The impact of junior doctors' worktime arrangements on their fatigue and well-being.

OBJECTIVE: Many doctors report working excessively demanding schedules that comply with the European Working Time Directive (EWTD). We compared groups of junior doctors working on different schedules in order to identify which features of schedule design most negatively affected their fatigue and well-being in recent weeks. METHODS: Completed by 336 doctors, the questionnaires focused on the respondents' personal circumstances, work situation, work schedules, sleep, and perceptions of fatigue, work-life balance and psychological strain. RESULTS: Working 7 consecutive nights was associated with greater accumulated fatigue and greater work-life interference, compared with working just 3 or 4 nights. Having only 1 rest day after working nights was associated with increased fatigue. Working a weekend on-call between 2 consecutive working weeks was associated with increased work-life interference. Working frequent on-calls (either on weekends or during the week) was associated with increased work-life interference and psychological strain. Inter-shift intervals of <10 hours were associated with shorter periods of sleep and increased fatigue. The number of hours worked per week was positively associated with work-life interference and fatigue on night shifts. CONCLUSION: The current findings identify parameters, in addition to those specified in the EWTD, for designing schedules that limit their impact on doctors' fatigue and well-being.

Serum angiotensin converting enzyme and the obstructive sleep apnea hypopnea syndrome.

STUDY OBJECTIVES: We wanted to see if the obstructive sleep apnea hypopnea syndrome (OSAHS) causes hypertension and endothelial dysfunction through activation of the angiotensin-converting enzyme (ACE). METHODS: A cross-sectional followed by a prospective, interventional study in a sleep disordered breathing clinic in a UK Hospital. We measured baseline serum ACE activity and ACE allele frequencies in 26 consecutive (untreated) OSAHS patients, 26 consecutive Sleepy Snorers, and 26 healthy (non-sleepy) controls. The OSAHS and Sleepy Snorers had serum ACE repeated after 6 months, with the OSAHS group receiving CPAP in the interim. RESULTS: There was no difference in baseline mean serum ACE among OSAHS (33 lU/L), sleepy snorers (36 IU/L), and healthy controls (32 IU/L), p = 0.63. There was no difference in serum ACE activity between OSAHS and sleepy snorers after 6 months (p = 0.9) and no change in serum ACE from baseline in either group. In particular, there was no change in ACE activity in the OSAHS group on an intention to treat basis or when limiting analysis was limited to only "good" CPAP users (n = 16, p = 0.68), despite significant improvements in their Epworth scores and blood pressure and normalization of the 4% dip-rate. CONCLUSIONS: Changes in serum ACE activity do not occur in OSAHS; therefore it is unlikely to be associated with the hypertension and other cardiovascular dysfunction often reported in OSAHS.

Simple interventions improve re-attendance when treating the sleep apnoea syndrome.

BACKGROUND AND PURPOSE: Interventions to improve treatment outcomes in sleep apnoea-hypopnoea syndrome (SAHS) have had mixed success. Most have concentrated on following the use of a continuous positive airway pressure (CPAP) machines; poorer users may not return for machine readings, so any compliance study must take into account rates of attendance rates. We hypothesised that a series of additional, early support measures would improve re-attendance over a sustained period. PATIENTS AND METHODS: Prospective, single-blinded interventional study. Seventy-two consecutive patients starting CPAP for SAHS were randomised to receive standard follow-up or extra early support. Attendance rates, CPAP use, Epworth scores, side-effects scores and number of changes to equipment were compared, by intent to treat, in both groups at 1 and 12 months. RESULTS: Re-attendance rates were higher in the intervention group at 1 month (P=0.04), 6 months (P=0.07) and 12 months (P=0.12). Those who defaulted tended previously to be poor users of the CPAP machine. For those who re-attended there was no difference in machine use or other outcomes. CONCLUSIONS: Simple interventions while commencing CPAP improve re-attendance with maximal benefit early on. This could provide more opportunities for solving problems early or considering alternative treatments. By confirming that poorer CPAP users eventually have higher default rates we recommend that future studies on CPAP compliance should first account for re-attendance rates.

Early predictors of CPAP use for the treatment of obstructive sleep apnea.

STUDY OBJECTIVES: To identify factors before a trial of nasal continuous positive airway pressure (CPAP) treatment that are associated with lower compliance. DESIGN: A prospective cohort study. Initial Hospital Anxiety and Depression Scale scores and other demographic data were noted. Machine use was recorded by clock timer after a 1-month trial of treatment. SETTING: District General Hospital sleep-disordered breathing clinic. PATIENTS OR PARTICIPANTS: Eighty consecutive patients with symptoms of sleep apnea-hypopnea syndrome and a 4% Sao2 desaturation index greater than 10 events per hour. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Those reporting 'initial problems' with CPAP went on to have an average of 2.4 hours of on time per night, while those not reporting initial problems had an on time of 5.0 hours per night (P < .001). Those living alone had a machine on time of 3.2 hours compared with 4.5 hours for those with partners (P = .04). Pearson's correlations between hours on time were -0.08 (P = .48) for initial Anxiety score and 0.10 (P = .37) for initial Depression score. CONCLUSIONS: There was no association between baseline anxiety and depression scores, as measured by the Hospital Anxiety and Depression Scale, and subsequent machine use. Other factors observable prior to commencing treatment, in particular, 'initial problems' (reported at autotitration), 'recent life-events' and 'living alone' were associated with lower machine use. Regarding all initial variables, reporting problems after the first night of nCPAP seems the most important predictor of ensuing machine use. A single screening question immediately after autotitration is useful in identifying those at high risk of treatment failure.