough information. So what is jet lag? Basically it's a temporary sleep disorder that can occur when travelers rapidly cross time zones that results in a desynchrony between the external light-dark cycle of the traveler's new destination as well as the individual's inherent circadian rhythm, and it occurs in about two-thirds of travelers. So to make a diagnosis of jet lag disorder, the International Classification of Sleep Disorder Manual says that the following three criteria must all be met. First, there must be a complaint of insomnia or excessive daytime sleepiness that's associated with jet travel across at least two time zones. Second, there must be an associated impairment in either daytime function. So if I make mistakes today, please forgive me. I have jet lag, all right? Second, there may be abnormal malaise or somatic symptoms that occurs one to two days after travel, and three, the sleep disorder is not better explained by something else. Now it's important to distinguish jet lag disorder from travel fatigue, which is temporary exhaustion, headache, confusion that travelers may experience when traveling regardless of time zones crossed or mode of travel, and it's primarily due to the stress of travel, sleep loss, dehydration, and so forth. Now I was going to talk in detail about physiology of circadian rhythms, but Paul did such a wonderful job. So I'm just going to remind you that sleep is a circadian output as well as an input. And so through an interaction of the circadian clocks, we have an approximate 24-hour circadian rhythm. However, our circadian rhythm is not exactly 24 hours. And so to keep the 24-hour rhythm, the circadian clocks must be entrained or reset, if you will, on a daily basis by environmental factors called sight givers or time givers, the most powerful of which, as Paul mentioned, is light, which influences the production of melatonin in the pineal gland and hence also helps to regulate the sleep-wake cycle. So the circadian rhythms and jet lag are intertwined. And they're intertwined in that the timing of the sleep-wake cycle can be shifted to different time zones, depending on how we manipulate certain sight givers, particularly melatonin and light. So here you've got a typical phase response curve for melatonin seen in red and light seen in blue. Depending on how you dose melatonin and light, you can shift your circadian rhythms by advancing them, which is what happens when there's eastward travel or move our clock earlier. Or circadian rhythms can be delayed, which is what occurs when we travel west or move our clock later. Now there are two very important anchors to the phase response curves. And these are two variables that I want you to remember because I will be referring to them frequently throughout the remainder of this talk. The first is the minimum core body temperature, or CBT min. And this occurs approximately two to three hours before habitual wake-up time. The second anchor is the dim light melatonin onset, or DILMO. And this signals the point at which melatonin begins to rise in the evening, which is approximately two hours before habitual sleep onset. Now the effect of light on shifting the circadian rhythm is dependent upon three things. First it's dependent upon timing. So if you look at this phase response curve here for light, you can see that bright light administered after CBT min. causes phase advancement. Conversely, bright light administered after CBT min. causes phase delays. The longer the duration of exposure to light, the greater the effect will be on the phase shift. In addition, shorter blue light, as well as bright light, greater than 2,500 looks, appears to have a more significant effect on phase shift. Now with regards to melatonin and its effect on circadian phase shifting, that is also dependent on timing. However, this time it's with respect to DILMO. So as you can see here from this phase response curve, melatonin administered in the early evening, late afternoon, causes phase advancement. Whereas conversely, melatonin dosed in the morning after DILMO causes phase delay. Now remember, melatonin in of itself can have direct facetitive effects. So use it cautiously if it will be administered in the morning, and always use it cautiously in patients who have seizure disorders or autoimmune disease, as it can exacerbate those underlying conditions. All right, so now that we've established some important terms and concepts, let's get to the meat of the talk, which is how do you manage jet lag, okay? So by itself, our bodies will naturally adapt to the new time zone we find ourselves in. For westward travel, this occurs at about one and a half time zones per day. For eastward travel, it's one time zone per day, making eastward travel generally more difficult for travelers than westward travel. And therefore, the goal of these strategies or therapies is to try to more quickly realign this internal circadian rhythm with the new light-dark cycle, and hopefully improve symptoms of jet lag. And this is done via three approaches. The first are just general strategies. The second is manipulation of light and melatonin. And third is management of the actual jet lag symptoms. So with regards to general measures, there are certain interventions that can be taken three to four days prior to travel, as well as during travel. And they're slightly different if you're traveling eastward versus westward. And for the sake of time, I'm not going to go into the details of these, but you can find these on most, on any website. And they're really general approaches and very common sense things that you can do. The second approach is trying to manipulate melatonin and light. And how this is done is going to depend on the duration of travel, the number of zones crossed, as well as the direction of travel. So for short trips lasting less than three days, it's generally advised to try not to shift your circadian rhythm, to actually stay on your time of origin. This is because it's just too short of a time, and it's actually more disruptive to your circadian rhythms. Now if you do experience symptoms of insomnia or excessive daytime sleepiness, caffeine and very judicious use of hypnotics can be considered, although, again, I'm going to caution that you must weigh the benefits versus the risks of using hypnotics for short trips. Now for trips lasting greater than three days, it's a little bit more complicated. How and when you're going to time your light and melatonin is going to require you to calculate CBT-min and DILMO. So let's go through some scenarios. In this first scenario, you have, I'll say, a patient who's traveling eastward and crossing less than eight time zones. So for example, from Atlanta to Paris, which is six hours. In this case, because it's eastward travel, we need to advance our circadian rhythms. So in this hypothetical example, your patient has an habitual sleep time of 10 to 6 a.m., Atlanta time, which means that their CBT-min is going to occur at 4 a.m., Atlanta time, which is 10 a.m., Paris time. Based on the phase response curves that we talked about earlier, we know that bright light administered after CBT-min can cause phase advancement. So you would advise your patient to seek bright light after 10 a.m., Paris time, and conversely, avoid bright light prior to that. In addition, you can prescribe melatonin. And again, based on the phase response curve, we know that melatonin taken prior to DILMO, which is 8 p.m., Atlanta time, 2 a.m., Paris time, can help advance the circadian rhythm. Usually three milligrams is sufficient, and usually it is taken on the first day of arrival at your new destination for no more than five days. Now remember, this is a dynamic process, right? And so this has to be shifted every day by approximately one hour. So if your CBT-min is 10 a.m. on the first day, in Paris, it'll be 9 a.m. the second day, 8 a.m., and so forth. Okay, let's look at a second scenario. This time you have a patient who's traveling eastward but crossing more than eight time zones. And so even, so for example, from Atlanta to the Maldives, because I'd like to go there one day, which is a nine-hour time difference. Now here, even though your patient is actually traveling eastward, it may be easier to actually delay the circadian rhythms. And this is because of what we call antedromic shifting, which is when CBT-min occurs in the middle of the day at the new destination. So back to our hypothetical patient, who in Atlanta goes to bed at 10 and gets up at 6. Their CBT-min is gonna be 4 a.m. Atlanta time, which corresponds to 1 p.m. Maldives time. So based on the phase response curves we discussed earlier, we know that bright light administered prior to CBT-min can cause phase delay. So you would advise your patient to seek bright light in the Maldives up to 1 p.m., and then unfortunately go back into the hotel and avoid the beach till the rest of the evening, okay? Now the role of melatonin for eastward travel more than eight time zones has not been so clearly elucidated, so it's difficult to give any recommendation, although at this point there may not be an indication. And remember, once again, this is a dynamic process that needs to be done over, needs to be adjusted daily. Finally, in our third scenario, you have somebody who is traveling westward, from example Atlanta to surprise to surprise Honolulu, which is a six-hour difference. And in this case, it's westward travel, so we want to delay our circadian rhythms. So our patient who goes to bed at 10 p.m. Atlanta time gets up at 6. Their CBT-min is going to be 4 a.m. Atlanta time, which is 10 p.m. Honolulu time. So you would advise to seek bright light all the way to the evening till bedtime and then avoid it afterwards. Now melatonin for westward travel may be beneficial for shifts greater than 12 hours. So if you're crossing more than 12 hours, it may be beneficial. And again, dynamic process that needs to be adjusted daily. Okay. So now that we've discussed these first two approaches, let's shift gears and discuss how do you actually manage some of the sleep symptoms that you have with jet lag. So for symptoms of excessive daytime sleeping, excessive daytime sleepiness, napping as well as caffeine may be judiciously timed to help with some of the symptoms of excessive daytime sleepiness. That said, there's actually no good evidence behind this because no studies have actually looked at this. It's more just common sense things that we do. That's not the case for stimulants. There's been a couple of studies that have shown that stimulants may actually help with symptoms of excessive daytime sleepiness from jet lag. However, in this one particular randomized trial, even though armodafinil improved EDS objectively by MSLT, the side effects were much higher in the group that received stimulants compared to the control group. And remember, jet lag is not an FDA approved indication for stimulants, and so it will be hard to get it for your patients. What about insomnia? And I can attest to this because I've been waking up at 3 o'clock every morning, right? We know that hypnotics, both benzodiazepines as well as non-benzodiazepine receptor agonists, are actually helpful with symptom control of insomnia for jet lag, especially for eastward travel. With that said, it's generally not recommended to prescribe hypnotics routinely for jet lag due to the potential side effects such as sedation, they fall asleep, they miss their airplane, right, et cetera, as well as the amnesia. Now if you are going to use it, as always, prescribe the lowest possible dose. And so finally, in my last slide, you're going to tell me, my God, there's a lot of moving parts, is there an app for that? And the answer is there are. There's actually several apps that have been developed that you can download, which provide tailored advice to help manage the jet lag symptoms depending on where you're going and for how long. And this is something that you might also want to share with your patients. Now what I didn't have time to discuss today is the ongoing research currently exploring potential impacts of chronic circadian dyssynchrony, such as in pilots, I also didn't have time to discuss with you the ongoing research that is trying to better understand the effect of jet lag on neuroimaging functionality as well as performance, for example, in athletes. And finally, although some of the measures I discussed are helpful, they're not completely 100% effective. And so we clearly need a lot more research to help us better prevent our jet lag symptoms rather than just manage them. Thank you. All righty. Thank you so much for those first two talks. I will try and follow that up with a discussion of shift work, which will be practical but also follow some of the, you know, health implications that Paul elicited at the very beginning. All righty. So this is the Best Practices in Sleep for the Shift Worker. That is me there. I'm a Fellow in Sleep Medicine at University of Chicago. So our lesson objectives, as explained there, we're going to focus on the unique circadian consequences of shift work. We're going to recognize the importance of evaluating other sleep disorders in shift workers. And then we're going to outline a series of countermeasures to mitigate the risks of shift work. And that will be kind of the meat of the talk. So let's use a case. There is no audience response system so don't worry about being wrong. This is a case of Tired Tom. He's a 32-year-old male complaining of sleepiness while driving and difficulty falling and staying asleep. He's a police officer working four shifts per week from 9 p.m. to 7 a.m. His work schedule varies each week and includes shifts on weekdays and weekends. After working he falls asleep by 10 a.m. and stays asleep until 2 to 3 p.m. On days off he goes to bed at midnight but doesn't fall asleep until 2.30 a.m. and often sleeps until 10 a.m. So what is happening to Tom? So Tom is going to be experiencing the same two-process model that we all do but we're going to talk about his version of it in a second. This is just to remind you that excellent slide that Paul started our talk with. What is missing here is, I don't think you can see our pointer, but you're not seeing the S, excuse me, you're seeing the C phase here which is rising and falling here. But you're not capturing the S phase which is actually wearing down on this curve if you will. But wakefulness is captured in blue. So this is a normal day worker like many of us and so we sleep at night. However in our poor patient here he's having this experience. So he's having fragmented daytime sleep during the morning when we're all awake, he's trying to sleep. And then at night when he's supposed to be awake and he's required to be awake he's having impaired wakefulness and then he's experiencing the heavy weight of the circadian homeostatic effects in that period as well. So you can kind of see how going back and forth these are very different experiences for this person. So some key definitions as we approach shift work. What is a shift work? Well it's an occupation where normal hours of work are completely outside of the period of normal day. This is actually quite common. One in five workers in the U.S. perform some form of shift work and it's a very heterogeneous experience. You have some shift work that is clearly night and clearly day and then others that have like modified starts halfway through the day and so you end up with a very difficult condition to discuss. It is more common in females than males. By that I mean shift work the position is more commonly in females. Shift work disorder is actually an extrinsic circadian rhythm disorder and by extrinsic I mean to say that it is not something intrinsically wrong with the patient's internal clock. It's all due to desynchronization between the internal clock and external cues, similar to jet lag which we just discussed. The criteria from the ICD for shift work disorder is first you have to have some form of sleepiness or insomnia and then a reduction of total sleep time. You have to have a shift work schedule for at least three months. So it can't be something just temporary. And then you have to have a disturbed sleep-wake pattern actually demonstrated on sleep log or actigraphy. Ideally, if you're doing a very pure diagnosis, you'd have actigraphy with concurrent light exposure assessments as well. We often make this diagnosis off of sleep logs. And then the last thing which I'm going to emphasize over the next couple of slides is an absence of any other condition, sleep or otherwise, that explains the sleep disorder. So why is that important? Well there's actually many sleep conditions that a shift work disorder can experience outside of just pure shift work disorder and if you had this patient in your clinic you might say, oh, that sounds like you're a shift work patient and this is how we'll manage it. But you might miss something. And if you miss something it can be very critical to that patient. Your interventions for the shift work disorder will fail if other disorders are present. And then addressing sleep disorders has shown significant benefits in many other industries. These are truck drivers and airplane pilots and these different industries have had large initiatives to address things like sleep apnea and screen for these. They've shown decreased insurance costs, decreased crashes, et cetera. So it's a large thing definitely to be thinking about. Is there an association with OSA? So one in three U.S. police officers screened positive for OSA in a 2005-2007 JAMA cohort study. This was a screening. This wasn't polysomnography. But in this patient we might consider at least screening for other reasons for sleepiness. A 2021 meta-analysis showed no really increased risk of OSA in shift workers. As I will show you, at least it does make sleep apnea worse. Is there a role for a sleep study or a polysomnogram in addressing shift work disorder? The answer is no, unless you suspect that there's another sleep disorder present. You notice that was not part of the ICD criteria. That was just sleep log diaries and ectography. So a polysomnogram is really just used to address alternative diagnoses. And this is always a question that I think comes up and is, when do I do the sleep study? In some of these patients you might actually have them come to the sleep lab during the day because that's when they would be sleeping. To ask them to come to the sleep lab at night, you may not capture much data because they're used to being awake at those times. So you need to really work with your patients if you're trying to assess them for sleep apnea or other sleep conditions with a polysomnogram and perform the sleep study at the right time. So here's a nice little study that I want to highlight. It's a 2011 study where they actually did two sets of polysomnograms. They looked at 31 shift workers versus controls. These controls were matched for age, BMI, and they also experienced sleep deprivation. What they basically did in the study is they took the shift workers and they all had sleep apnea, both controls and shift workers. They were moderate to severe as you can see at baseline in both groups. And they compared their polysomnograms in the shift workers between daytime polysomnogram and nighttime polysomnogram. Then they did the same for the controls where the controls obviously had to have an experience of sleep deprivation in order to do their daytime polysomnogram. What you can tell is that in the shift workers, their daytime polysomnogram is much worse than their nighttime polysomnogram. I think what that highlights is that this does worsen sleep apnea. This sleep fragmentation, this trying to sleep during the day when you should be awake, that's a hallmark of shift work disorder. But to see it within our sleep apnea patients and see the difference in the AHI just between this group here, these 31 shift workers is I think very, it's an extreme finding for sure. It makes you wonder about whether our PAP settings are correct for these folks. Should we be thinking about, I mean we all use AutoPAP, many of us use AutoPAP and thank you for AutoPAP. But maybe it's not fully addressing these folks either. And then you can see that there was a significant difference between shift workers and controls for daytime polysomnogram. This was being performed after one night of sleep deprivation. I think this highlights the chronicity of this condition. This is definitely something that maybe after one night you could recover from. If you put many nights together, you're going to have significant effects on your sleep apnea. I just wanted to highlight this because in this patient if I added a few more years to his life, maybe added hypertension, I think I could have gotten him to a higher stopping and we would be worried about obstructive sleep apnea. But that's not the talk for today, is it? Going back to poor Tired Ted, excuse me, Tired Tom. So Tired Tom actually has come up with a strategy. He's been talking to his colleagues, his co-workers at the police office and they have all come up with how they address their sleepiness. He drinks coffee around the clock no matter what time. He also has tried a few things, Ambien and Trazodone. He's been taking both of these at his bedtime, which for him is 9 a.m. on work days and midnight on days off. Unfortunately this has left him still very tired, which is why he's in your office. And he often feels very hungover from these measures. So how can we better help Tom? Well that will be the heart of our talk today. So some countermeasures that Tom could do before the shift, and you'll see that these next slides are broken down based on the timing of your shift. So if you're going into work, these are the things you're going to be thinking about. And in the next two slides we'll talk about what you do at work and after work. So some countermeasures for Tom, maximizing sleep hygiene and schedule, we all know and all hear about this, but resuming the bedroom for sleep and intimacy, sleeping in a low-noise, light-free environment with minimum eruptions, and establishing a regular wake time dependent on shift, night or day. These are obviously easier said than done. And I know many people will say how do I block out the light when I don't have these proper curtains and all these different things, and how do I make a low-noise environment when it's during the day? And to be honest, there's no perfect answers for these things. Often you'll find patients are delimited simply by finances to achieve perfect environments. So it's not a perfect treatment, obviously. Napping, there is a role and there is evidence for prophylactic napping. This is right before the start of the shift, so basically the evening before going in. And then caffeine, there's actually a role for that as well, especially if you have an extended commute or you're expecting a long shift. This would be before the shift. And then stimulants, they can be used for extended commute or expected long shift, but the jury's kind of out in terms of their benefit. And I'm going to speak specifically about modafinil. There's a very nice New England Journal study from 2005 looking at modafinil, specifically in shift work disorder. In this study, it was a three-month randomized double-blind trial comparing 200 milligrams of modafinil versus placebo in 209 patients with shift work disorder. What they found was modafinil did reduce the extreme sleepiness, and it did show a small but significant improvement in performance. So we probably imagine that that's excellent and good for modafinil and we should all take it before we go in for our shifts. However, there was still an extreme amount of residual excessive sleepiness and there was still impaired night performance. And just to kind of highlight that on our table here, you can see that compared to the placebo group, you had a better level of sleepiness score, but this is still quite high. And the scale they're using in this study is the Karolinska sleepiness scale, which ranges from 1 being alert to 9 very sleepy. And you can see that these patients are still quite sleepy despite it being a significant improvement. And that same is true during the commute home as well. I think what's nice to see is that there was less accidents reported in the modafinil group, and that's always a large concern for us as well. No change or difference in sleep efficiency and no change in terms of caffeine use as well. So it's not like slam dunk that everybody should be using modafinil, but there may be a role in particular folks. I think it should be a case-by-case to use stimulants in these cases. So countermeasures at work. So when you're at work, or Tom's at work, he should be getting bright or blue light. He should be getting it within his work environment as much as possible, but really try and limit it to the first half of the shift. So an example of a prescription I might prescribe to him is 10,000, 1-2 feet for 2 hours. I have an actual personal anecdote on this one because in our ICU we had a resident who was struggling with shift work disorder because she was in ICU of course. And so she actually got one of these lights and was using it at her desk. And then once she left those string of nights, she donated it to our ICU and we now all have it if we need it. So it's just a kind of nice thing to see. So these things do work. They do keep you more awake, especially at the first half of your shift. But you can also plan in naps. And I think strategic napping, scheduled napping is a very important part of the work experience. These need to be sanctioned and supported by a quiet dark space. Now one problem people always talk about is, well if I take a nap at work and I wake up groggy and I'm not as responsive to my pager, in this person's case he may not be as responsive to an emergency as a police officer. So the goal here is to schedule that nap, know when that person's napping, have coverage during that nap, and also keep the nap short. You want to definitely aim to like 30 minutes at the most. You need at least 10 minutes to experience any benefit from it. But after 30 minutes it seems that there's more post-nap sleep inertia, which is really that grogginess you're referring to. There is evidence for caffeine before napping. There's actually a couple good studies that looked at this. So you actually ingest caffeine before you go to sleep for that nap, and then you wake up and that inertia is less with the caffeine in your system. And then activity breaks. This is kind of like going for a walk or some exercise. It's hard to know how much desk work Tom does or if he's walking on his shift, but there is a role for at least improving the sleepiness with walking and that activity break. There is not much role of it in terms of improving the actual shifting or improving your cognition. So the jury's a little out on this one as well. Caffeine, we always say it's helpful during the day. We know that as day workers, but also night workers. We would recommend low and frequent as opposed to large doses infrequently. And please try and limit it to the first half of the shift. And so most of these recommendations at work are really for the first half of the shift. Because after the shift is really when you want to try and downshift. We would like the patient avoiding bright or blue light, using sunglasses on the drive home or even goggles when they get home or before they leave for work. The napping, there is definitely a role for napping anytime you're about to be drowsy and a drowsy driver. We always recommend against it. So if that person feels like they can't drive without a nap, then you need to allow them a place to sleep at their work. Alternatively, if you're trying to shift back to a day schedule, then actually napping when you get home as opposed to taking a full night of sleep in the morning is approved there as well for rescheduling yourself. Exercise always avoid one hour before bedtime. And then caffeine, avoid after shift unless you're trying to avoid an extended commute. And in which case I would still recommend rideshare or public transportation over using caffeine right after your shift because it will wake you back up. Hypnotics, they usually result in residual sleepiness in most cases. So with excellent strategy and a health care provider, you can schedule a melatonin. That's the one that has the best data before you would like to go to sleep. Although I would highly recommend only doing this with a physician because you can actually worsen all the circadian issues we just discussed before. So it's really not a totally benign medication. And I think it was mentioned earlier that it does have effects on other systems as well. So how can we best support shift workers? This is Hall. Employers, they can acknowledge sleepiness as human. I think that there's sometimes this feeling that the stronger will stay awake and why are you so sleepy? And it's seen as a form of weakness. But it's really not. This is our body's internal clock. There are some people who are better at it. And I think that that probably reflects them not being as good during the day either. There's different chronotypes that have been described. And so if someone's really good at nights, it doesn't mean they're really good at days and vice versa. So we should really acknowledge this as being a human condition. And then giving advance notice of working time as opposed to being on call and going right in at that moment allows pre-work napping. Sanctioned workplace napping is also important. And then adequate time off between shifts for greater recovery. And then any investment in research and fatigue prediction, detection of warning technologies is very important. And obviously artificial intelligence will be part of that going forward. And then family and household support. So several studies have actually shown that work and family conflict and poor work-life balance, there has been no, and this is for any of us that do shifts, there has been no correlation or causation behind increased divorces or anything like that. But there is definite data that shows that families are strained. And we should definitely ask our families to minimize noise and interruptions to only emergencies during this quiet time. And then to set expectations and make plans for night shifts and recovery days that they're not going to be as available for errands and being there for the family. And then do your best to maintain communication and plan meals with one another, special dates as you can despite long stretches of nights. And then always try to include family at future appointments because you really need their buy-in to have a successful plan. Thank you so much for your time. How's everybody doing? Healthcare workers? So I'm going to talk about the healthcare workers who are in Hawaii and really falling asleep. I'm Ritwik Agarwal. I am a sleep medicine physician until last month or so. I was at Baylor College of Medicine. I moved to New York and Long Island now. And my academic appointment is ongoing so that's why it's not in there. This says I have nothing to disclose but actually I have a similar thing to disclose as Maria. I will write questions for ABIM but there is no question here which will come in your board so don't get very happy with that. But having said that, what we are going to talk about today is in this talk, in this particular section is what you have heard in previous three sections. Put everything together and put it on a healthcare worker and that's what we're going to talk about. These are the objectives. But let's start with this case. This is me. I was an intern and there was a resident. This is in my residency several years ago. So I just joined and this was a central, I'm sorry, a DABAFTU which was placed in a patient. The resident was asked to clear this DABAFTU and you guys can see what's going on here. This is not that patient because at that time none of the radiological images were digital but you can see this tube was placed in the wrong place and the patient got fed. So this is something which we have seen or maybe we were a part of this. What should we do? What might have caused this error? So let's talk about this resident. She was one of the brightest residents I worked with. And she would not miss things like these. But this was ICU. In my hospital, we had these shifts which would start at 7, go until the next day around 11, 12. And this happened around 5 or 6 in the morning. At the same time, she was having some personal family issues. Her mother was sick. So there were a lot of issues which were going on and this led to an adverse outcome. And what can we do to help with these? So there are a lot of stuff going on in this particular regard. But I'll talk about the sleep medicine approach, what we can do in healthcare workers to minimize this kind of errors. So these are things which can happen, acute sleep deprivation, acute sleep loss. Most of us have noticed, even though we are not doing shift work, we are just doing the regular work. We have a peer support group at my hospital which I joined. And a lot of us tell that we get up early to help with the family, get done with work at 5, 6, 7, then come home, chart for some time, 8, 9, then time for rest, maybe watch TV for a few hours and then get overall sleep about 5 to 6 hours every night. And that's pretty standard for high functional professional LICA. So sleep deprivation is actually fairly common on top of those additional shifts we do once in a while. There's a lot of sleep fragmentation. We end up in getting poor quality sleep, and this is well documented, study after study healthcare workers at a high risk. And napping, we end up in, you know, the old saying, eat when you can, sleep when you can when you're on call. And that particular issue does alter our sleep. Finally there's chronic sleep disorders. We talked about shift work disorder. Just like any other healthcare, normal person, healthcare workers also are at risk of sleep apnea which is often undiagnosed. And finally the common disorder, restless leg syndrome and narcolepsy. I had in my sleep medicine practice at least three narcolepsy patients who were residents or fellows in surgical specialties. So we have colleagues who are working around us with severe sleep disorders. So it all compounds in our group. And then sleep disorders are well documented in bidirectional way. There are mental health issues because of sleep disorders or the mental health issues lead to sleep disorders. We tend to procrastinate our sleep. One thing after another, big problem. And then finally depression, anxiety, and PTSD. PTSD is not some esoteric disease we read in the books. It is very well documented in healthcare worker, especially with this COVID pandemic. Almost all of us have some sort of mental trauma at some point of our life. It may not be directly work related. There are so many PTSD related issues which ultimately impact our sleep. So just like most of the general population, healthcare workers have underlying sleep disorders but perhaps a little more compounded just because how high functional we are. This is one of the work which we did. I work with data science, big data. And my data science group looked at the tweets during COVID pandemic. And we looked at how people are perceiving insomnia by tweet. And it's a little busy slide, but you'll see here that the negative sentiment was much higher during COVID pandemic. And this is, some say this is one very easy way to predict which direction the society is going very quickly if you analyze what they really put forward in social media. And we found that. And there's also some study that before midnight or after midnight, how it's impacting the tweets, the sentiments associated with it. So really interesting data we found and definitely COVID has impacted healthcare worker quite a lot. So then what are the consequences? We have all these sleep disorders. What are the consequences? And we saw one example which I presented. There are increased risk of errors. Some of the errors happen are simple or easily correctable. But some are serious. Patients get hurt. So our sleep has a direct correlation on how we care for the patients. It's also associated with needle stick injuries. There have been a few studies which have written, which have talked about this needle stick injury. After a vehicle accident, jet lag disorder, Nathan has talked about that if you are doing a shift work, try to use Uber or Lyft or something like that in the morning. Because it is quite real. One of my colleagues, director of the critical care, ended up in doing a long shift. And he almost, his car crashed into a subway. And unfortunately was not moving very fast. But he fell asleep. So things like that are frequently happening. And then there are psychological impact. Mood swings. You have met people in your work surroundings, people who are sometimes very pleasant to work with. But sometimes they are not easy to. Just be kind to them. Think of them that this could be a wider problem. Burnout, anxiety and stress. So AASM has put out a statement not too long ago that sleep fatigue and burnout among physicians is fairly high. And we should be mindful for it. And burnout is not necessarily the main topic here. But I think it's important to talk about. And I wish it was an interactive session. But the burnout rates are fairly high. This particular article talks about that nearly 50% of us have burnout rate, burnout. There are many data gaps in this how we finally reach the stage of burnout from day-to-day work. There are many work factors. High demand. We are all type A personality in some way or other. And finally, these are some of the key causes. If you look at it, you know, how many times we have discussed that documentation burden is so high, we spend 10 minutes with the patient, 20 minutes writing down the note. Bureaucracy in the hospital or at the clinics. Patient relationship, malpractice concerns, education, certification requirements, financial stresses. This statement talks about that really it's not the clinical care which burns us out. It's these additional causes which lead to our ultimate burnout rate. And this is a slide which talks about how we go from a happy comfort zone to the burnout. It's kind of like Starling's curve. But if you look at it, on the left-hand side, we are very productive to a certain point until we reach a stage of fatigue. And then we start reaching exhaustion, ill health, breakdown, and so forth. If you are good at stress management, you can probably improve your productivity a little bit. But ultimately, it will lead to fatigue and burnout. And this is extremely important to recognize the place where we are reaching that stage. In the peer support group, one of the physicians was talking about that I really have no motivation. I go in the morning. I just see patients. I don't care whether they are getting better, getting worse. I just want to do my stuff and go home. And in reality, that physician was burnt out because they were down by one partner. They were working long hours. They were working two or three weekends a month. And it ultimately impacted them. And we were able to support them. We were able to ask the team to get extra help for the doctor. We asked the doctor to actually take some time off. So burnout is a real problem. All of us are susceptible to it. So ASM gave out some of the things which we should do in order to improve our sleep health. And these look, I mean, for us sleep doctors, we tell exactly the same thing to our insomnia patients for sleep hygiene. But think about it, how many times actually you do it in your case or in your colleagues you see. How often we are able to get a regular sleep schedule. Can we get seven hours of sleep every night? And unwinding part is a big deal for us. We are unable to unwind. That last patient we saw in the clinic which needs a CT scan two months down the road, did I forget to order that? Stuff like that, we are unable to stop unwinding. Alcohol abuse is a big problem in healthcare workers, perhaps more than general population. I think other speakers talk about dark, quiet space. I can tell you my example. When I worked in the night shift, I went, got these black curtains, a lot of things which I did, but every morning there would be somebody who would be coming around, there would be a lawnmower coming, mowing them lawn. Or there's something, I could never get good sleep during daytime. Even though I did everything, I'm a sleep doctor. It's very common. It's unfortunate the society is not designed for people to sleep during daytime. And finally, stay active and get outdoor light. You know, we are having a conference in a dark room here. Ideally, we should have a conference outside in Hawaii next to the beach where everybody gets a lot of sunlight, you know. And finally, the second part of the statement is bank extra sleep on day off. This is not ideal. There is something called hysteresis. So if you lose sleep during certain parts of the week, you cannot really catch up easily. You always lose some of it. And David Dinges from UPenn talks a lot about it. But if you can, try to catch up over the time when you are not working. Use caffeine judiciously. And I did not know that 50 milligrams per hour is the right dose. I wonder how much is the Starbucks, to be honest. I think it's 200, 300 milligrams. It's 80. Take short naps if you can. Bright light, night shifts. These are all the things we talked about. So I'm not going to go on for it. But one last thing I do want to talk about is the checklist. And so a few things, are our off days truly off days? A lot of us have admin responsibilities. So if you're not in the ICU working, you still have to deal with a lot of stuff which goes on. You are always on with your email. Your cell phone always keeps on pinging. So are we truly off? How many of you are really responding to emails while you are sitting in this session learning? So we are almost never off. The checklist part is important. If you can do it, I have started doing it after these guidelines. I have a, Atul Gawande talks about checklists in a different way. But at the end of the day, I write five, six things which I need to do, patient care, family care, et cetera, in a checklist. And I leave it in a diary which I have or on the phone. And it really helps me avoid kind of going back and forth, ruminating about it. Oh, did I forget about that or not? And this is proven. This is proven by studies that if you write down things, it just takes the stress out of them, you know, the extra worry out of them. So think about, do something like that. Also, I found out there's a support line. If somebody is, you know, or yourself feel that you're overwhelmed, there's a physician support line. There's this number to it. And this number you can call. It's fully confidential and it's provided by mental health care workers. You can talk to them because it is a big problem. And CHEST also has a lot of resources, especially during COVID. I was fortunate to be a part of this wellness initiative where there was a discussion, but there is a lot of resource free of cost. You can go online and use them. CHEST does provide a lot of resources to prevent burnout from smart people. So this is my final slide. And can anybody guess why I put Tom Cruise there in this fancy sunglasses? He doesn't sleep. No, that's not true. The real reason was when I was in my fellowship, one of my attendings gave me a fancy pair of sunglasses so that when I drive home, I can put them on so I can go home and sleep. And that was perhaps the best piece of gift I had during that rotation. I was fortunate to have somebody who would think in that direction and support the fellows for that. So with that, this is the last slide I have. I'm open for questions. Please ask questions. Discuss among each other. This is a big topic. We can talk about it all day, but it is very important for healthcare workers. Thank you.

sleep challenges

healthcare workers

shift work

jet lag

circadian system

managing jet lag

risks of shift work

managing sleepiness

support from employers

improving sleep hygiene