Crew Endurance Training Program for the US Navy

Prepared for: Naval Advanced Medical Development Program; Naval Medical Research Center; 503 Robert Grant Avenue, Silver Spring, MD 20910The Crew Endurance Training program was designed to provide fleet-wide support to the US Navy on the successful implementation of circadian-based watchbills, and guidance on sleep management and crew endurance best practices. The first phase of the study included the evaluation of existing educational programs and the analysis of training needs. Combining information from studies conducted by the Naval Postgraduate School Crew Endurance team on USN ships, the expertise of the Sleep Matters Initiative (SMI), and feedback from active-duty service members (ADSMs), we developed the first version of training materials in 2019. The second phase of the project included the delivery of the training program, its assessment, and the analysis and refinement of the training. This iterative procedure was repeated throughout the second phase of the project. The training was provided to more than 1,160 ADSMs, both USN Sailors and Marines. Overall, the responses from all audiences were positive with a high level of satisfaction with the training provided in terms of understanding the importance of sleep, sleep hygiene practices, the effect of sleep on operational performance and endurance, how best to implement circadian-based watchbills, and with the instructors, course content, and training duration. In general, trainees asked for more in-depth information, but operational commitments limited the time available to answer all questions. Also, we updated the Crew Endurance website to support sharing of lessons learned and best practices for the individual and the command. The website includes references, tools, and training materials for use by the warfighter and shipboard leaders, as well as templates for shipboard watchbills and instructions to support circadian-based watchbills. Based on the findings from this study and the expressed need for training on crew endurance and guidance regarding the efficient application of circadian-based watchbills, we recommend the continuation of the Crew Endurance Training project.Naval Advanced Medical Development Program; Naval Medical Research CenterNaval Advanced Medical Development ProgramApproved for public release; distribution is unlimited

Sleep-Wake Actigraphy and Light Exposure During Spaceflight-Long

Sleep-Wake Actigraphy and Light Exposure During Spaceflight-Long (Sleep-Long) will examine the effects of spaceflight and ambient light exposure on the sleep-wake cycles of the crew members during long-duration stays on the space station

Extended Work Duration and the Risk of Self-Reported Percutaneous Injuries in Interns

Context: In their first year of postgraduate training, interns commonly work shifts that are longer than 24 hours. Extended-duration work shifts are associated with increased risks of automobile crash, particularly during a commute from work. Interns may be at risk for other occupation-related injuries. Objective: To assess the relationship between extended work duration and rates of percutaneous injuries in a diverse population of interns in the United States. Design, Setting, and Participants: National prospective cohort study of 2737 of the estimated 18 447 interns in US postgraduate residency programs from July 2002 through May 2003. Each month, comprehensive Web-based surveys that asked about work schedules and the occurrence of percutaneous injuries in the previous month were sent to all participants. Case-crossover within-subjects analyses were performed. Main Outcome Measures: Comparisons of rates of percutaneous injuries during day work (6:30 am to 5:30 pm) after working overnight (extended work) vs day work that was not preceded by working overnight (nonextended work). We also compared injuries during the nighttime (11:30 pm to 7:30 am) vs the daytime (7:30 am to 3:30 pm). Results: From a total of 17 003 monthly surveys, 498 percutaneous injuries were reported (0.029/intern-month). In 448 injuries, at least 1 contributing factor was reported. Lapse in concentration and fatigue were the 2 most commonly reported contributing factors (64% and 31% of injuries, respectively). Percutaneous injuries were more frequent during extended work compared with nonextended work (1.31/1000 opportunities vs 0.76/1000 opportunities, respectively; odds ratio [OR], 1.61; 95% confidence interval [CI], 1.46-1.78). Extended work injuries occurred after a mean of 29.1 consecutive work hours; nonextended work injuries occurred after a mean of 6.1 consecutive work hours. Injuries were more frequent during the nighttime than during the daytime (1.48/1000 opportunities vs 0.70/1000 opportunities, respectively; OR, 2.04; 95% CI, 1.98-2.11). Conclusion: Extended work duration and night work were associated with an increased risk of percutaneous injuries in this study population of physicians during their first year of clinical training

Perspectives on fatigue in short-haul flight operations from US pilots: A focus group study

There are few studies investigating the impact of fatigue in short-haul flight operations conducted under United States (US) 14 Code of Federal Regulations Part 117 flight and duty limitations and rest requirements. In order to understand the fatigue factors unique to short-haul operations, we conducted a series of focus groups across four major commercial passenger airlines in the US. Ninety short-haul pilots were recruited through emails distributed by airline safety teams and labor representatives. Fourteen focus groups were conducted via an online conferencing platform in which participants were asked to identify short-haul schedules and operations that they felt: a) elevated fatigue, b) were not fatiguing, and c) were important to study. Data were collected anonymously and coded using conventional qualitative content analysis, with axial coding and summative analysis used to identify main themes and over-arching categories. The six fatigue factor categories identified were: circadian disruption, high workload, inadequate rest opportunity, schedule changes, regulation implementation and policy issues, and long sits. It appears that additional mitigation strategies may be needed to manage fatigue in short-haul operations beyond the current regulations. Future field studies of short-haul operations in the US should investigate the prevalence and impact of these factors

A Nationally Representative Survey Assessing Restorative Sleep in US Adults

Restorative sleep is a commonly used term but a poorly defined construct. Few studies have assessed restorative sleep in nationally representative samples. We convened a panel of 7 expert physicians and researchers to evaluate and enhance available measures of restorative sleep. We then developed the revised Restorative Sleep Questionnaire (REST-Q), which comprises 9 items assessing feelings resulting from the prior sleep episode, each with 5-point Likert response scales. Finally, we assessed the prevalence of high, somewhat, and low REST-Q scores in a nationally representative sample of US adults (n= 1,055) and examined the relationship of REST-Q scores with other sleep and demographic characteristics. Pairwise correlations were performed between the REST-Q scores and other self-reported sleep measures. Weighted logistic regression analyses were conducted to compare scores on the REST-Q with demographic variables. The prevalence of higher REST-Q scores (4 or 5 on the Likert scale) was 28.1% in the nationally representative sample. REST-Q scores positively correlated with sleep quality (r=0.61) and sleep duration (r=0.32), and negatively correlated with both difficulty falling asleep (r=-0.40) and falling back asleep after waking (r=-0.41). Higher restorative sleep scores (indicating more feelings of restoration upon waking) were more common among those who were: ≥60 years of age (OR=4.20, 95%CI: 1.92-9.17); widowed (OR=2.35, 95%CI:1.01-5.42), and retired (OR=2.02, 95%CI:1.30-3.14). Higher restorative sleep scores were less frequent among those who were not working (OR=0.36, 95%CI: 0.10-1.00) and living in a household with two or more persons (OR=0.51,95%CI:0.29-0.87). Our findings suggest that the REST-Q may be useful for assessing restorative sleep

Impact of Extended-Duration Shifts on Medical Errors, Adverse Events, and Attentional Failures

BACKGROUND: A recent randomized controlled trial in critical-care units revealed that the elimination of extended-duration work shifts (≥24 h) reduces the rates of significant medical errors and polysomnographically recorded attentional failures. This raised the concern that the extended-duration shifts commonly worked by interns may contribute to the risk of medical errors being made, and perhaps to the risk of adverse events more generally. Our current study assessed whether extended-duration shifts worked by interns are associated with significant medical errors, adverse events, and attentional failures in a diverse population of interns across the United States. METHODS AND FINDINGS: We conducted a Web-based survey, across the United States, in which 2,737 residents in their first postgraduate year (interns) completed 17,003 monthly reports. The association between the number of extended-duration shifts worked in the month and the reporting of significant medical errors, preventable adverse events, and attentional failures was assessed using a case-crossover analysis in which each intern acted as his/her own control. Compared to months in which no extended-duration shifts were worked, during months in which between one and four extended-duration shifts and five or more extended-duration shifts were worked, the odds ratios of reporting at least one fatigue-related significant medical error were 3.5 (95% confidence interval [CI], 3.3–3.7) and 7.5 (95% CI, 7.2–7.8), respectively. The respective odds ratios for fatigue-related preventable adverse events, 8.7 (95% CI, 3.4–22) and 7.0 (95% CI, 4.3–11), were also increased. Interns working five or more extended-duration shifts per month reported more attentional failures during lectures, rounds, and clinical activities, including surgery and reported 300% more fatigue-related preventable adverse events resulting in a fatality. CONCLUSIONS: In our survey, extended-duration work shifts were associated with an increased risk of significant medical errors, adverse events, and attentional failures in interns across the United States. These results have important public policy implications for postgraduate medical education

Implementing a Sleep Health Education and Sleep Disorders Screening Program in Fire Departments: A Comparison of Methodology

Objective: The objective of this study is to compare three methods of administering a sleep health program (SHP) in fire departments. Methods: An SHP, comprising sleep health education and screening for common sleep disorders, was implemented in eight fire departments using three approaches: expert-led, train-the-trainer, and online. Participation rates, knowledge assessments, surveys, and focus group interviews were analyzed to assess the reach and effectiveness of the methodologies. Results: The Expert-led SHP had the highest participation rate, greatest improvement in knowledge scores, and prompted more firefighters to seek clinical sleep disorder evaluations (41%) than the other approaches (20 to 25%). Forty-two percent of focus group participants reported changing their sleep behaviors. Conclusion: All approaches yielded reasonable participation rates, but expert-led programs had the greatest reach and effectiveness in educating and screening firefighters for sleep disorders

Guiding principles for determining work shift duration and addressing the effects of work shift duration on performance, safety, and health

The article of record as published may be found at http://dx.doi.org/10.1093/sleep/zsab161Risks associated with fatigue that accumulates during work shifts have historically been managed through working time arrangements that specify fixed maximum durations of work shifts and minimum durations of time off. By themselves, such arrangements are not sufficient to curb risks to performance, safety, and health caused by misalignment between work schedules and the biological regulation of waking alertness and sleep. Science-based approaches for determining shift duration and mitigating associated risks, while addressing operational needs, require: 1) a recognition of the factors contributing to fatigue and fatigue-related risks; 2) an understanding of evidence-based countermeasures that may reduce fatigue and/or fatigue-related risks; and 3) an informed approach to selecting workplace-specific strategies for managing work hours. We propose a series of guiding principles to assist stakeholders with designing a shift duration decision-making process that effectively balances the need to meet operational demands with the need to manage fatigue-related risks.Academy of Sleep Medicine (AASM)Sleep Research Societ

What Can WMAP Tell Us About The Very Early Universe? New Physics as an Explanation of Suppressed Large Scale Power and Running Spectral Index

The Wilkinson Microwave Anisotropy Probe microwave background data may be giving us clues about new physics at the transition from a ``stringy'' epoch of the universe to the standard Friedmann Robertson Walker description. Deviations on large angular scales of the data, as compared to theoretical expectations, as well as running of the spectral index of density perturbations, can be explained by new physics whose scale is set by the height of an inflationary potential. As examples of possible signatures for this new physics, we study the cosmic microwave background spectrum for two string inspired models: 1) modifications to the Friedmann equations and 2) velocity dependent potentials. The suppression of low ``l'' modes in the microwave background data arises due to the new physics. In addition, the spectral index is red (n<1) on small scales and blue (n>1) on large scales, in agreement with data.Comment: 18 pages, 2 figures, submitted for publication in Physical Review D, references added in this versio

The Epoxygenases CYP2J2 Activates the Nuclear Receptor PPARα In Vitro and In Vivo

Peroxisome proliferator-activated receptors (PPARs) are a family of three (PPARalpha, -beta/delta, and -gamma) nuclear receptors. In particular, PPARalpha is involved in regulation of fatty acid metabolism, cell growth and inflammation. PPARalpha mediates the cardiac fasting response, increasing fatty acid metabolism, decreasing glucose utilisation, and is the target for the fibrate lipid-lowering class of drugs. However, little is known regarding the endogenous generation of PPAR ligands. CYP2J2 is a lipid metabolising cytochrome P450, which produces anti-inflammatory mediators, and is considered the major epoxygenase in the human heart.Expression of CYP2J2 in vitro results in an activation of PPAR responses with a particular preference for PPARalpha. The CYP2J2 products 8,9- and 11-12-EET also activate PPARalpha. In vitro, PPARalpha activation by its selective ligand induces the PPARalpha target gene pyruvate dehydrogenase kinase (PDK)4 in cardiac tissue. In vivo, in cardiac-specific CYP2J2 transgenic mice, fasting selectively augments the expression of PDK4.Our results establish that CYP2J2 produces PPARalpha ligands in vitro and in vivo, and suggests that lipid metabolising CYPs are prime candidates for the integration of global lipid changes to transcriptional signalling events