Andragogy in Practice: Applying a Theoretical Framework to Team Science Training in Biomedical Research.

This study is the first to apply the theoretical principles of Malcolm Knowles' theory of andragogy to evaluate data collected from learners who participated in team science training workshops in a biomedical research setting. Briefly, andragogy includes six principles: the learner's self-concept, the role of experience, readiness to learn, orientation to learning, the learner's need to know, and intrinsic motivation. Using an embedded study design, the primary focus was on qualitative data, with quantitative data complementing the qualitative findings. The deductive analysis demonstrated that approximately 85% of the qualitative data could be connected to at least one andragogical principle. Participant responses to positive evaluation questions were largely related to two principles: readiness to learn and problem-based learning orientation. Participant responses to negative questions were largely connected to two different principles: the role of experience and self-direction. Inductive analysis found an additional theme: meeting biological needs. Quantitative survey results supported the qualitative findings. The study findings demonstrate that andragogy can serve as a valuable construct to integrate into the development of effective team science training for biomedical researchers.

Sleep Apnea and Incident Stroke in a National Cohort of Black and White Adults.

BACKGROUND AND OBJECTIVES: Racial/ethnic differences have been documented in the relationship between obstructive sleep apnea (OSA) and stroke incidence, yet racial differences in OSA symptoms or treatment and their relationship with stroke incidence are underexplored and may contribute to stroke disparities. We comprehensively examined OSA symptoms and their relationships to stroke incidence by race/ethnicity. METHODS: Data were collected from the REasons for Geographic and Racial Differences in Stroke (REGARDS) study, a population-based cohort of Black and White individuals in the United States. Participants free from a stroke diagnosis at baseline were included. Participants self-reported the following: (1) snoring; (2) daytime sleepiness; (3) provider-diagnosed sleep apnea (PDSA); and (4) treatment for PDSA using positive airway pressure (PAP). OSA risk was categorized as high or low based on the Berlin Sleep Questionnaire. Incident stroke was defined as first occurrence of stroke over an average of 12 (SD 3.9) years of follow-up. We report the relationships between snoring, OSA risk, PDSA, PAP therapy use, and incident stroke by race/ethnicity using Cox proportional hazards models after adjusting for demographic and socioeconomic factors and stroke risk factors. RESULTS: Among the 22,192 participants (mean age [SD] 64.2[9.1] years), 38.1% identified as Black. Overall, snoring was not associated with incident stroke (hazard ratio [HR] 0.98, 95% CI 0.85-1.13). However, among White individuals but not Black individuals, high OSA risk and PDSA were associated with incident stroke (HR 1.22, 95% CI 1.01-1.47; HR 1.33, 95% CI 1.04-1.70, respectively). PAP therapy use among those with PDSA (compared with non-PDSA) was associated with incident stroke in White individuals (HR 1.38, 95% CI 1.05-1.80). PAP therapy use among those with PDSA (compared with those with PDSA without PAP therapy use) was associated with reduced risk of incident stroke in Black (HR 0.39, 95% CI 0.17-0.91) but not White (HR 0.63, 95% CI 0.37-1.10) individuals. DISCUSSION: White individuals with high OSA risk and those with PDSA with or without PAP therapy use were at increased incident stroke risk, whereas Black individuals reporting PDSA and PAP had reduced incident stroke risk relative to those not using PAP. Future research is needed to understand the mechanisms underlying racial differences in OSA and stroke such as differences in assessment modes and treatment.

Sleep Patterns of Premedical Undergraduate Students: Pilot Study and Protocol Evaluation.

BACKGROUND: Poor sleep hygiene persists in college students today, despite its heavy implications on adolescent development and academic performance. Although sleep patterns in undergraduates have been broadly investigated, no study has exclusively assessed the sleep patterns of premedical undergraduate students. A gap also exists in the knowledge of how students perceive their sleep patterns compared to their actual sleep patterns. OBJECTIVE: This study aims to address 2 research questions: What are the sleep patterns of premedical undergraduate students? Would the proposed study protocol be feasible to examine the perception of sleep quality and promote sleep behavioral changes in premedical undergraduate students? METHODS: An anonymous survey was conducted with premedical students in the Medical Science Baccalaureate program at an R1: doctoral university in the Midwest United States to investigate their sleep habits and understand their demographics. The survey consisted of both Pittsburg Sleep Quality Index (PSQI) questionnaire items (1-9) and participant demographic questions. To examine the proposed protocol feasibility, we recruited 5 students from the survey pool for addressing the perception of sleep quality and changes. These participants followed a 2-week protocol wearing Fitbit Inspire 2 watches and underwent preassessments, midassessments, and postassessments. Participants completed daily reflections and semistructured interviews along with PSQI questionnaires during assessments. RESULTS: According to 103 survey responses, premedical students slept an average of 7.1 hours per night. Only a quarter (26/103) of the participants experienced good sleep quality (PSQI<5), although there was no significant difference (P=.11) in the proportions of good (PSQI<5) versus poor sleepers (PSQI≥5) across cohorts. When students perceived no problem at all in their sleep quality, 50% (14/28) of them actually had poor sleep quality. Among the larger proportion of students who perceived sleep quality as only a slight problem, 26% (11/43) of them presented poor sleep quality. High stress levels were associated with poor sleep quality. This study reveals Fitbit as a beneficial tool in raising sleep awareness. Participants highlighted Fitbit elements that aid in comprehension such as being able to visualize their sleep stage breakdown and receive an overview of their sleep pattern by simply looking at their Fitbit sleep scores. In terms of protocol evaluation, participants believed that assessments were conducted within the expected duration, and they did not have a strong opinion about the frequency of survey administration. However, Fitbit was found to provide notable variation daily, leading to missing data. Moreover, the Fitbit app's feature description was vague and could lead to confusion. CONCLUSIONS: Poor sleep quality experienced by unaware premedical students points to a need for raising sleep awareness and developing effective interventions. Future work should refine our study protocol based on lessons learned and health behavior theories and use Fitbit as an informatics solution to promote healthy sleep behaviors.

History of obstructive sleep apnea associated with incident cognitive impairment in white but not black individuals in a US national cohort study.

BACKGROUND: We sought to determine if risk for obstructive sleep apnea (OSA), a history of OSA, and/or treatment of OSA has a different association with incident cognitive impairment or cognitive decline in Black individuals and White individuals. METHODS: To determine whether the risk for OSA, a history of OSA, and/or treatment of OSA has a different association with incident cognitive impairment or cognitive decline in Black individuals and White individuals; data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) was used. Participants that completed the sleep questionnaire module, had baseline cognitive assessment, and at least one cognitive assessment during follow-up were included. Risk of OSA was determined based on Berlin Sleep Questionnaire. History of sleep apnea was determined based on structured interview questions. Optimally treated OSA was defined as treated sleep apnea as at least 4 h of continuous positive airway pressure use per night for ≥5 nights per week. RESULTS: In 19,017 participants stratified by race, White participants with history of OSA were 1.62 times more likely to have incident cognitive impairment compared to White participants without history of OSA after adjusting for demographic characteristics, history, and lifestyle factors (OR = 1.62, 95% CI = 1.05-2.50, p-value = 0.03). This relationship was not seen in Black participants (OR = 0.92, 95% CI = 0.60-1.43, p-value = 0.72). DISCUSSION: A previous diagnosis of OSA is associated with incident cognitive impairment in White Americans but not Black Americans. Further investigations are required to determine the mechanism for this difference.

Obstructive Sleep Apnea as a Risk Factor for Intracerebral Hemorrhage.

BACKGROUND AND PURPOSE: To determine whether obstructive sleep apnea (OSA) is associated with intracerebral hemorrhage (ICH) risk, we assessed premorbid OSA exposure of patients with nontraumatic ICH and matched controls. METHODS: Ethnic/Racial Variations of Intracerebral Hemorrhage is a multicenter, case-control study evaluating risk factors for ICH that recruited 3000 cases with ICH and 3000 controls. OSA status was ascertained using the Berlin Questionnaire as a surrogate for premorbid OSA. We performed logistic regression analyses to evaluate the association between OSA and ICH. RESULTS: Two thousand and sixty-four (71%) cases and 1516 (52%) controls were classified as having OSA by the Berlin Questionnaire. Cases with OSA were significantly more likely to be male and have hypertension, heart disease, hyperlipidemia, and higher body mass index compared with those without OSA. OSA was more common among cases compared with controls (71% versus 52%, odds ratio, 2.28 [95% CI, 2.05-2.55]). In a multivariable logistic regression model, OSA was associated with increased risk for ICH (odds ratio, 1.47 [95% CI, 1.29-1.67]). CONCLUSIONS: OSA is a risk factor for ICH.

Racial differences in sleep duration intersect with sex, socioeconomic status, and U.S. geographic region: The REGARDS study.

OBJECTIVES: Short and long sleep duration are associated with poor health outcomes and are most prevalent among racial/ethnic minorities. Few studies have investigated the intersection of other sociodemographic characteristics with race/ethnicity on sleep duration prevalence. DESIGN: Longitudinal retrospective analysis of continental U.S. cohort, the REasons for Geographic And Racial Differences in Stroke (REGARDS) PARTICIPANTS: Black (n = 7,547) and white (n = 12,341) adults, 56% women, ≥45 years MEASUREMENTS: At baseline (2003-07), participants reported age, sex, race, education, income, marital status, U.S. region, and employment status. The weighted average of reported sleep duration on weekdays and weekends, assessed at follow-up (2008-10), was categorized as <6, 6.0-6.99, 7.0-7.99 [reference], 8.0-8.99, and ≥9 h. Multinomial logistic regression models examined the independent and multivariable associations of sociodemographic factors with sleep duration. Interactions terms between race with education, income, region, and sex were examined. RESULTS: Average sleep duration was 7.0 h (SD=1.3). Prevalence of short (<6 h) and long (≥9 h) sleep duration was 11.4% (n = 2,260) and 7.0% (n = 1,395), respectively. In the multivariable model, interactions terms race*income, race*sex, and race*region were significant (P < .05). Relative to white adults, black adults, were most likely to have short sleep duration. The magnitude of that likelihood increased across greater levels of household income, but with greatest odds among black adults living outside of the Southeast and Appalachian United States, particularly for men (≥$75k; black men OR = 5.47, 95%CI: 3.94,7.54; black women OR = 4.28, 95%CI: 3.08, 5.96). CONCLUSIONS: Race in the context of socioeconomic, sex, and regional factors should be examined as key modifiers of sleep duration.

Orthostatic hypotension and REM sleep behaviour disorder: impact on clinical outcomes in α-synucleinopathies.

OBJECTIVE: Review the effect of orthostatic hypotension (OH) and rapid-eye-movement sleep behavioural disorder (RBD) on survival, cognitive impairment and postural stability, and discuss pathogenic mechanisms involved in the association of these two common non-motor features with relevant clinical outcomes in α-synucleinopathies. METHODS: We searched PubMed (January 2007-February 2019) for human studies of OH and RBD evaluating cognitive impairment, postural instability, and survival in Parkinson's disease (PD), dementia with Lewy bodies (DLB), multiple system atrophy (MSA) and pure autonomic failure (PAF). Included studies were analysed for design, key results and limitations as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: OH and RBD showed a positive association with cognitive impairment in PD and DLB, conflicting association in PAF, and no association in MSA. OH was correlated with incident falls and postural instability in PD and DLB but not in MSA. The association between RBD and postural instability was inconclusive; positive in five studies, negative in seven. OH, but not RBD, correlated with reduced survival in PD, DLB and MSA. The combination of OH and RBD was associated with cognitive impairment and more rapid progression of postural instability. CONCLUSIONS: OH and RBD yielded individual and combined negative effects on disability in α-synucleinopathies, reflecting a 'malignant' phenotype of PD with early cognitive impairment and postural instability. Underlying mechanisms may include involvement of selected brainstem cholinergic and noradrenergic nuclei.

Age and sex differences in burnout, career satisfaction, and well-being in US neurologists.

OBJECTIVE: To examine age and sex differences in burnout, career satisfaction, and well-being in US neurologists. METHODS: Quantitative and qualitative analyses of men's (n = 1,091) and women's (n = 580) responses to a 2016 survey of US neurologists. RESULTS: Emotional exhaustion in neurologists initially increased with age, then started to decrease as neurologists got older. Depersonalization decreased as neurologists got older. Fatigue and overall quality of life in neurologists initially worsened with age, then started to improve as neurologists got older. More women (64.6%) than men (57.8%) met burnout criteria on univariate analysis. Women respondents were younger and more likely to work in academic and employed positions. Sex was not an independent predictive factor of burnout, fatigue, or overall quality of life after controlling for age. In both men and women, greater autonomy, meaning in work, reasonable amount of clerical tasks, and having effective support staff were associated with lower burnout risk. More hours worked, more nights on call, higher outpatient volume, and higher percent of time in clinical practice were associated with higher burnout risk. For women, greater number of weekends doing hospital rounds was associated with higher burnout risk. Women neurologists made proportionately more negative comments than men regarding workload, work-life balance, leadership and deterioration of professionalism, and demands of productivity eroding the academic mission. CONCLUSIONS: We identified differences in burnout, career satisfaction, and well-being in neurologists by age and sex. This may aid in developing strategies to prevent and mitigate burnout and promote professional fulfillment for different demographic subgroups of neurologists.

Sleep duration and risk of incident stroke by age, sex, and race: The REGARDS study.

OBJECTIVE: To investigate the association between reported sleep duration and incident stroke in a US cohort of black and white adults, and evaluate race, age, and sex as potential effect modifiers. METHODS: From 2008 to 2010, 16,733 black and white adults, aged ≥45 years, without a history of stroke or sleep-disordered breathing from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, reported their habitual sleep duration (<6, 6.0-6.9, 7.0-8.9 [reference], ≥9 hours). Incident strokes were identified through biannual participant contact followed by physician adjudication of medical records. Cox proportional hazards analysis was conducted to calculate hazard ratios of interactions between sleep duration with race, age, sex, and 2-way combinations of these factors on incident stroke adjusting for stroke risk factors and sleep-disordered breathing risk. RESULTS: The sample comprised 10.4% (n = 1,747) short sleepers (<6 hours) and 6.8% (n = 1,134) long sleepers (≥9 hours). Over an average 6.1 years follow-up, 460 strokes occurred. There were significant interactions between sleep duration and race (p = 0.018) and sleep duration and race-sex groups (p = 0.0023) in association with incident stroke. Short sleep duration was significantly associated with decreased risk for stroke among black participants (hazard ratio [HR] 0.49 [95% confidence interval (CI) 0.28-0.85]), particularly black men (HR 0.21 [95% CI 0.07-0.69]), whereas long sleep duration was significantly associated with increased risk for stroke among white men (HR 1.71 [95% CI 1.06-2.76]). CONCLUSIONS: The association of sleep duration with incident stroke differs by race and sex, with short sleep duration among black men associated with decreased risk, whereas long sleep duration among white men associated with increased risk for stroke.

Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016.

OBJECTIVE: To study prevalence of and factors contributing to burnout, career satisfaction, and well-being in US neurology residents and fellows. METHODS: A total of 938 US American Academy of Neurology member neurology residents and fellows were surveyed using standardized measures of burnout, career satisfaction, and well-being from January 19 to March 21, 2016. RESULTS: Response rate was 37.7% (354/938); about 2/3 of responders were residents and 1/3 were fellows. Median age of participants was 32 years and 51.1% were female. Seventy-three percent of residents and 55% of fellows had at least one symptom of burnout, the difference largely related to higher scores for depersonalization among residents. For residents, greater satisfaction with work-life balance, meaning in work, and older age were associated with lower risk of burnout; for fellows, greater satisfaction with work-life balance and effective support staff were associated with lower risk of burnout. Trainees experiencing burnout were less likely to report career satisfaction. Career satisfaction was more likely among those reporting meaning in work and more likely for those working in the Midwest compared with the Northeast region. CONCLUSIONS: Burnout is common in neurology residents and fellows. Lack of work-life balance and lack of meaning in work were associated with reduced career satisfaction and increased risk of burnout. These results should inform approaches to reduce burnout and promote career satisfaction and well-being in US neurology trainees.

Burnout, career satisfaction, and well-being among US neurologists in 2016.

OBJECTIVE: To study prevalence of and factors that contribute to burnout, career satisfaction, and well-being in US neurologists. METHODS: A total of 4,127 US American Academy of Neurology member neurologists who had finished training were surveyed using validated measures of burnout, career satisfaction, and well-being from January 19 to March 21, 2016. RESULTS: Response rate was 40.5% (1,671 of 4,127). Average age of participants was 51 years, with 65.3% male and nearly equal representation across US geographic regions. Approximately 60% of respondents had at least one symptom of burnout. Hours worked/week, nights on call/week, number of outpatients seen/week, and amount of clerical work were associated with greater burnout risk. Effective support staff, job autonomy, meaningful work, age, and subspecializing in epilepsy were associated with lower risk. Academic practice (AP) neurologists had a lower burnout rate and higher rates of career satisfaction and quality of life than clinical practice (CP) neurologists. Some factors contributing to burnout were shared between AP and CP, but some risks were unique to practice setting. Factors independently associated with profession satisfaction included meaningfulness of work, job autonomy, effectiveness of support staff, age, practicing sleep medicine (inverse relationship), and percent time in clinical practice (inverse relationship). Burnout was strongly associated with decreased career satisfaction. CONCLUSIONS: Burnout is common in all neurology practice settings and subspecialties. The largest driver of career satisfaction is the meaning neurologists find in their work. The results from this survey will inform approaches needed to reduce burnout and promote career satisfaction and well-being in US neurologists.

The interaction of sleep and amyloid deposition on cognitive performance.

Sleep difficulties are emerging as a risk factor for dementia. This study examined the effect of sleep and amyloid deposition on cognitive performance in cognitively normal adults. Sleep efficiency was determined by actigraphy. Cerebrospinal fluid Aß42 levels <500 pg mL-1 , indicating amyloid deposition, was present in 23 participants. Psychometric tests included the Free and Cued Selective Reminding Test, Trail Making Test A and B, Animal Fluency, Letter Number Sequencing, and the Mini Mental State Examination. The interaction term of sleep efficiency and amyloid deposition status was a significant predictor of memory performance as measured by total Selective Reminding Test scores. While Trail Making Test B performance was worse in those with amyloid deposition, sleep measures did not have an additive effect. In this study, amyloid deposition was associated with worse cognitive performance, and poor sleep efficiency specifically modified the effect of amyloid deposition on memory performance.

The STOP-BANG questionnaire improves the detection of epilepsy patients at risk for obstructive sleep apnea.

Patients with epilepsy and obstructive sleep apnea (OSA) are at risk for worsened seizure control and quality of life. We performed a quality improvement project, evaluating for improvements in the screening of OSA in epilepsy patients using the STOP-BANG questionnaire. The electronic medical records of patients seen in our epilepsy clinic were screened for 4 months prior to the intervention. We subsequently implemented the STOP-BANG questionnaire for 3 months. Only 22/664 patients (3.3%) had their sleeping habits explored during the pre-intervention period; 11 (1.7%) were referred to sleep medicine. Following implementation of the STOP-BANG questionnaire, the percentage of patients screened for OSA increased to 41.6% (269/647, Chi-square Fisher's Exact test 2-sided p<0.001). Of the 269 patients screened, 84 (31.2%) met criteria for elevated OSA risk. Forty-one patients were referred to sleep medicine during the subsequent 3 month period, including 33 who met STOP-BANG criteria for OSA. This represented 6.3% and 5.1% (respectively) of all 647 patients, a significant improvement over the percentage referred prior to the intervention (Chi-square Fisher's Exact test 2-sided p<0.001). Twelve of the 33 patients referred based on the STOP-BANG questionnaire saw sleep medicine; 11 (91.7%) were referred for polysomnography (PSG). Of the 10 patients who underwent PSG, 9 (90%) were diagnosed with OSA and offered treatment with continuous positive airway pressure (CPAP).

Treatment and Management of Dementia Due to Alzheimer's Disease.

OPINION STATEMENT: Alzheimer's disease (AD) is a progressive neurological disorder typically associated with episodic memory loss as the initial symptom, but individuals <65 years old may present with executive dysfunction, word finding difficulties, or visual processing deficits. In those with AD, curative treatments are not available, but there are interventions which may modify disease course, symptom appearance and severity, enhance quality of life for patient and caregivers, and maintain safety. Both pharmacological and non-pharmacological interventions are important.

Over-the-counter and prescription sleep medication and incident stroke: the REasons for Geographic and Racial Differences in Stroke study.

BACKGROUND: Preliminary evidence suggests sleep medications are associated with risk of vascular events; however, the long-term vascular consequences are understudied. This study investigated the relation between sleep medication use and incident stroke. METHODS: Within the REasons for Geographic And Racial Differences in Stroke study, 21,678 black participants and white participants (≥45 years) with no history of stroke were studied. Participants were recruited from 2003 to 2007. From 2008 to 2010, participants self reported their prescription and over-the-counter sleep medication use over the past month. Suspected stroke events were identified by telephone contact at 6-month intervals and associated medical records were retrieved and physician-adjudicated. Proportional hazards analysis was used to estimate hazard ratios for incident stroke associated with sleep medication use (0, 1-14, and 15+ days per month) controlling for sociodemographics, stroke risk factors, mental health symptoms, and sleep apnea risk. RESULTS: At the sleep assessment, 9.6% of the sample used prescription sleep medication and 11.1% used over-the-counter sleep aids. Over an average follow-up of 3.3 ± 1.0 years, 297 stroke events occurred. Over-the-counter sleep medication use was associated with increased risk of incident stroke in a frequency-response relationship (P = .014), with a 46% increased risk for 1-14 days of use per month (hazards ratio [HR] = 1.46; 95% confidence interval [CI], .99-2.15) and a 65% increased risk for 15+ days (HR = 1.65; 95% CI, .96-2.85). There was no significant association with prescription sleep medications (P = .80). CONCLUSIONS: Over-the-counter sleep medication use may independently increase the risk of stroke beyond other risk factors in middle-aged to older individuals with no history of stroke.