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Sleep, SMS Unplugged

Sleep on it: The quest for rest in the modern hospital

Sleep on it: The quest for rest in the modern hospital

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

hospital bed cornerI first saw it on the face of a resident at the end of a 24-hour shift. And then again on the weary visage of a nurse after a whirlwind shift in the emergency room. Soon it was written across my own brow: The expression that said, It’s time to take a break. But as I soon realized, it wasn’t just the students, doctors and nurses who were struggling to get enough rest.

“It’s impossible to get any sleep here,” remarked one patient whom we awoke on early morning rounds. “There’s just constant disruption. I don’t feel like I’m healing.”

“Is there anything we can offer him besides sleep medications?” I asked the supervising physician after we left the room.

“Everyone says they can’t sleep,” he replied. “Unfortunately it’s just part of being in the hospital.”

I often ask patients to suggest one thing we can improve in their medical care. An overwhelming majority of them comment on the lack of peace and quiet. Perhaps the most memorable example was an elderly gentleman hospitalized for tuberculosis. Even in an individual room with airtight separation from others (“respiratory isolation”), he couldn’t go more than a few minutes without being disrupted. Doctors and medical students started their morning rounds before sunrise, vital signs were measured every four hours (including at night), and nurses constantly came in and out with meals and medications. He lamented, “The only thing I want to do is sleep. But as soon as I do, someone else comes in.”

Hospitals didn’t always used to be hectic. In fact, restful environments were long thought to have healing properties. Early in the 19th century, the French physician Laennec noticed lower rates of tuberculosis in seaside communities away from the hustle and bustle of the city. Wanting to bring a piece of that environment to his urban-dwelling patients, he began putting ocean seaweed under the beds of Parisians. More recently in the 1940s, a popular treatment for tuberculosis and other serious illnesses was the ‘sanatorium.’ Patients enjoyed the fresh air of the countryside, where it was thought they could rest and give their bodies a chance to build protective ‘walls’ around the infected nodules in their lungs.

The advent of antibiotics around the time of World War II brought a rapid end to seaweed, sanatoriums and other similar remedies. Nowadays, it’s easy to look back and chuckle at the idea of trying to cure tuberculosis by lying in a bed on the seashore. But it’s also increasingly difficult to justify the (somewhat) controlled chaos of today’s hospitals – an environment that is at best claustrophobic and at worst dangerous. After all, the benefits of a good night’s sleep have been proven beyond the shadow of a doubt. And numerous studies show that many people live longer and healthier if sent home instead of staying in the hospital with the exact same disease. Granted, much of the benefit of going home lies in avoiding exposure to others with contagious infections. But after seeing innumerable patients exhausted from being poked and prodded around the clock, it’s hard to shake the thought that the hospital environment itself may be more pathologic than we once believed.

Many of our clinical mentors came to this realization long ago, and teach us on a daily basis how mindful doctors can buffer patients from the stresses of a bustling hospital. Of course, helping someone to rest comfortably is more easily said than done. But as students, we can at least identify role models who are the kind of physicians we want to be – physicians who notice when a patient is sleeping and decide, “I’ll come back later.” Or those who notice when someone is exhausted and ask, “What can we do to help?” And if we can help patients sleep a little better, maybe – just maybe – their doctors will too.

Mihir Gupta is a third-year medical student at Stanford. He grew up in Minnesota and attended Harvard College. Prior to writing for Scope, Mihir served as co-editor in chief of H&P, Stanford medical school’s student journal.

Photo by oddmenout

In the News, Sleep, Technology

Mobile devices at bedtime? Sleep experts weigh in

Mobile devices at bedtime? Sleep experts weigh in

ipad in bed

Find yourself tossing and turning after checking e-mail on your smartphone or tablet before bed? Blame your body for being slow to catch up with modern times. As Stanford sleep expert John Peachey, PhD, explains today in a Real Business piece:

In the long span of human existence, we have had limited time to adapt to artificial light in the last 200 years. Humans evolved to essentially sleep with the sun. Because the brain assumes all light is sunlight, nighttime light exposure tricks the brain into believing the sun has not yet set, and therefore results in continued alertness.

Peachy and two other sleep experts, including Stanford’s Michelle Primeau, MD, go on to provide a few tips on how to “see the light and still get your Zs.”

Previously: Can adjusting your mobile device’s brightness help promote better sleep?
Photo by Johan Larrson

Pediatrics, Research, Sleep, Stanford News

Studying pediatric sleep disorders an “integral part” of the future of sleep medicine

Studying pediatric sleep disorders an "integral part" of the future of sleep medicine

kid_sleepingAs the new mom of a four-month old, I’ve become obsessed with infants and children’s sleep habits. So I was interested to read a recent entry on the Stanford Sleep Center’s blog about how studying children’s sleep disorders can further discoveries in the field for patients both big and small.

In the entry, sleep specialist Rafael Pelayo, MD, recounts Stanford’s historic role in the development of sleep medicine and notes that “infants and small children were even an early part of [research conducted by legendary Stanford sleep researcher William Dement, MD, PhD,] into rapid eye movement (REM) sleep.”  He also notes that “children were among the first patients seen” at the burgeoning clinic now known as the Stanford Center for Sleep Sciences and Medicine.

Looking toward the future, he writes:

In 2009, the historic clinic previously situated on Quarry Road near Stanford’s main campus was relocated to a state-of-the-art 14 bedroom facility at the Stanford outpatient campus in Redwood City. Thousands of patients are seen every year for diagnosis and management of sleep disorders, of which approximately 25 percent are children. This speaks to the future of sleep medicine: recognizing these conditions in childhood so that interventions can change development, affecting everything from growth to behavior. It is a significant need and one that deserves wider attention on a national and international basis.

Decades ago the synergy of neuroscience and psychiatry was essential in establishing this new field. The study of normal sleep and sleep disorders in children is an especially integral part of the development of the future of modern sleep medicine.

Previously: Stanford study sheds light on narcolepsy, “will shape the next decade of research” into the disease, Expert argues that for athletes, “sleep could mean the difference between winning and losing”, BBC study: Oh, what a difference an hour of sleep makes and Ask Stanford Med: Rafael Pelayo answers questions on sleep research and offers tips for ‘springing forward’
Photo by tamakisono

In the News, Sleep

A look at dreams in art

A look at dreams in art

catdreamHere’s something you may have missed over the holidays: A fun piece on that uses artists’ renderings to demonstrate how certain cultures have depicted dreams over time and what nighttime imaginings could tell us about ourselves in the waking world. From Homer to Lewis Carroll, Alfred Hitchcock and Salvador Dalí, writers, filmmakers, painters and more have attempted to share what’s otherwise known only to the one who sleeps and dreams it. Now, science has opened windows into some of the neurological processes at work.

From the piece:

Normally, we don’t think our dreams are bizarre while we’re dreaming them – a quirk that researchers ascribe to reduced activity in the frontal and parietal cortices of the brain. Director Michel Gondry exploits this oddity in The Science of Sleep (2006), as dreams and real life begin to merge for Stéphane Miroux (played by Gael García Bernal).

Oversized features such as Miroux’s gigantic hands should be one of the surest signs we are dreaming. These exaggerated proportions may be a result of reduced working memory, which makes it difficult for the brain to keep all the elements in perspective as the scene changes.

Previously: Exploring the possibility of decoding our dreamsEye movement in REM sleep: Rapid, but perhaps not random and What we know about the meaning of dreams
Photo by RCB

Autoimmune Disease, Research, Sleep, Stanford News

Stanford study sheds light on narcolepsy, “will shape the next decade of research” into the disease

Stanford study sheds light on narcolepsy, "will shape the next decade of research" into the disease

Back in 2009, I wrote about Stanford research indicating that narcolepsy is an autoimmune disease, caused when patients’ immune systems kill the neurons that produce the protein hypocretin. A just-published study confirms that finding while also showing that the condition can sometimes be triggered by a similarity between a region of hypocretin and a portion of a protein from the pandemic H1N1 virus. My colleague Krista Conger explains the detailed science behind the work and summarizes its significance in a release:

The study provides some of the most compelling cellular and molecular evidence to date for a scientific concept known as “molecular mimicry.” Mimicry is the idea that the normal immune response to a pathogen, in this case the pandemic 2009 H1N1 influenza virus, can trigger autoimmunity — when the immune system mistakenly attacks healthy components of the body — because of similarity between a pathogen protein and a human protein.

“The relationship between H1N1 infection, vaccination and narcolepsy gave us some very interesting insight into possible causes of the condition,” said Emmanuel Mignot, MD, PhD, professor of psychiatry and behavioral sciences [and director of the Stanford Center for Sleep Sciences and Medicine. “In particular, it strongly suggested to us that T cells of the immune system primed to attack H1N1 can occasionally also cross-react with hypocretin and somehow cause the destruction of hypocretin-producing neurons.”

The new study suggests new ways to try to intervene before complete destruction of the specialized brain cells. Their loss is the hallmark of the disease and leads to its dramatic symptoms. The study also could pave the way to a new blood test to diagnose narcolepsy. And it sheds light on a previously observed association between a pandemic H1N1 vaccine used in Europe in 2009 and an increase in narcolepsy cases in Scandinavia the subsequent year.

Mignot shares senior authorship of the research with immunology researcher Elizabeth Mellins, MD, who told Conger that the findings “will shape the next decade of research into narcolepsy.” The study appears today in Science Translational Medicine.

Previously: Does influenza trigger narcolepsy?, More clues about narcolepsy and Narcolepsy = autoimmune disease

Sleep, Women's Health

Fortysomething and sleepless

Fortysomething and sleepless

Much has been in the news lately about insomnia. Over on, Stanford physician Leah Millheiser, MD, recently shared her own sleep struggles and described why women in their 40s often experience difficulty sleeping:

…It is most likely a combination of decreasing estrogen & progesterone levels as well as increasing life stressors that contribute to episodes of acute insomnia. Although a woman in her early 40s may be years away from menopause, the change in hormones can manifest itself as sleep disturbance even when other signs or perimenopause, such as hot flushes and night sweats, are absent.

Millheiser outlined several things that readers can do to get a better night’s sleep, including avoiding bedtime exposure to bright devices like TV and smartphones. (Are you guilty of looking at e-mails on your phone before bed? Yes, me too.)

Previously: Can adjusting your mobile device’s brightness help promote better sleep?Yoga may help relieve insomnia in menopausal women, study finds, Discussing the effects of long-term exercise for insomniacs, Tips for fighting fatigue after a sleepless night, and Researchers say: Don’t work your brain when you’re trying to go to sleep

In the News, Mental Health, Sleep, Stanford News

Good news: Many studies recommend downtime for increased productivity

Good news: Many studies recommend downtime for increased productivity

woman on beanbag chairIt’s fitting to be flagging a Scientific American article on the benefits of quality-of-life-enhancing practices such as time away from work, mindfulness meditation, and nature walks as I prepare to attend an intensive yoga-teacher training workshop called “Sensation: The Language of the Body.” (For the record, though, practicing authentic movement is more challenging for me than solving a calculus problem.) Okay, yogini, but how can rest from the daily grind affect, say, physicians?

From the piece:

In a 2002 study by Rebecca Smith-Coggins of Stanford University and her colleagues, 26 physicians and nurses working three consecutive 12-hour night shifts napped for 40 minutes at 3 A.M. while 23 of their colleagues worked continuously without sleeping. Although doctors and nurses that had napped scored lower than their peers on a memory test at 4 A.M., at 7:30 A.M. they outperformed the no-nap group on a test of attention, more efficiently inserted a catheter in a virtual simulation and were more alert during an interactive simulation of driving a car home.

The article reviews much research on a variety of topics and offers a good amount of context – including the siesta’s roots in the Roman Catholic Church – so fluff a bean bag chair, sign out of your work e-mail, and ease in to a good read.

Previously: Using mindfulness interventions to help reduce physician burnoutStudy finds less time worked not always linked to happiness, Ask Stanford Med: Answers to your questions about willpower and tools to reach our goals, Companies add nap rooms to perk up workers, boost productivity and Do siestas make you smarter?
Photo by Bekathwia

In the News, Research, Sleep, Sports, Stanford News

Expert argues that for athletes, “sleep could mean the difference between winning and losing”

Expert argues that for athletes, "sleep could mean the difference between winning and losing"

Boston CelticsGoodnight Butler Bulldogs, goodnight Boston Celtics. A recent article in the Boston Globe spotlights ways coaches of elite basketball teams are turning to scientific research on sleep to improve players’ performance on the court.

As outlined in the piece, Brad Stevens enlisted the help of Stanford Sleep Disorders Clinic and Research Laboratory researcher Cheri Mah to help his Bulldogs play their best during a challenging travel schedule when he was their head coach. Charles Czeisler, MD, PhD, chief of the division of sleep medicine at Brigham and Women’s Hospital and director of sleep medicine at Harvard Medical School, has advised the Celtics on planning sleep for optimal results. And sleep influences more than stamina, coordination and muscular power: Czeisler points out that lack of sleep can lead to delayed reaction times, loss of control over emotions, and impaired consolidation of memories – all of which matter when playing ball.

From the article:

The optimal amount of sleep for an average person varies, but Mah and Czeisler each said it is around eight hours — though NBA players might need at least nine.

Many NBA players take pregame naps — Miami’s LeBron James and the Lakers’ Kobe Bryant swear by them — and Mah and Czeisler said that naps are a good power boost that can last for a few hours, but naps and caffeine can’t replace a night of proper sleep.

“It won’t turn a couch potato into an NBA player,” Czeisler said, “but if you’re looking for a potential advantage, sleep could mean the difference between winning and losing.”

Previously: Ask Stanford Med: Cheri Mah responds to questions on sleep and athletic performanceA slam dunk for sleep: Study shows benefits of slumber on athletic performance and Want to be like Mike? Take a nap on game day

In the News, Public Health, Research, Sleep

BBC study: Oh, what a difference an hour of sleep makes

BBC study: Oh, what a difference an hour of sleep makes

snooze buttonWith two Nobel winners this week, our Stanford office is positively humming with excitement, activity and pride. There’s really only one thing that’s in short supply around here these days: Sleep. Okay, sleep and coffee. But, mostly sleep.

That’s why I feel compelled to write about this BBC study on the effects of one hour of sleep.

Now, you may have read that last sentence and thought to yourself, of course an extra hour of sleep is beneficial – it’s an extra hour of sleep! But does one hour of sleep have a measurable effect on how we feel and perform during the day? Or can I safely shave 60 minutes off my slumber in exchange for an extra cup of coffee and a few more layers of skillfully applied makeup?

To find out, Michael Mosley, MD, of the BBC contacted the University of Surrey Sleep Research Centre. Earlier this year, the centre published a study on the effects of sufficient versus insufficient sleep. But that research compared extreme, not one-hour, differences in sleep schedules. So, Mosley and the center’s researchers recruited seven volunteers to participate in a new, two-week sleep study that compared the effects of six-and-a-half versus seven-and-a-half hours of sleep.

Their findings are reported in the BBC story:

Computer tests revealed that most of them struggled with mental agility tasks when they had less sleep, but the most interesting results came from the blood tests that were run.

Dr Simon Archer and his team at Surrey University were particularly interested in looking at the genes that were switched on or off in our volunteers by changes in the amount that we had made them sleep.

“We found that overall there were around 500 genes that were affected,” Archer explained.

When the volunteers cut back from seven-and-a-half to six-and-a-half hours’ sleep a night, genes that are associated with processes like inflammation, immune response and response to stress became more active. The team also saw increases in the activity of genes associated with diabetes and risk of cancer. The reverse happened when the volunteers added an hour of sleep.

In short, it seems there’s no cosmetic that can “make up” for an hour of lost sleep. As troubling as it is to think that there’s something my coffee cannot cure, it’s nice to know that an extra hour of sleep isn’t purely an indulgence.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: Study shows lack of sleep during adolescence may have “lasting consequences” on the brainStanford expert: Students shouldn’t sacrifice sleepStudy shows rotating night shift work may raise risk of Type 2 diabetesTips for fighting fatigue after a sleepless nightWhat are the consequences of sleep deprivation? and Exploring the effect of sleep loss on health
Photo by Jellaluna
Via The Guardian

Aging, Research, Sleep, Women's Health

Yoga may help relieve insomnia in menopausal women, study finds

Yoga may help relieve insomnia in menopausal women, study finds

tree_yogaOne of my favorite evening wind-down rituals is practicing what restorative yoga master teacher Judith Hanson Lasater calls “Instant Maui”: lying on your back with padding underneath your sacrum and elevating your legs bent at a 90-degree angle – lower legs resting on the seat of a chair or sofa – to induce the relaxation response.

So I was interested to read how yoga may provide benefit to a particular group of women: those who are menopausal and suffering from insomnia. In the MsFLASH (Menopause Strategies: Finding Lasting Answers for Symptoms and Health) Network randomized controlled trial, taking 90-minute weekly yoga classes and practicing at home for 12 weeks was linked to less insomnia among a group of 249 healthy, previously inactive menopausal women. Night sweats and hot flashes – two other common symptoms of menopause – were not found to be affected by the practice.

In the NIH-funded study, which appears online in the journal Menopause, participants were randomized to try yoga, aerobic exercise or neither, and given either an omega-3 fatty acid supplement or a placebo. As noted in a recent Group Health Research Institute release, the link between yoga and better sleep was the only statistically significant finding – but it could be an important one for insomnia sufferers.

“Hormone therapy is the only Food and Drug Administration-approved treatment for hot flashes and night sweats, and fewer women are opting for hormone therapy these days,” lead author Katherine Newton, PhD, commented.

Previously: Large federal analysis: Hormone therapy shouldn’t be used for chronic-disease preventionAnxiety, poor sleep, and time can affect accuracy of women’s self-reports of menopause symptoms and Acupuncture appears helpful at easing hot flashes
Photo by Oblong Land Conservancy

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