Journal articles on the topic 'Subjective disrupted sleep'

ObjectivesHigh rates of sleep difficulties have been found in patients with advanced cancer. However, not much is known about factors that are associated with sleep impairments in this population and that could constitute their potential risk factors or consequences. This study conducted in patients with cancer receiving palliative care aimed to evaluate the relationships of subjective (sleep diary; Insomnia Severity Index, ISI) and objective (actigraphy) sleep–wake variables with several physical and psychological symptoms, maladaptive sleep behaviours, erroneous beliefs about sleep, quality of life, time to death and environmental factors.MethodsThe sample was composed of 57 community-dwelling patients with cancer receiving palliative care and with an Eastern Cooperative Oncology Group Scale score of 2 or 3. Actigraphic, light and sound recording and a daily sleep and pain diary were completed for seven consecutive days. A battery of self-report scales was also administered.ResultsGreater disruptions of subjective and objective sleep–wake variables were more consistently associated with worse physical symptoms than with psychological variables. Disrupted objective sleep–wake parameters were also associated with a greater frequency of maladaptive sleep behaviours. Finally, a greater nocturnal noise in the bedroom was correlated with more impairments in subjective and objective sleep–wake variables while a lower 24-hour light exposure was associated with more disruption of subjectively assessed sleep only.ConclusionsAlthough longitudinal studies are needed to establish the etiology of sleep–wake difficulties in patients with advanced cancer, our findings suggest that physical symptoms, maladaptive sleep behaviours and environmental factors can contribute to their development or their persistence and need to be adequately addressed.

Abstract Introduction Disrupted nighttime sleep (DNS) is a core narcolepsy symptom subjectively described as spontaneous awakenings during the night, but researchers use varied polysomnogram (PSG) definitions based on sleep state transitions, NREM 1% and poor sleep efficiency. These sleep measures have yet to be validated to determine the best objective measure of DNS. Furthermore, it unknown to what extent DNS occurs in pediatric narcolepsy as children have greater sleep drive than adults. Here, we assess the construct validity of various DNS objective measures and evaluate its diagnostic utility for pediatric Narcolepsy Type 1 (NT1) when combined with a nocturnal Sleep Onset REM period (nSOREMP) in a large cohort of pediatric patients with CNS hypersomnias. Methods Retrospective, cross-sectional study of consecutive PSGs and multiple sleep latency tests (MSLTs) obtained at Boston Children’s Hospital and University of Bologna. Participants were drug-free or drug naïve, ages 6-18 years and slept at least 6 hours during the PSG. We analyzed associations between objective DNS measures and outcomes of self-reported sleep disturbance, Epworth Sleepiness Score, mean sleep latency, NT1 diagnosis, and CSF hypocretin values when available. We then combined the best performing DNS measure with the presence of a nSOREMP to determine the diagnostic value for NT1 using bootstrap analysis. We included n=151 NT1, n=21 narcolepsy type 2 (NT2), n=27 idiopathic hypersomnia (IH) and n= 117 subjectively sleepy controls in this analysis. Results Across groups, the Wake and NREM 1 bouts index had the most robust associations with objective sleepiness, subjective sleep disturbance and CSF hypocretin levels (p’s <0.0001). From 1000 bootstrap samples, the Wake/N1 index and presence of a nSOREMP have greater diagnostic accuracy for NT1 than the nSOREMP alone (p<0.0001). Conclusion Among a variety of sleep quality measures, we find that a Wake and NREM 1 bout index is the best objective measure of DNS. In combination with a nSOREMP, this DNS measure can aid in pediatric NT1 diagnosis using PSG alone and potentially reduce diagnostic delays. Support This study was supported by K23 National Institutes of Health (NINDS, K23 NS104267-01A1) grant and Investigator Initiated Research grant from Jazz Pharmaceuticals, Inc. to Dr. Maski

Abstract Introduction While sleep duration is known to affect next-day cognitive performance and alertness, largely in a dose-response manner, the effects of disrupted sleep (where one is awoken multiple times overnight, common in military settings) are much less understood. Therefore, we examined the effects of experimentally disrupted sleep on morning cognitive performance and alertness. Methods We tested 34 healthy participants (12 men, 22 women, 28.1±3.9 years; mean±SD) who slept for 8-hours time-in-bed on three consecutive nights with polysomnography in a controlled sleep lab. The final two nights were randomized and counterbalanced between an undisrupted and a disrupted sleep condition. On the disrupted sleep night, participants were awoken by auditory tones for a 5–10 min period every hour. The following morning, participants completed a cognitive test battery that included Karolinska Sleepiness Scale (KSS), 10-min psychomotor vigilance task (PVT), addition calculations (ADD), go/no-go (GNG), task switching (TS), and working memory (WM). Mixed effects models were used to test factors: condition (undisrupted vs. disrupted), condition-order, and their interaction. Results Significant (p<0.05) effects of condition (i.e., disrupted sleep caused worse performance) were found for PVT reaction time (RT), GNG RT, TS RT, WM percent correct, and KSS alertness ratings. Condition was not significant for number or percent correct on ADD, GNG, and TS. Condition-order was significant for TS percent correct, and significant interactions were found for ADD number correct and TS RT. Conclusion One night of sleep disruption caused significant negative effects on morning subjective alertness and on several, but not all, cognitive performance domains tested, including RT and WM. Condition-order and interaction effects were also found, indicating that some performance outcomes were impacted by possible learning effects over the study. Sleep disruption factors should be taken into account, especially in operational settings like the military where environmental factors (e.g., noise) disrupt sleeping conditions. Support Office of Naval Research, Code 34

AbstractObjective:Prevalence rates of sleep difficulties in advanced cancer patients have varied widely across studies (12 to 96%), and none of these employed a diagnostic interview to distinguish different types of sleep–wake disorders. Moreover, very limited information is available on subjective and objective sleep parameters in this population. Our study was conducted in palliative cancer patients and aimed to assess rates of sleep–wake disorders and subsyndromal symptoms and to document subjective and objective sleep–wake parameters across various types of sleep–wake difficulties.Method:The sample was composed of 51 community-dwelling cancer patients receiving palliative care and having an Eastern Cooperative Oncology Group score of 2 or 3. Relevant sections of the Duke Interview for Sleep Disorders were administered over the phone. An actigraphic recording and a daily sleep diary were completed for 7 consecutive days.Results:Overall, 68.6% of the sample had at least one type of sleep–wake difficulty (disorder or symptoms): 31.4% had insomnia and 29.4% had hypersomnolence as their main sleep–wake problem. Participants with insomnia as their main sleep difficulty had greater disruptions of subjective sleep parameters, while objectively-assessed sleep was more disrupted in patients with hypersomnolence comorbid with another sleep–wake difficulty.Significance of the Results:The high rates of sleep–wake difficulties found in this study indicate a need to screen more systematically for sleep–wake disorders, including insomnia and hypersomnolence, in both palliative care research and clinical practice, and to develop effective nonpharmacological interventions specifically adapted to this population.

Abstract Introduction During the past years, an increasing number of articles has focused on comparing sleep in youths with and without ADHD. However, so far no meta-analysis has been conducted summarizing the findings. Therefore, the current study assesses sleep architecture (i.e. the basic sleep structure), sleep problems, and sleep hygiene. Sleep was assessed both subjectively and objectively and the two groups were compared on multiple variables. Methods Two researchers independently performed a literature search (1980–2020). Studies using a case-control design comparing sleep in youths (12–25 years) with and without ADHD were included. Study quality was evaluated using the Newcastle-Ottawa Scale. Standardized mean differences were calculated for each outcome domain being reported by at least two studies. Results 10379 publications were screened, resulting in 11 studies and 52 effect sizes (nADHD=2377, ncontrol=21687). These effect sizes were summarized into 7 objective and 11 subjective variables measuring sleep. Two objective sleep variables were significantly worse in the ADHD group; total sleep time (z=2.16, p=.03) and sleep onset latency (z=2.39, p=.02). The two groups did not differ on sleep efficiency, sleep onset/offset time, and time in bed. Comparing the groups on subjective variables resulted in the same pattern, with total sleep time (z=21.27, p<.001) being significantly shorter in the ADHD group, and sleep onset latency (z=15.39, p<.001) and wake after sleep onset (z=13.50, p<.001) being significantly longer. Additionally, the ADHD group reported a significantly lower sleep efficiency (z=20.15, p<.001) and subjective sleep satisfaction (z=3.50, p<.001). Wake time and number of awakenings during the night were not significant. Youths with ADHD also reported significantly more sleep problems, including insomnia (z=6.38, p<.001), daytime sleepiness (z=26.68, p<.001) and sleep disturbances (z=8.00, p<.001). Due to only two studies measuring it, with a focus on different variables, sleep hygiene could not be included. Conclusion In general, youths with ADHD have a disrupted sleep architecture and experience more sleep problems compared to their typically developing peers. Consequently, sleep assessment should become a routine part during the diagnostic process of ADHD. Additionally, more research is needed focusing on sleep architecture and sleep hygiene, and on the development of a sleep intervention for youths with ADHD. Support (if any):

Abstract Introduction Sleep is critical to children’s health and recovery, but pediatric inpatient sleep is often disrupted by nonessential overnight interruptions. The COVID-19 pandemic necessitated social distancing policies which minimized contact with low-risk patients. These policies have the potential to decrease overnight disruptions and improve sleep for hospitalized patients. Methods This cohort study compared sleep disruptions for pediatric inpatients admitted prior to (Sep 2018 – Feb 2020) and during (Apr 2020 – Aug 2020) the COVID-19 pandemic at a single site, urban academic medical center. Objective disruptions were measured as room entries detected by hand hygiene sensors for occupied rooms pre-pandemic (n_average=56) and during the pandemic (n_average=48) for 69 and 154 nights, respectively. Subjective reports of overnight disruptions, sleep quantity, and caregiver mood were measured by surveys adopted from validated tools: the Karolinska Sleep Log, Potential Hospital Sleep Disruptions and Noises Questionnaire, and Visual Analog Mood Scale. Caregivers of a convenience sample of pediatric general medicine inpatients completed surveys. Caregivers pre-pandemic were surveyed in person, and during the pandemic, surveys were conducted over the phone. Results 293 pre-pandemic (age_patients=4.1±4.4 years) and 154 pandemic (age_patients=8.7±5.6 years) surveys were collected from caregivers. The majority (71% pre-pandemic and 52% pandemic) of the study population identified as Black/African American. Nighttime room entries initially decreased 36% (95% CI: 30%, 42%, p<0.001), then returned towards pre-pandemic levels as the COVID-19 hospital caseload decreased. Despite this, caregivers reported more disrupted patient sleep (p<0.001) due to tests (21% vs. 38%) as well as stress (30% vs. 49%), anxiety (23% vs. 41%), and pain (23% vs. 48%). Caregivers also reported children slept 61 minutes less (95% CI: 12 min, 110 min, p<0.001) and had more awakenings. Caregivers self-reported feeling more sad and weary, less calm, and worse overall (p<0.001 for all). Conclusion Despite fewer objective room entries, caregivers reported increased sleep disruptions and an hour less nighttime sleep with more awakenings during the pandemic for pediatric patients. Caregivers also self-reported worse mood. This highlights the importance of addressing subjective perceptions and experiences of hospitalized children and their caregivers during hospitalization. Support (if any):

410 Background: Sleep disruption is a prevalent problem among cancer patients and survivors, but clinical correlates of poor sleep are understudied, especially in colorectal cancer. We recently showed that metastatic breast cancer patients with poor sleep efficiency have a shorter overall survival. The primary study objective is to clarify the relationship between subjective sleep disruption and survival in patients with metastatic colorectal cancer (MCC). Methods: 240 pts (63% male, mean age=59; SD=11.0) treated for MCC in 1st to 5th line of 5-fluorouracil based chemotherapy completed the QOL Questionnaire (EORTC QLQ-C30). We considered sleep to be disrupted if patients reported little to severe trouble sleeping (scores >0 ). Multivariate Cox models included age, gender, site of primary tumor, stage at diagnosis, number of metastatic sites, performance status and prior chemotherapy. Results: 65.4% of the patients reported mild to severe sleep disruption according to EORTC QLQ-C30. Patients with trouble sleeping had poorer overall survival as compared to those without sleep disruption (HR: 1.47 [1.11 to 1.95]; p=0.008). Respective median survival times (months) were 14.2 [95% CI: 12.3 to 16.1] and 17.7 [10.0 to 25.3]. The survival benefit observed in patients without sleep disruption remained statistically significant after adjustment for other prognostic factors. The final multivariate prognostic model included subjective sleep disruption (HR: 1.49 [1.11 to 2.00]; p=0.009), number of metastatic sites (p<0.001), performance status (p=0.023), and prior chemotherapy (p<0.001). Conclusions: Our findings show that patients reported sleep disruption is an independent prognostic factor for overall survival in MCC. Future research is needed to determine the mechanisms of sleep disruption and its effect on survival, and whether treatment of sleep disruption can improve survival in MCC.

The prevalence of moderate-to-severe sleep problems is significantly higher among people with multiple sclerosis (MS) than in the general population. In 2002, we found a significant relationship between fatigue and disrupted sleep in patients with relapsing-remitting MS (RRMS). The objectives of this study were to determine whether eszopiclone (Lunesta; Sunovion Pharmaceuticals Inc, Marlborough, MA) was superior to placebo in improving sleep among patients with MS-related fatigue and sleep complaints (primary end point); and to assess the impact of improved sleep on daytime fatigue and functioning (secondary end point). This was a double-blind, placebo-controlled pilot trial lasting 7 weeks. Thirty ambulatory adults under age 65 years with RRMS, fatigue, and sleep disturbances were randomized to receive either eszopiclone or placebo. The outcome measures included subjective and objective changes in sleep-onset latency (SOL), total sleep time (TST), wakefulness after sleep onset (WASO), sleep efficiency (SE), fatigue scales, and neuropsychological measures of daytime functioning. Compared with placebo, eszopiclone was superior only in increasing TST. Fatigue improved in both groups, but there was no statistically significant correlation between increased TST and improved fatigue, and no statistically significant differences were observed between the two groups. Thus, in this study, eszopiclone did not improve sleep sufficiently to improve fatigue in MS patients. This result may be due to the multifactorial nature of sleep disturbances and fatigue in people with MS.

Humans regularly enter into co-sleeping arrangements with human and non-human partners. Studies of adults who co-sleep report that co-sleeping can impact sleep quality, particularly for women. Although dog owners often choose to bedshare with their dogs, we know relatively little about the nature of these relationships, nor the extent to which co-sleeping might interfere with sleep quality or quantity. In an effort to rectify this, we selected a sample of 12 adult female human (M = 50.8 years) and dog dyads, and monitored their activity using actigraphy. We collected movement data in one-minute epochs for each sleep period for an average of 10 nights per participant. This resulted in 124 nights of data, covering 54,533 observations (M = 7.3 hours per night). In addition, we collected subjective sleep diary data from human participants. We found a significant positive relationship between human and dog movement over sleep periods, with dogs influencing human movement more than humans influenced dog movement. Dog movement accompanied approximately 50% of human movement observations, and dog movement tripled the likelihood of the human transitioning from a non-moving state to a moving state. Nevertheless, humans rarely reported that their dog disrupted their sleep. We encourage the continued exploration of human-animal co-sleeping in all its facets and provide recommendations for future research in this area.

AbstractObstructive sleep apnea (OSA) is characterized by disrupted breathing and hypoxemia during sleep, daytime sleepiness, and changes in cognition and mood. One important question is regarding the reversibility of cognitive deficits after treatment with continuous positive airway pressure (CPAP). Here, we report the outcomes of CPAP treatment as measured by tests of attention and executive function. Thirty-seven individuals with moderate to severe OSA and compliant on CPAP treatment were studied with working memory tasks, neuropsychological testing, and overnight polysomnographic sleep study and compared to 27 healthy controls. CPAP improved the respiratory disturbance index, minimum and mean oxygen saturation (SpO2), subjective sleep quality, and daytime sleepiness ratings compared to pre-treatment values. In terms of current neurocognitive function, treated individuals with OSA performed at a comparable level to controls on basic working memory storage functions but still showed a significant reduction on tests of working memory requiring the central executive. The OSA group also performed worse on neuropsychological measures of complex attention, executive function, and psychomotor speed. While CPAP is an effective treatment for OSA in terms of ameliorating breathing disruption and oxygen desaturation during sleep, as well as daytime sleepiness, some cognitive deficits may be more resistant to treatment. (JINS, 2010,16, 1077–1088.)

Abstract Introduction Obesity is a major public health concern disproportionately affecting people of lower socioeconomic status. Involuntary job loss is a predictor of economic hardship and unemployment has been associated with poor sleep quality. Little is known about daily sleep and energy intake in this high-risk population. We hypothesized that disrupted, short sleep would be associated with increased energy intake among individuals who experienced involuntary job loss within the last 90 days. Methods Complete baseline data were analyzed from the ongoing Assessing Daily Activity Patterns through occupational Transitions (ADAPT) study. Over the same two-week period, participants (n = 191; 117 female; 63 Hispanic) were instructed to complete 14 days of daily sleep diaries and up to three 24-hour dietary recalls, conducted by trained interviewers using the Nutrition Data System for Research. The primary sleep variable was a composite score summarizing standardized number of awakenings and reversed-scored total sleep time; higher scores represented worse sleep. Energy intake was estimated as average 24 hour reported kcals/day. Linear regression was employed with age, gender, and body mass index as covariates. Results Higher sleep composite scores were associated with higher self-reported intake in kilocalories (kcal), B = 84.83, SE = 38.01, t = 2.23, &lt;i&gt; p &lt;/i&gt; &lt; .05. Wake time after sleep onset, sleep onset latency, and sleep efficiency were not associated with energy intake. Interestingly, higher subjective sleep quality was associated with consumption of more average daily kcals. Conclusion In a sample population of adults experiencing stress and economic hardship related to job loss, sleep continuity and quantity were associated with higher energy intake. With further prospective support, these findings suggest that public health interventions for obesity may benefit from behavioral sleep intervention components targeting both sleep fragmentation and sleep restriction. Support #1R01HL117995-01A1

Abstract Introduction Executive functioning (EF) deficits are a key feature of ADHD, and sleep disturbances may be an important contributor. Specifically, disturbed sleep is prevalent in ADHD and similar EF deficits are observed in ADHD and sleep disorders. Associations between disrupted sleep and EF in ADHD are poorly understood, particularly during adolescence. This study is among the first to examine relationships between sleep and EF using polysomnography (PSG) among adolescents across the ADHD symptom continuum. Methods In this ongoing study, 42 adolescents aged 13 to 17 (mean age = 14.86, 20 females) completed 3 nights of at-home PSG recording (total sleep time; TST) and self-reports of sleep quality, daytime sleepiness, and chronotype. Seventeen had ADHD and 25 were healthy controls (HC). Participants and parents also completed a measure of EF (BRIEF-2; global and behavioral, emotional, and cognitive subscales). Linear regressions controlling for age and sex evaluated associations between sleep and EF. Results Self-reported poorer sleep quality and greater daytime sleepiness and eveningness tendency (p’s&lt;.05), but not TST, were associated with poorer self-reported global EF among adolescents. Shorter TST and greater eveningness were correlated with poorer parent-reported global EF (p’s&lt;.05). Follow up analyses examine differential relationships between sleep and behavioral, emotional, and cognitive domains of EF and between ADHD and HC groups. Conclusion This study is among the first to examine relationships between sleep and EF across the ADHD continuum in an adolescent-specific sample using PSG. Objectively-measured TST as well as subjective measures of sleep were associated with poorer EF in adolescents across the ADHD continuum. Prevention/intervention strategies focused on sleep may support EF among adolescents, and future studies should examine this possibility. In addition, given variability in EF among individuals with ADHD, future studies should investigate whether sleep disturbances identify a phenotypic subgroup within ADHD at risk for EF deficits. Support This work was supported by NIMH K23 MH108704 (Dr. Lunsford-Avery)

The circadian system regulates daily rhythms of physiology and behavior. Although extraordinary advances have been made to elucidate the brain mechanisms underlying the circadian system in nocturnal species, less is known in diurnal species. Recent studies have shown that retinorecipient brain areas such as the intergeniculate leaflet (IGL) and olivary pretectal nucleus (OPT) are critical for the display of normal patterns of daily activity in diurnal grass rats ( Arvicanthis niloticus). Specifically, grass rats with IGL and OPT lesions respond to light in similar ways to intact nocturnal animals. Importantly, both the IGL and OPT project to one another in nocturnal species, and there is evidence that these 2 brain regions also project to the superior colliculus (SC). The SC receives direct retinal input, is involved in the triggering of rapid eye movement sleep in nocturnal rats, and is disproportionately large in the diurnal grass rat. The objective of the current study was to use diurnal grass rats to test the hypothesis that the SC is critical for the expression of diurnal behavior and physiology. We performed bilateral electrolytic lesions of the SC in female grass rats to examine behavioral patterns and acute responses to light. Most grass rats with SC lesions expressed significantly reduced activity in the presence of light. Exposing these grass rats to constant darkness reinstated activity levels during the subjective day, suggesting that light masks their ability to display a diurnal activity profile in 12:12 LD. Altogether, our data suggest that the SC is critical for maintaining normal responses to light in female grass rats.

Abstract Introduction Lockdowns imposed to stem the spread of COVID-19 have disrupted the lifestyles of many worldwide, but studies to date are mostly confined to observations within a limited number of countries, based on subjective reports and survey from a narrow time window. In the present study, we investigate associations between the severity of lockdown policies and objective sleep and resting-heart rate measures. Methods Data from 113,000 users of a consumer sleep tracker across 20 countries were gathered between Jan–Jul 2020 and compared with an equivalent period in 2019 as a control for naturally occurring seasonal fluctuations. Lockdown stringency was derived using scores from the Oxford Government Response Tracker. Multilevel growth curve models were used to quantify the effect of lockdown stringency on changes to sleep patterns (midsleep time and midsleep variability) and resting heart rate changes, and to predict changes in resting heart rate from changes to sleep patterns. Results Lockdown severity modulated the size of shifts in sleep midpoint and regularity during this period. Midsleep times were delayed in all countries during strict lockdowns, particularly on weekdays, while midsleep variability reduced. The largest shifts in midsleep time (+0.09 to +0.58 hours), midsleep variability (–0.12 to –0.26 hours) and resting heart rate (–0.35 to –2.08 bpm) occurred in April and May - when most countries imposed their strictest lockdown measures. In addition, multilevel modelling revealed that for each unit increase in stringency index, midsleep time was delayed by 0.96 min, midsleep variability decreased by 0.46 min and resting heart rate decreased by 0.06 bpm. Finally, in models predicting changes in resting heart rate from changes to sleep patterns, midsleep variability was shown to be the strongest predictor of resting heart rate, wherein an hour increase in the standard deviation of midsleep variability predicted a 5.12 increase in bpm, while an hour increase in midsleep time only predicted a 1.25 decrease in bpm. Conclusion Our findings demonstrate the utility of large-scale data from consumer wearables in providing population-level insights into how lockdown severity directly impacts sleep health during this pandemic period. Support (if any) Work conducted at NUS is supported by a grant awarded to Michael Chee (NMRC/STAR19may-0001).

Study objectives Brain regulation of autonomic function in obstructive sleep apnea (OSA) is disrupted in a sex-specific manner, including in the insula, which may contribute to several comorbidities. The insular gyri have anatomically distinct functions with respect to autonomic nervous system regulation; yet, OSA exerts little effect on the organization of insular gyral responses to sympathetic components of an autonomic challenge, the Valsalva. We further assessed neural responses of insular gyri in people with OSA to a static handgrip task, which principally involves parasympathetic withdrawal. Methods We measured insular function with blood oxygen level dependent functional MRI. We studied 48 newly-diagnosed OSA (age mean±std:46.5±9 years; AHI±std:32.6±21.1 events/hour; 36 male) and 63 healthy (47.2±8.8 years;40 male) participants. Subjects performed four 16s handgrips (1 min intervals, 80% subjective maximum strength) during scanning. fMRI time trends from five insular gyri—anterior short (ASG); mid short (MSG); posterior short (PSG); anterior long (ALG); and posterior long (PLG)—were assessed for within-group responses and between-group differences with repeated measures ANOVA (p<0.05) in combined and separate female-male models; age and resting heart-rate (HR) influences were also assessed. Results Females showed greater right anterior dominance at the ASG, but no differences emerged between OSA and controls in relation to functional organization of the insula in response to handgrip. Males showed greater left anterior dominance at the ASG, but there were also no differences between OSA and controls. The males showed a group difference between OSA and controls only in the ALG. OSA males had lower left activation at the ALG compared to control males. Responses were mostly influenced by HR and age; however, age did not impact the response for right anterior dominance in females. Conclusions Insular gyri functional responses to handgrip differ in OSA vs controls in a sex-based manner, but only in laterality of one gyrus, suggesting anterior and right-side insular dominance during sympathetic activation but parasympathetic withdrawal is largely intact, despite morphologic injury to the overall structure.

Surgical Treatment of Drug-Resistant Nocturnal Frontal Lobe Epilepsy. Nobili L, Francione S, Mai R, Cardinale F, Castana L, Tassi L, Sartori I, Didato G, Citterio A, Colombo N, Galli C, Lo Russo G, Cossu M. Brain 2007;130(Pt 2):561–573. Of the cases with nocturnal frontal lobe epilepsy (NFLE) 30% are refractory to antiepileptic medication, with several patients suffering from the effects of both ongoing seizures and disrupted sleep. From a consecutive series of 522 patients operated on for drug-resistant focal epilepsy, 21 cases (4%), whose frontal lobe seizures occurred almost exclusively (>90%) during sleep, were selected. All patients underwent a comprehensive pre-surgical evaluation, which included history, interictal EEG, scalp video-EEG monitoring, high-resolution MRI and, when indicated, invasive recording by stereo-EEG (SEEG). There were 11 males and 10 females, whose mean age at seizure onset was 6.2 years, mean age at surgery was 24.7 years and seizure frequency ranged from <20/month to >300/month. Nine patients reported excessive daytime sleepiness (EDS). Prevalent ictal clinical signs were represented by asymmetric posturing (6 cases), hyperkinetic automatisms (10 cases), combined tonic posturing and hyperkinetic automatisms (4 cases) and mimetic automatisms (1 case). All patients reported some kind of subjective manifestations. Interictal and ictal EEG provided lateralizing or localizing information in most patients. MRI was unrevealing in 10 cases and it showed a focal anatomical abnormality in one frontal lobe in 11 cases. Eighteen patients underwent a SEEG evaluation to better define the epileptogenic zone (EZ). All patients received a microsurgical resection in one frontal lobe, tailored according to pre-surgical evaluations. Two patients were operated on twice owing to poor results after the first resection. Histology demonstrated a Taylor-type focal cortical dysplasia (FCD) in 16 patients and an architectural FCD in 4. In one case no histological change was found. After a post-operative follow-up of at least 12 months (mean 42.5 months) all the 16 patients with a Taylor's FCD were in Engel's Class Ia and the other 5 patients were in Engel's Classes II or III. After 6 months post-surgery EDS had disappeared in the 9 patients who presented this complaint pre-operatively. It is concluded that patients with drug-resistant, disabling sleep-related seizures of frontal lobe origin should be considered for resective surgery, which may provide excellent results both on seizures and on epilepsy-related sleep disturbances. An accurate pre-surgical evaluation, which often requires invasive EEG recording, is mandatory to define the EZ. Further investigation is needed to explain the possible causal relationships between FCD, particularly Taylor-type, and sleep-related seizures, as observed in this cohort of NFLE patients.

Abstract Purpose To investigate the effect of early evening exercise training at different intensities on nocturnal sleep and cardiac autonomic activity in endurance-trained runners. Methods Eight runners completed three experimental trials in a randomised, counterbalanced order. In the early evening (end of exercise 3.5 h before bedtime), participants performed either: (i) a 1 h high-intensity interval running session (HIGH, 6 × 5 min at 90% VO2peak interspersed with 5 min recovery); (ii) a 1 h low-intensity running session (LOW, 60 min at 45% VO2peak) or (iii) no exercise (CON). Subsequent nocturnal sleep was assessed using polysomnography, wristwatch actigraphy, and subjective sleep quality. A two-lead electrocardiogram recorded nocturnal cardiac autonomic activity. Results Total sleep time increased after HIGH (477.4 ± 17.7 min, p = 0.022) and LOW (479.6 ± 15.6 min, p = 0.006) compared with CON (462.9 ± 19.0 min). Time awake was lower after HIGH (31.8 ± 18.5 min, p = 0.047) and LOW (30.4 ± 15.7 min, p = 0.008) compared with CON (46.6 ± 20.0 min). There were no differences between conditions for actigraphy and subjective sleep quality (p > 0.05). Nocturnal heart rate variability was not different between conditions, but average nocturnal heart rate increased after HIGH (50 ± 5 beats min−1) compared with LOW (47 ± 5 beats min−1, p = 0.02) and CON (47 ± 5 beats min−1, p = 0.028). Conclusion When performed in the early evening, high-intensity exercise does not disrupt and may even improve subsequent nocturnal sleep in endurance-trained runners, despite increased cardiac autonomic activity. Additionally, low-intensity exercise induced positive changes in sleep behaviour that are comparable to those obtained following high-intensity exercise.

Abstract Introduction U.S. Army Reserve Officer Training Corps (ROTC) Advanced Camp (AC) is a 29-day training that assesses military skills and leadership potential in college students training to become Commissioned Officers (i.e. Cadets). Military trainings are widely known to disrupt normative sleep. Additionally, operational sleep disruption is linked to performance decrements. This study examined the ability for objective and subjective sleep during ROTC AC to predict Cadet performance. Methods One hundred and fifty-nine ROTC Cadets (age 22.06±2.49 years; 76.1% male) wore an actiwatch device continuously for 29 days during AC. Paper surveys administered at the end of AC captured subjective sleep metrics during the training. ROTC instructors evaluated Cadet performance and provided scores of overall class rank and summary performance. Multiple and ordinal linear regressions assessed the predicative utility of subjective (sleep duration [SD]; Global score [Global] from the Pittsburgh Sleep Quality Index) and objective (Total Sleep Time [TST]; Sleep Efficiency [SE]; Sleep Latency Onset [SOL]; Wake After Sleep Onset [WASO] from actigraphy) sleep on performance. Results The interaction of SD and Global, when controlling for age and gender, significantly predicted increased Cadet rank, F(4,153) = 3.09, p = 0.018. Models testing the prediction of SD and Global on summary performance score were non-significant. Further, regressing of both Cadet rank and summary performance individually on objective sleep metrics, when controlling for age and gender, resulted in non-significant findings. Conclusion Subjective and objective sleep showed no significant individual predictive utility on performance. However, the combined subjective model significantly predicted that Cadets who slept worse (lower SD; higher Global) during AC received a lower rank at the end of the training. These findings suggest there may be a unique combined predictive utility of subjective sleep on performance when compared to the predictive power of individual variables. Therefore, subjective sleep may be better for predicting operational performance than objective sleep. Future analyses will refine these models and examine how performance on individual AC events may be influenced by sleep. Support for this study came from the Military Operational Medicine Research Program (MOMRP) of the United States Army Medical Research and Development Command (USAMRDC). Support (if any):

Aim: subjective assessment by patients with allergic rhinitis (AR) of the efficacy in control of the main symptoms, seeking medical care for AR symptoms and general treatment methods. Patients and Methods: from April to August 2020, a study was conducted of 328 adult respondents (buyers of medicines for the AR treatment: antihistamines and/or intranasal corticosteroids), who voluntarily agreed to an online survey. 164 respondents purchased medicines based on the prescription or doctor recommendation, while other 164 chose medicines independently. Visual analog scale (VAS) was used to assess the severity of individual AR symptoms (nasal congestion, runny nose/nasal discharge, sneezing, itchy nose, cough), as well as eye and general symptoms (general malaise, drowsiness, headache). Results: 56% of respondents had persistent AR symptoms. Herewith, 60% of respondents suffered from seasonal AR, 40% — perennial AR. 52% of respondents had a mild AR form. However, the main triad of AR symptoms (nasal congestion, rhinorrhea and sneezing), despite the non-severe AR form in the absolute majority of respondents corresponded to moderate or severe severity (VAS>5) and indicated a lack of AR control. 31% of those surveyed experienced severe AR symptoms that disrupted daytime activity and sleep. The respondents were most concerned about nasal congestion, runny nose/rhinorrhea, and sneezing (the average VAS score was 7.3, 7.1, and 6.5, respectively). The frequency of visits to the doctor for AR was very low: 95% of respondents visited their doctor no more than once a year, while 48% of them — every few years. The first choice in therapy was antihistamines, regardless of the presence or absence of doctor’s recommendation. In second place were decongestants, in third — intranasal corticosteroids, which were more commonly purchased on the doctor’s recommendation. Conclusion: adult respondents with a suspected diagnosis of AR, despite uncontrolled and marked symptoms, underestimate their disease, rarely consult a doctor, and prefer to follow the recommendations of relatives and friends or pharmacists for treatment. The lack of AR control among adults in our country is obvious and requires the active participation of the medical and pharmaceutical community for salvation of such problem. KEYWORDS: allergic rhinitis, visual analog scale, control of allergic rhinitis symptoms, survey, therapy choice, severity of allergic rhinitis symptoms. FOR CITATION: Nenasheva N.M., Shilenkova V.V. Control of allergic rhinitis symptoms in adults in the Russian Federation: online survey results. Russian Medical Inquiry. 2021;5(1):25–31. DOI: 10.32364/2587-6821-2021-5-1-25-31.

Background. Sleep is important for consolidation of motor learning, but brain injury may affect sleep continuity and therefore rehabilitation outcomes. Objective. This study aims to assess the relationship between sleep quality and motor recovery in brain injury patients receiving inpatient rehabilitation. Methods. Fifty-nine patients with brain injury were recruited from 2 specialist inpatient rehabilitation units. Sleep quality was assessed (up to 3 times) objectively using actigraphy (7 nights) and subjectively using the Sleep Condition Indicator. Motor outcome assessments included Action Research Arm test (upper limb function), Fugl-Meyer Assessment (motor impairment), and the Rivermead Mobility Index. The Functional Independence Measure (FIM) was assessed at admission and discharge by the clinical team. Fifty-five age- and gender-matched healthy controls completed one assessment. Results. Inpatients demonstrated lower self-reported sleep quality ( P < .001) and more fragmented sleep ( P < .001) than controls. For inpatients, sleep fragmentation explained significant additional variance in motor outcomes, over and above that explained by admission FIM score ( P < .017), such that more disrupted sleep was associated with poorer motor outcomes. Using stepwise linear regression, sleep fragmentation was the only variable found to explain variance in rate of change in FIM ( R2adj = 0.12, P = .027), whereby more disrupted sleep was associated with slower recovery. Conclusions. Inpatients with brain injury demonstrate impaired sleep quality, and this is associated with poorer motor outcomes and slower functional recovery. Further investigation is needed to determine how sleep quality can be improved and whether this affects outcome.

Abstract Introduction Sleeping is understood as essential to affective function, yet little is known about how sleep shapes more specific and contextualized emotional responses besides anxiety and depression, such as anger. Anger itself involves arousal and can disrupt sleep. To examine the causal role of sleep in anger, a daily-diary study and an experimental study tested whether shortened sleep amplifies angry feelings, while exploring mediating mechanisms of this influence. Methods The daily-diary study (N = 202) collected daily reports of last-night’s sleep, daily stressors, and state anger across one month from college students, examining sleep and anger within everyday life. The experimental laboratory study (N = 147 community residents) examined changes in anger experienced during aversive noise following random assignment to either at-home sleep restriction (by about 5 hours across 2 nights), or to individuals’ regular schedule. Results In the daily-diary study, individuals experienced more anger on days following less sleep than their usual, with half of this effect attributed to the increased frequency of stressors experienced on such days, and somewhat independently from the effect of sleep duration on negative affect more generally. In the experimental study, well-slept individuals adapted to noise and reported less anger and negative affect after 2 days. In contrast, sleep-restricted individuals exhibited higher and increased anger responses. The impact of sleep restriction on anger held even after accounting for negative emotions more generally. Subjective sleepiness accounted for most of the experimental effect of sleep loss on anger. Conclusion Together, these results provide compelling evidence that lost sleep amplifies anger in both the laboratory and everyday life, while also pointing to short-term (subjective sleepiness) and mid-term (stress) mediators of these influences. The findings also point to the value of examining specific emotional reactions (and their regulation) in the context of sleep disruption, alongside affect more broadly. Support N/A

Objectives. We determined the effect of three consecutive days of sub-maximal-intensity mountain biking (4.5 hours per day, ~64 km per day), on the sleep of ten healthy, trained male and female mountain bikers. Methods. The sleep of the mountain bikers was assessed both subjectively (visual analogue scales and sleep questionnaires) and objectively (activity data logger) on each night of mountain biking and for seven nights when they were not cycling (pre-exercise, mean of seven nights). The cyclists’ mood and muscular pain were assessed each night using visual analogue scales. The cyclists slept at home in their normal environment. Results. There was no significant difference between the mountain bikers’ muscular pain and mood (calm/anxious visual analogue scale) measured during the pre-exercise stage and their pain and mood measured on each of the mountain biking nights (p>0.05). However, compared with the pre-exercise stage, the mountain bikers reported that they were significantly more tired (tired/energetic visual analogue scale) on each night of cycling (p<0.01). The sleep of the mountain bikers was disrupted on the night of the third day of mountain biking only. On this night, compared with the pre-exercise stage, the mountain bikers reported that they woke up more during the night (double the number of times) (p<0.001), and an activity data logger recorded that they were awake for about half an hour longer during the night (p<0.05). Conclusion. We have shown that three days of repeated, endurance sub-maximal mountain biking disrupted the sleep of the mountain bikers on the third night of cycling.

Abstract Introduction Chronic insufficient sleep is linked to a variety of adverse health outcomes, with African Americans reporting and objectively receiving poorer sleep outcomes in comparison to their non-Hispanic white counterparts. African Americans live disproportionately in low-income and disordered neighborhoods that increase one’s risk of experiencing a traumatic event and interfere with sleep. It has been demonstrated that posttraumatic stress disorder disrupts sleep in part due to its association with sleep-related fears. However, less research has evaluated the additional contribution of perceived neighborhood stress on the sleep-related fears African Americans experience in their sleep environments. Methods The present study features a nonclinical sample of 163 African American participants (ages 18–35) who reside in DC to investigate whether PTSD severity (Clinician Administered PTSD Scale for DSM-5 Severity Score, CAPS-5) and perceived neighborhood stress (City Stress Index, CSI) are predictive of sleep-related fears (Fear of Sleep Inventory, FoSI). Results After controlling for gender, hierarchical linear regression analyses revealed that PTSD severity and perceptions of the neighborhood environment accounted for approximately 33% of the variance in sleep-related fears (∆R2 = .329, p = .000). Regression coefficients suggest that subjective perceptions of the neighborhood (β = .388) may be a stronger predictor of sleep-related fears than PTSD severity (β = .300) Conclusion Results from this study have implications for future interventions that involve improving coping skills among African Americans in the context of their sleep environments. Support (if any) 5R01HL136626 from the National Heart Lung and Blood Institute

Background Cancer-related fatigue is a serious side effect of cancer, and its treatment can disrupt the quality of life of patients. Clinically, the standard method for assessing cancer-related fatigue relies on subjective experience retrieved from patient self-reports, such as the Brief Fatigue Inventory (BFI). However, most patients do not self-report their fatigue levels. Objective In this study, we aim to develop an objective cancer-related fatigue assessment method to track and monitor fatigue in patients with cancer. Methods In total, 12 patients with lung cancer who were undergoing chemotherapy or targeted therapy were enrolled. We developed frequency-domain parameters of heart rate variability (HRV) and BFI based on a wearable-based HRV measurement system. All patients completed the BFI-Taiwan version questionnaire and wore the device for 7 consecutive days to record HRV parameters such as low frequency (LF), high frequency (HF), and LF-HF ratio (LF-HF). Statistical analysis was used to map the correlation between subjective fatigue and objective data. Results A moderate positive correlation was observed between the average LF-HF ratio and BFI in the sleep phase (ρ=0.86). The mapped BFI score derived by the BFI mapping method could approximate the BFI from the patient self-report. The mean absolute error rate between the subjective and objective BFI scores was 3%. Conclusions LF-HF is highly correlated with the cancer-related fatigue experienced by patients with lung cancer undergoing chemotherapy or targeted therapy. Beyond revealing fatigue levels objectively, continuous HRV recordings through the photoplethysmography watch device and the defined parameters (LF-HF) can define the active phase and sleep phase in patients with lung cancer who undergo chemotherapy or targeted chemotherapy, allowing a deduction of their sleep patterns.

Abstract Introduction Although sleep in patients with Multiple Sclerosis (MS) has been investigated in several studies using subjective measures, objective sleep data collected using polysomnography (PSG) are still scanty and often divergent. We herein present the largest study to date evaluating sleep architecture and total leg movement activity during sleep (LMS) in patients with MS. Methods We collected PSG recordings from 80 patients affected by multiple sclerosis (MS, 48.1±10.61yo 67.5% females), and 60 age and gender matched healthy control subjects (HC, 48.5±17.20 yo, 56% females). Group differences were computed using non-parametric statistics for all traditional sleep architecture parameters, LMS, short-interval (SILMS), periodic (PLMS), isolated LMS (ISOLMS) indices and duration, inter-movement interval (IMI) graphs and time-of-night distribution of LMS. Results Patients with MS showed a significantly decreased total sleep period, an increased number of awakenings and stages shifts per hour of sleep, and an increased representation of stage 1 (min and %) compared to the HC group; 26 (32.5%) MS patients had PLMS ≥15/hour versus 8 (13.3%) HC subjects. On average, the comparison between MS and HC groups yielded significant results in terms of an increase in LMS, PLMS, SILMS and ISOLMS indices but not durations. Moreover, MS patients displayed a higher periodicity index, an increased PLMS activity at all inter-movement intervals considered and their PLMS time-of-night distribution revealed that the PLMS increase was stable over the course of the night. Conclusion Sleep continuity is significantly impaired in patients with MS. Moreover, MS patients also an increased total LMS activity, including PLMS, which may contribute to disrupt sleep continuity. A disinhibition of lower spinal network due to cervical or supraspinal MS lesions might be implicated in the mechanisms underlying this latter finding. Support The Employer Department of Neurology, Regional Hospital Lugano (EOC), Lugano, Switzerland receives financial support from Teva, Merck Serono, Biogen Idec, Bayer Schering, Genzyme, Roche and Novartis. The submitted work is not related to these agreements.

Pencahayaan di perpustakaan merupakan aspek penting dalam menunjang aktivitas mahasiswa dan pegawai. Kondisi pencahayaan yang tidak memenuhi standar dapat mengganggu aktivitas dan menyebabkan keluhan kesehatan khususnya kelelahan mata. Penelitian ini bertujuan mengetahui kesesuaian tingkat pencahayaan di ruang perpustakaan yang ada di lingkungan UI. Penelitian ini menggunakan desain evaluasi dengan membandingkan hasil pengukuran dengan standar serta melakukan analisis terhadap kondisi lingkungan, respons subjektif pengguna, dan keluhan kelelahan mata. Hasil penelitian menunjukkan tingkat kesesuaian pencahayaan di perpustakaan berkisar antara 0% sampai 100%. Sebagian besar pencahayaan mempunyai tingkat kesesuaian antara 30% sampai 60%. Kondisi ini disebabkan oleh distribusi pencahayaan yang kurang baik karena banyak lampu yang mati, intensitas yang rendah, tata letak peralatan yang kurang baik, serta warna ruangan yang agak gelap. Di samping itu, terdapat perpustakaan yang mempunyai pencahayaan yang sangat tinggi sehingga menyebabkan silau, mengganggu aktivitas, dan menyebabkan keluhan kelelahan mata. Kelelahan mata yang umum dirasakan oleh mahasiswa dan pegawai adalah mata selalu terasa mengantuk dan tegang pada daerah leher dan bahu. Umumnya keluhan yang dirasakan selama melakukan aktivitas tersebut mengindikasikan tingkat pencahayaan di perpustakaan harus segera dibenahi agar sesuai dengan standar dan memperkecil risiko kelelahan mata.Lighting the library is an important aspect in supporting both students and employees activity. Lighting conditions that do not meet the standard can disrupt activity and cause eye fatigue. This study aimed to determine the suitability level of lighting in library of UI. This study performed evaluation design by comparing results with standard and an analysis of environmental conditions, subjective response, and eye fatigue. Results showed the level of suitability of lighting in the library ranged from 0% to 100%. Most of the illumination has a level of suitability from 30% to 60%. This condition is caused by poor lighting distribution because some lamps are not lit, low intensity, poor layout of equipment, and slightly darker color of the room. Besides, there are libraries that have a very high lighting causing glare, disturbing activity, and cause eye fatigue. Common eye fatigue felt by students and employees is sleepy eyes and pain in the neck and shoulders. Complaints generally felt during activity. This indicates that the level of lighting in the library must be immediately corrected to meet standard and minimize the risk of eye fatigue.

Abstract Study Objectives Disrupted nighttime sleep (DNS) is a core narcolepsy symptom of unconsolidated sleep resulting from hypocretin neuron loss. In this study, we define a DNS objective measure and evaluate its diagnostic utility for pediatric narcolepsy type 1 (NT1). Methods This was a retrospective, multisite, cross-sectional study of polysomnograms (PSGs) in 316 patients, ages 6–18 years (n = 150 NT1, n = 22 narcolepsy type 2, n = 27 idiopathic hypersomnia, and n = 117 subjectively sleepy subjects). We assessed sleep continuity PSG measures for (1) their associations with subjective and objective daytime sleepiness, daytime sleep onset REM periods (SOREMPs), self-reported disrupted nocturnal sleep and CSF hypocretin levels and (2) their predictive value for NT1 diagnosis. We then combined the best performing DNS measure with nocturnal SOREMP (nSOREMP) to assess the added value to the logistic regression model and the predictive accuracy for NT1 compared with nSOREMP alone. Results The Wake/N1 Index (the number of transitions from any sleep stage to wake or NREM stage 1 normalized by total sleep time) was associated with objective daytime sleepiness, daytime SOREMPs, self-reported disrupted sleep, and CSF hypocretin levels (p’s &lt; 0.003) and held highest area under the receiver operator characteristic curves (AUC) for NT1 diagnosis. When combined with nSOREMP, the DNS index had greater accuracy for diagnosing NT1 (AUC = 0.91 [0.02]) than nSOREMP alone (AUC = 0.84 [0.02], likelihood ratio [LR] test p &lt; 0.0001). Conclusions The Wake/N1 Index is an objective DNS measure that can quantify DNS severity in pediatric NT1. The Wake/N1 Index in combination with or without nSOREMP is a useful sleep biomarker that improves recognition of pediatric NT1 using only the nocturnal PSG.

Abstract Study Objectives Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease due to loss of motor neurons. However, the autonomic nervous system (ANS) can also be involved. The aim of this research was to assess the sleep macro- and microstructure, the cardiac ANS during sleep, and the relationships between sleep, autonomic features, and clinical parameters in a cohort of ALS patients. Methods Forty-two consecutive ALS patients underwent clinical evaluation and full-night video-polysomnography. Only 31 patients met inclusion criteria (absence of comorbidities, intake of cardioactive drugs, or recording artifacts) and were selected for assessment of sleep parameters, including cyclic alternating pattern (CAP) and heart rate variability (HRV). Subjective sleep quality and daytime vigilance were also assessed using specific questionnaires. Results Although sleep was subjectively perceived as satisfactory, compared with age- and sex-matched healthy controls, ALS patients showed significant sleep alteration: decreased total sleep time and sleep efficiency, increased nocturnal awakenings, inverted stage 1 (N1)/stage 3 (N3) ratio, reduced REM sleep, and decreased CAP rate, the latter supported by lower amounts of A phases with an inverted A1/A3 ratio. Moreover, a significant reduction in HRV parameters was observed during all sleep stages, indicative of impaired autonomic oscillations. Conclusion Our results indicate that sleep is significantly disrupted in ALS patients despite its subjective perception. Moreover, electroencephalogram activity and autonomic functions are less reactive, as shown by a decreased CAP rate and a reduction in HRV features, reflecting an unbalanced autonomic modulation.

Abstract Due to the coronavirus disease 2019 (COVID-19) pandemic, populations from many countries have been confined at home for extended periods of time in stressful environmental and media conditions. Cross-sectional studies already evidence deleterious psychological consequences, with poor sleep as a risk factor for impaired mental health. However, limitations of cross-sectional assessments are response bias tendencies and the inability to track daily fluctuations in specific subjective experiences in extended confinement conditions. In a prospective study conducted across three European countries, we queried participants (N = 166) twice a day through an online interface about their sleep quality and their negative psychological experiences for two consecutive weeks. The focus was set on between- and within-person associations of subjective sleep quality with daytime experiences, such as rumination, psychotic-like experiences, and somatic complaints about the typical symptoms of the coronavirus. The results show that daily reports of country-specific COVID-19 deaths predicted increased negative mood, psychotic-like experiences, and somatic complaints during the same day and decreased subjective sleep quality the following night. Disrupted sleep was globally associated with negative psychological outcomes during the study period, and a relatively poorer night of sleep predicted increased rumination, psychotic-like experiences, and somatic complaints the following day. This temporal association was not paralleled by daytime mental complaints predicting relatively poorer sleep quality on the following night. Our findings show that night-to-night changes in sleep quality predict how individuals cope the next day with daily challenges induced by home confinement.

Abstract Study Objectives Sleep disturbance is common among midlife women. Poor self-reported sleep characteristics have been linked to cerebrovascular disease and dementia risk. However, little work has considered the relation of objectively assessed sleep characteristics and white matter hyperintensities (WMHs), a marker of small vessel disease in the brain. Among 122 midlife women, we tested whether women with short or disrupted sleep would have greater WMH, adjusting for cardiovascular disease (CVD) risk factors, estradiol, and physiologically assessed sleep hot flashes. Methods We recruited 122 women (mean age = 58 years) without a history of stroke or dementia who underwent 72 h of actigraphy to quantify sleep, 24 h of physiologic monitoring to quantify hot flashes; magnetic resonance imaging to assess WMH; phlebotomy, questionnaires, and physical measures (blood pressure, height, and weight). Associations between actigraphy-assessed sleep (wake after sleep onset and total sleep time) and WMH were tested in linear regression models. Covariates included demographics, CVD risk factors (blood pressure, lipids, and diabetes), estradiol, mood, and sleep hot flashes. Results Greater actigraphy-assessed waking after sleep onset was associated with more WMH [B(SE) = .008 (.002), p = 0.002], adjusting for demographics, CVD risk factors, and sleep hot flashes. Findings persisted adjusting for estradiol and mood. Neither total sleep time nor subjective sleep quality was related to WMH. Conclusions Greater actigraphy-assessed waking after sleep onset but not subjective sleep was related to greater brain WMH among midlife women. Poor sleep may be associated with brain small vessel disease at midlife, which can increase the risk for brain disorders.

AbstractLockdowns imposed to stem the spread of COVID-19 massively disrupted the daily routines of many worldwide, but studies to date have been mostly confined to observations within a limited number of countries, based on subjective reports and surveys from specific time periods during the pandemic. We investigated associations between lockdown stringency and objective sleep and resting-heart rate measures in ~ 113,000 users of a consumer sleep tracker across 20 countries from Jan to Jul 2020, compared to an equivalent period in 2019. With stricter lockdown measures, midsleep times were universally delayed, particularly on weekdays, while midsleep variability and resting heart rate declined. These shifts (midsleep: + 0.09 to + 0.58 h; midsleep variability: − 0.12 to − 0.26 h; resting heart rate: − 0.35 to − 2.08 bpm) correlated with the severity of lockdown across different countries (all Ps < 0.001) and highlight the graded influence of stringency lockdowns on human physiology.

Abstract Study Objectives To evaluate functional connectivity and topological properties of brain networks, and to investigate the association between brain topological properties and neuropsychiatric behaviors in adolescent narcolepsy. Methods Resting-state functional magnetic resonance imaging (fMRI) and neuropsychological assessment were applied in 26 adolescent narcolepsy patients and 30 healthy controls. fMRI data were analyzed in three ways: group independent component analysis and a graph theoretical method were applied to evaluate topological properties within the whole brain. Lastly, network-based statistics was utilized for group comparisons in region-to-region connectivity. The relationship between topological properties and neuropsychiatric behaviors was analyzed with correlation analyses. Results In addition to sleepiness, depressive symptoms and impulsivity were detected in adolescent narcolepsy. In adolescent narcolepsy, functional connectivity was decreased between regions of the limbic system and the default mode network (DMN), and increased in the visual network. Adolescent narcolepsy patients exhibited disrupted small-world network properties. Regional alterations in the caudate nucleus (CAU) and posterior cingulate gyrus were associated with subjective sleepiness and regional alterations in the CAU and inferior occipital gyrus were associated with impulsiveness. Remodeling within the salience network and the DMN was associated with sleepiness, depressive feelings, and impulsive behaviors in narcolepsy. Conclusions Alterations in brain connectivity and regional topological properties in narcoleptic adolescents were associated with their sleepiness, depressive feelings, and impulsive behaviors.

Background: The longer-term impact of the pandemic on autistic adults' sleep are yet to be revealed, with studies concentrating on sleep in autistic children or mental health outcomes and coping strategies of autistic adults. Given the prevalence of sleep problems experienced by autistic adults and the changes in routine that have occurred as a result of COVID-19 societal restrictions, this study assessed the impact of the COVID-19 pandemic on sleep problems via a longitudinal subjective assessment method.Methods: Sleep data were gathered at three time points from 95 autistic adults, namely prior to the pandemic, at the start of COVID-19 and several months into COVID-19 to obtain a rich longitudinal dataset ascertaining how/if sleep patterns have changed in autistic adults over these several months.Results: In comparison to pre-lockdown, several sleep components were shown to improve during the lockdown. These improvements included reduced sleep latency (time taken to fall asleep), longer sleep duration, improved sleep efficiency, improved sleep quality, as well as improved daytime functioning. Pre-sleep cognitive arousal scores were found to decrease compared to pre-lockdown, meaning cognitive arousal improved. Approximately 65% of participants reported that they felt their sleep had been impacted since COVID-19 since Time 1, with the most common reasons reported as waking up exhausted (36.92%), not being able to get to sleep (33.85%), waking up in the night (29.23%), having a disrupted sleep pattern (27.69%), and nightmares (18.46%).Conclusions: Improvements in sleep may be related to societal changes (e.g., working from home) during the pandemic. Some of these changes are arguably beneficial for autistic adults in creating a more autism-inclusive society, for example telehealth opportunities for care. Further exploration of the associations between mental health and sleep are warranted.

Background: Sleep improvement protocols are recommended for use in the intensive care unit (ICU) despite questions regarding which interventions to include, whether sleep quality or duration will improve, and the role of pharmacists in their development and implementation. Objective: To characterize the impact of a pharmacist-led, ICU sleep improvement protocol on sleep duration and quality as evaluated by a commercially available activity tracker and patient perception. Methods: Critical care pharmacists from a 40-bed, mixed ICU at a large community hospital led the development and implementation of an interprofessional sleep improvement protocol. It included daily pharmacist medication review to reduce use of medications known to disrupt sleep or increase delirium and guideline-based recommendations on both environmental and nonpharmacological sleep-focused interventions. Sleep duration and quality were compared before (December 2018 to December 2019) and after (January to June 2019) protocol implementation in non–mechanically ventilated adults using both objective (total nocturnal sleep time [TST] measured by an activity tracker (Fitbit Charge 2) and subjective (patient-perceived sleep quality using the Richards-Campbell Sleep Questionnaire [RCSQ]) measures. Results: Groups before (n = 48) and after (n = 29) sleep protocol implementation were well matched. After protocol implementation, patients had a longer TST (389 ± 123 vs 310 ± 147 minutes; P = 0.02) and better RCSQ-perceived sleep quality (63 ± 18 vs 42 ± 24 mm; P = 0.0003) compared with before implementation. Conclusion and Relevance: A sleep protocol that incorporated novel elements led to objective and subjective improvements in ICU sleep duration and quality. Application of this study may result in increased utilization of sleep protocols and pharmacist involvement.

Abstract Purpose Avoiding supine position can reduce snoring in most habitual snorers. However, devices that restrict the sleeping position cause discomfort or disrupt sleep resulting in low compliance. Therefore, mechanisms, which lift the trunk of the user without disturbing sleep, have been proposed. We present the first study, which investigates whether individual interventions provided by beds with lifting mechanisms are able to stop snoring (success rate) and whether they reduce the snoring index (number of total snores divided by total time in bed) using a repeated measures design. In addition, we investigated whether the intervention is interfering with the subjective sleep quality. Methods Twenty-two subjects were observed for four nights (adaptation, baseline, and two intervention nights). During intervention nights, the bed lifted the trunk of the user in closed-loop manner. Subjects were divided in three groups (non-snorer, snorer one, and snorer two). Non-snorers were lifted by the bed at random time points during the night. In group snorer one, a stepwise increase of the bed inclination was compared with going directly to a randomly selected angle. In group snorer two, the influence of a small inclination angle (10 ∘) and a big inclination angle (20 ∘) was compared. Results Snoring was stopped successfully in 22% (small angle) and 67% (big angle) of the interventions. This did not lead to a significant reduction in the snoring index. The subjective sleep quality was not reduced by the intervention. Conclusion The anti-snoring bed is able to stop individual episodes of habitual snoring without reducing the subjective sleep quality. Trial Registration https://clinicaltrials.gov, no. NCT04053738, registered 12 August 2019 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04053738.

Human adaptation to extreme environments has been explored for over a century to understand human psychology, integrated physiology, comparative pathologies, and exploratory potential. It has been demonstrated that these environments can provide multiple external stimuli and stressors, which are sufficient to disrupt internal homeostasis and induce adaptation processes. Multiday hyperbaric and/or saturated (HBS) environments represent the most understudied of environmental extremes due to inherent experimental, analytical, technical, temporal, and safety limitations. National Aeronautic Space Agency (NASA) Extreme Environment Mission Operation (NEEMO) is a space-flight analog mission conducted within Florida International University’s Aquarius Undersea Research Laboratory (AURL), the only existing operational and habitable undersea saturated environment. To investigate human objective and subjective adaptations to multiday HBS, we evaluated aquanauts living at saturation for 9–10 days via NASA NEEMO 22 and 23, across psychologic, cardiac, respiratory, autonomic, thermic, hemodynamic, sleep, and body composition parameters. We found that aquanauts exposed to saturation over 9–10 days experienced intrapersonal physical and mental burden, sustained good mood and work satisfaction, decreased heart and respiratory rates, increased parasympathetic and reduced sympathetic modulation, lower cerebral blood flow velocity, intact cerebral autoregulation and maintenance of baroreflex functionality, as well as losses in systemic bodyweight and adipose tissue. Together, these findings illustrate novel insights into human adaptation across multiple body systems in response to multiday hyperbaric saturation.

When characters in the Fox Television sitcom The Mindy Project call Mindy Lahiri fat, Mindy sees it as a case of misidentification. She reminds the character that she is a “petite Asian woman,” that she has large, beautiful breasts, that she has nothing in common with fat people, and the terms “chubbster” and “BBW – Big Beautiful Woman” are offensive and do not apply to her. Mindy spends some of each episode on her love for food and more food, and her hatred of fitness regimes, while repeatedly falling for meticulously fit men. She dates, has a string of failed relationships, adventurous sexual techniques, a Bridget Jones-scale search for perfect love, and yet admits to shame in showing her naked body to lovers. Her contradictory feelings about food and body image mirror our own confusions, and reveal the fear and fascination we feel for fat in our fat-obsessed culture. I argue that by creating herself as sexy, successful, popular, sporadically confident and insecure, Mindy works against stigmas that attach both to big women – women who are considered big in comparison to the societal size-zero ideal – and women who have historically been seen as belonging to “primitive” or colonized cultures, and therefore she disrupts the conflation of thinness to civilization. In this article, I look at the performance of fat and ethnic identity on American television, and examine the bodily mechanisms through which Mindy disrupts these. I argue that Mindy uses issues of fat and body image to disrupt stereotypical iterations of race. In the first part of the paper, I look at the construction of South Asian femininity in American pop culture, to set up the discussion of fat, gender and race as interrelated performative categories. Race, Gender, Performativity As Judith Butler says of gender, “performativity must be understood not as a singular or deliberate ‘act,’ but, rather as the reiterative and citational practice by which discourse produces the effects that it names” (Bodies, 2). Bodies produce and perform their gender through repeating and imitating norms of clothing, body movement, choices in gesture, action, mannerism, as well as gender roles. They do so in such a way that the discourses and histories that are embedded in them start to seem natural; they are seen to be the truth, instead of as actions that have a history. These choices do not just reflect or reveal gender, but rather produce and create it. Nadine Ehlers takes performativity into the realm of race. Ehlers says that “racial performativity always works within and through the modalities of gender and sexuality, and vice versa, and these categories are constituted through one another” (65). In this sense, neither race nor gender are produced or iterated without also producing their interrelationship. They are in fact produced through this interrelationship. So, for example, when studying the performativity of black bodies, you would need to specify whether you are looking at black femininity or masculinity. And on the other hand, when studying gender, it is important to specify gender where? And when? You couldn’t simply pry open the link between race and gender and expect to successfully theorize either on its own. Mindy’s performance of femininity, including her questions about body image and weight, her attractive though odd clothing choices, her search for love, these are all bound to her iteration of race. She often explains her body through defining herself as Asian. Yet, I suggest in a seeming contradiction that her othering of herself as a big woman (relative to normative body size for women in American film and television) who breaks chairs when she sits on them and is insecure about her body, keeps the audience from othering her because of race. Her weight, clumsiness, failures in love, her heartbreaks all make her a “normal” woman. They make her easy to identify with. They suggest that she is just a woman, an American woman, instead of othering her as a South Asian woman, or a woman from a “primitive”, colonized or minority culture.Being South Asian on American Television Mindy Lahiri (played by writer, producer and actor Mindy Kaling) is a successful American obstetrician/gynaecologist, who works in a successful practice in New York. She breaks stereotypes of South Asian women that are repeated in American television and film. Opposite to the stereotype of the traditional, dutiful South Asian who agrees to an arranged marriage, and has little to say for him or herself beyond academic achievement that is generally seen in American and British media, Mindy sleeps with as many men as she can possibly fit into a calendar year, is funny, self-deprecating, and has little interest in religion, tradition or family, and is obsessed with popular culture. The stereotypical characteristics of South Asians in the popular British media, listed by Anne Ciecko (69), include passive, law-abiding, following traditional gender roles and traditions, living in the “pathologized” Asian family, struggling to find self-definitions that incorporate their placement as both belonging to and separate from British culture. Similarly, South Asian actors on American television often play vaguely-comic doctors and lawyers, seemingly with no personal life or sexual desire. They are simply South Asians, with no further defining personality traits or quirks. It is as if being South Asian overrides any other character trait. They are rarely in lead roles, and Mindy is certainly the first South Asian-American woman to have her own sitcom, in which she plays the lead. What do South Asians on American television look and sound like? In her study on performativity of race and gender, Ehlers looks at various constructions of black femininity, and suggests that black femininity is often constructed in the media in terms of promiscuity and aggression (83), and, I would add, the image of the mama with the big heart and even bigger bosom. Contrary to black femininity, South Asian femininity in American media is often repressed, serious, concerned with work and achievement or alternatively with menial roles, with little in terms of a personal or sexual life. As Shilpa S. Dave says in her book on South Asians in American television, most South Asians that appear in American television are shown as immigrants with accents (8). That is what makes them recognizably different and other, more so even than any visual identification. It is much more common to see immigrants of Chinese or Korean descent in American television as people with American accents, as people who are not first generation immigrants. South Asians, on the other hand, almost always have South Asian accents. There are exceptions to this rule, however, the exceptions are othered and/or made more mainstream using various mechanisms. Neela in ER (played by Parminder Nagra) and Cece in New Girl (played by Hannah Simone) are examples of this. In both instances the characters are part of either an ensemble cast, or in a supporting role. Neela is a step removed from American and South Asian femininity, in that she is British, with a British accent – she is othered, but this othering makes her more mainstream than the marking that takes place with a South Asian accent. The British accent and a tragic marriage, I would say, allow her to have a personal and sexual life, beyond work. Cece goes through an arranged marriage scenario, full with saris and a South Asian wedding that is the more recognized and acceptable narrative for South Asian women in American media. The characters are made more acceptable and recognizable through these mechanisms. Bhoomi K. Thakore, in an article on the representation of South Asians in American television, briefly explains that after the 1965 Immigration and Nationality act, highly-educated South Asians could immigrate to the United States, either to get further education, or as highly skilled workers (149) – a phenomenon often called “brain-drain.” In addition, says Thakore, family members of these educated South Asians immigrated to the States as well, and these were people that were less educated and worked often in convenience stores and motels. Thakore suggests that immigrants to the United States experience a segmented assimilation, meaning that not all immigrants (first and second generation) will assimilate to the same extent or in the same way. I would say from my own experience that the degree to which immigrants can assimilate into American society often depends on not only financial prospects or education, but also attractiveness, skin tone, accent, English-speaking ability, interests and knowledge of American popular culture, interest in an American way of life and American social customs, and so on. Until recently, I would say that South Asian characters in American television shows have tended to represent either first-generation immigrants with South Asian accents and an inability or lack of desire to assimilate fully into American society, or second-generation immigrants whose personal and sexual lives are never part of the narrative. Examples of the former include South Asians who play nameless doctors and cops in American television. Kal Penn’s character Lawrence Kutner in the television series House is an example of the latter. Kutner, one of the doctors on Dr. House’s team, did not have a South Asian accent. However, he also had no personal narrative. All doctors on House came with their relationship troubles and baggage, their emotional turmoil, their sexual and romantic ups and downs – all but Kutner, whose suicide in the show (when he left it to join the Obama administration) is framed around the question – do we ever really know the people we see every day? Yet, we do know the other doctors on House. But we never know anything about Kutner’s private life. His character is all about academic knowledge and career achievement. This is the stereotype of the South Asian character in American television. Yet, Mindy, with her American accent, sees herself as American, doesn’t obsess about race or skin colour, and has no signs of a poor-me narrative in the way she presents herself. She does not seem to have any diasporic longings or group belongings. Mindy doesn’t ignore race on the show. In fact, she deploys it strategically. She describes herself as Asian on more than one occasion, often to explain her size, her breasts and femininity, and in one episode she goes to a party because she expects to see black sportsmen there, and she explains, “It’s a scientific fact that black men love South Asian girls.” Her production of her femininity is inextricably bound up with race. However, Mindy avoids marking herself as a racial minority by making her quest for love and her confusions about body image something all women can identify with. But she goes further in that she does not place herself in a diaspora community, she does not speak in a South Asian accent, she doesn’t hide her personal life or the contours of her body, and she doesn’t harp on parents who want her to get married. By not using the usual stereotypes of South Asians and Asians on American television, while at the same time acknowledging race, I suggest that she makes herself a citizen of the alleged “melting pot” as the melting pot should be, a hybrid space for hybrid identities. Mindy constructs herself as an American woman, and suggests that being a racial minority is simply part of the experience of being American. I am not suggesting that this reflects the reality of experience for many women in the USA who belong to ethnic minorities. I am suggesting that Mindy is creating a possible or potential reality, in which neither size nor being a racial minority are causes for shame. In a scene in the second season, a police officer chastises Mindy for prescribing birth control to his young daughter. He charges out of her office, and she follows him in to the street. She is wearing a version of her usual gear – a check-pinafore, belted over a printed shirt – her shoulders curved forward, arms folded, in the characteristic posture of the big-breasted, curvy woman. She screams at the officer for his outdated views on birth-control. He questions if she even has kids, suggesting that she knows nothing about raising them. She says, “How dare you? Do I look like a woman who’s had kids? I have the hips of an eleven-year-old boy.” She then informs him that she wolfed down a steak sandwich at lunch, has misgivings about the outfit she is wearing, and says that she is not a sex-crazed lunatic. He charges her for public female hysteria. She screams after him as he drives off, “Everyone see this!” She holds up the citation. “It’s for walking, while being a person of colour.” She manages in the space of a two-minute clip to deploy race, size and femininity, without shame or apology, and with humour. It is interesting to note that, contrary to her persona on the show, in interviews in the media, Kaling suggests that she is not that concerned with the question of weight. She says that though she would like to lose fifteen pounds, she is not hung up on this quest. On the other hand, she suggests that she considers herself a role model for minority women. In fact, in real life she makes the question of race as something more important to her than weight – which is opposite to the way she treats the two issues in her television show. I suggest that in real life, Kaling projects herself as a feminist, as someone not so concerned about size and weight, an intelligent woman who is concerned about race. On the show, however, she plays an everywoman, for whom weight is a much bigger deal than race. Neither persona is necessarily real or assumed – rather, they both reveal the complexities by which race, gender and body size constitute each other, and become cruxes for identification and misidentification. Is It Civilized to Be Fat? When Mindy and her colleague Danny Castellano get together in the second season of the show, you find yourself wondering how on earth they are going to sustain this sitcom, without an on-again/off-again romance, or one that takes about five years to start. When Danny does not want to go public with the relationship, Mindy asks him if he is ashamed of her. Imagine one of the Friends or Sex in the City women asking this question to see just how astonishing it is for a successful, attractive woman to ask a man if he is ashamed to be seen with her. She doesn’t say is it because of my weight, yet the question hangs in the air. When Danny does break up with her, again Mindy feels all the self-disgust of a woman rejected for no clear reason. As Amy Erdman Farrell suggests in her book on fat in American culture and television, fat people are not expected to find love or success. They are expected to be self-deprecating. They are supposed to expect rejection and failure. She says that not only do fat people bear a physical but also a character stigma, in that not only are they considered visually unappealing, but this comes with the idea that they have uncontrolled desires and urges (7-10). Kaling suggests through her cleverly-woven writing that it is because of her body image that Mindy feels self-loathing when Danny breaks up with her. She manages again to make her character an everywoman. Not a fat South Asian woman, but simply an American woman who feels all the shame that seems to go with weight and body image in American culture. However, this assumed connection of fat with immorality and laziness goes a step further. Farrell goes on to say that fat denigration and ethnic discrimination are linked, that popularity and the right to belong and be a citizen are based both on body size and ethnicity. Says Farrell, “our culture assigns many meanings to fatness beyond the actual physical trait – that a person is gluttonous, or filling a deeply disturbed psychological need, or is irresponsible and unable to control primitive urges” (6) – psychological traits that have historically been used to describe people in colonized cultures. Farrell provides an intriguing analysis of Oprah Winfrey and her public ups and downs with weight. She suggests that Winfrey’s public obsession with her own weight, and her struggles with it, are an attempt to be an “everywoman”, to be someone all and not only black women can identify with. Says Farrell, “in order to deracinate herself, to prove that ‘anyone’ can make it, Winfrey must lose weight. Otherwise, the weight of all that fat will always, de facto, mark her as a ‘black woman’, with all the accompanying connotations of inferior, primitive, bodily and out of control” (126). She goes on to say that, “Since the end of the 19th century, fatness has … served as a potent signifier of the line between the primitive and the civilized, feminine and masculine, ethnicity and whiteness, poverty and wealth, homosexuality and heterosexuality, past and future” (126). This suggests that Winfrey’s public confrontations with the question of weight help the women in the audience identify with her as a woman, rather than as a black woman. In a volume on fat studies, Farrell explains that health professionals have further demarcated lines between “civilization and primitive cultures, whiteness and blackness, sexual restraint and sexual promiscuity, beauty and ugliness, progress and the past” (260). She suggests that fat is not just part of discourses on health and beauty, but also intelligence, enterprise, work ethics, as well as race, ethnicity, sexuality and class. These connections are of course repeated in media representations, across media genres and platforms. In women’s magazines, an imperative towards weightloss comes hand-in-hand with the search for love, a woman’s ability to satisfy a man’s as well as her own desires, and with success in glamorous jobs. Sitcom couples on American television often feature men who are ineffectual but funny slobs, married to determined, fit women who are mainly homemakers, and in fact, responsible for the proper functioning of the family, and consequentially, society. In general, bigger women in American and British media are on a quest both for love and weight loss, and the implication is that deep-seated insecurities are connected to both weight gain, as well as failures in love, and that only a resolution of these insecurities will lead to weight loss, which will further lead to success in love. Films such as My Big Fat Greek Wedding and Bridget Jones’s Diary are examples of this prevailing narrative. Thakore investigates the changing image of South Asians on American television, suggesting that South Asians are represented more and more frequently, and in increasingly more central roles. However, Thakore suggests that, “all women of colour deal with hegemonic skin tone ideologies in their racial/ethnic communities, with lighter skin tone and Caucasian facial features considered more appealing and attractive … . As media producers favour casting women who are attractive, so too do the same media producers favour casting women of colour who are attractive in terms of their proximity to White physical characteristics” (153). Similarly, Lee and Vaught suggest that in American popular culture, “both White women and women of colour are represented as reflecting a White ideal or aesthetic. These women conform to a body ideal that reflects White middle class ideals: exceedingly thin, long, flowing hair, and voluptuous” (458). She goes on to say that Asian American women would need to take on a White middle class standing and a simultaneous White notion of the exotic in order to assimilate. For Mindy, then, fat allows her to be an everywoman, but also allows her to adopt her own otherness as a South Asian, and make it her own. This trend shows some signs of changing, however, and I expect that women like Lena Dunham in the HBO comedy Girls and Mindy Kaling are leading the march towards productions of diverse femininities that are at the same time iterated as attractive and desirable. On The Hollywood Reporter, when asked about the more ludicrous questions or comments she faces on social media, Kaling puts on a male voice and says, “You’re ugly and fat, it’s so refreshing to watch!” and “We’re used to skinny people, and you’re so ugly, we love it!” On David Letterman, she mentions having dark skin, and says that lazy beach holidays don’t work for her because she doesn’t understand the trend for tanning, and she can’t really relax. Mindy’s confusions about her weight and body image make her a woman for everyone – not just for South Asian women. Whereas Kaling’s concern over the question of race – and her relative lack of concern over weight – make her a feminist, a professional writer, a woman with a conscience. These personas interweave. They question both normative performances of gender and race, and question the historical conflation of size and minority identity with shame and immorality. Butler suggests that gender is “the repeated stylisation of the body” (Gender, 33). She argues that gender roles can be challenged through a “subversive reiteration” of gender (Gender, 32). In this way, women like Dunham and Kaling, through their deployment of diverse female bodies and femininities, can disrupt the normative iteration of gender and race. Their production of femininity in bodies that are attractive (just not normatively so) has more than just an impact on how we look at fat. They bring to us women that are flawed, assertive, insecure, confident, contradictory, talented, creative, that make difficult choices in love and work, and that don’t make an obsession with weight or even race their markers of self worth.References Bridget Jones’s Diary. Dir. Sharon Maguire. Miramax and Universal Pictures, 2001. Butler, Judith. Gender Trouble. London: Routledge, 1990. Butler, Judith. Bodies That Matter: On the Discursive Limits of Sex. London: Routledge, 1993. Ciecko, Anne. “Representing the Spaces of Diaspora in Contemporary British Films by Women Directors.” Cinema Journal 38.3 (Spring 1999): 67-90. Dave, Shilpa S. Indian Accents: Brown Voice and Racial Performance in American Television. U of Illinois, 2013. Ehlers, Nadine. Racial Imperatives: Discipline, Performativity, and Struggles against Subjection. Bloomington: Indiana University Press, 2012. ER. Warner Bros. Television. NBC, 1994-2009. Farrell, Amy. “‘The White Man’s Burden’”: Female Sexuality, Tourist Postcards, and the Place of the Fat Woman in Early 20th-Century U.S. Culture.” In Esther Rothblum and Sondra Solovay (eds.), The Fat Studies Reader. New York: New York University Press, 2009. Farrell, Amy Erdman. Fat Shame: Stigma and the Fat Body in American Culture. New York: New York University Press, 2011. Friends. Warner Bros. Television. NBC, 1994-2004. Girls. HBO Entertainment and Apatow Productions. HBO, 2012-present. House. Universal Television. Fox, 2004-2012. Lee, Stacey J., and Sabina Vaught. “‘You Can Never Be Too Rich or Too Thin’: Popular and Consumer Culture and the Americanization of Asian American Girls and Young Women.” The Journal of Negro Education 72.4 (2003): 457-466. My Big Fat Greek Wedding. Dir. Joel Zwick. Playtone, 2002. New Girl. 20th Century Fox. Fox, 2011-present. Nicholson, Rebecca. “Mindy Kaling: ‘I Wasn’t Considered Attractive or Funny Enough to Play Myself.’” The Observer 1 June 2014. ‹http://www.theguardian.com/tv-and-radio/2014/jun/01/mindy-kaling-project›. Sex in the City. Warner Bros. Television and HBO Original Programming. HBO, 1998-2004. Strauss, Elissa. “Why Mindy Kaling – Not Lena Dunham – Is the Body Positive Icon of the Moment.” The Week 22 April 2014. ‹http://theweek.com/article/index/260126/why-mindy-kaling-mdash-not-lena-dunham-mdash-is-the-body-positive-icon-of-the-moment›. Thakore, Bhoomi K. “Must-See TV: South Asian Characterizations in American Popular Media.” Sociology Compass 8.2 (2014): 149-156. The Mindy Project. Universal Television, 3 Arts Entertainment, Kaling International. Fox, 2012-present. Ugly Betty. ABC Studios. ABC, 2006-2010. YouTube. “Mindy Kaling on David Letterman.” 29 April 2013. 21 Oct. 2014 ‹http://www.youtube.com/watch?v=z8K1ye2gnJw›. YouTube. “Mindy on Being Called Fat and Ugly on Social Media.” The Hollywood Reporter 14 June 2014. 21 Oct. 2014 ‹http://www.youtube.com/watch?v=Ockt-BeMOWk›. YouTube. “Chris Messina: ‘I Think Mindy Kaling’s Beautiful.’” HuffPost Live 24 April 2014. 21 Oct. 2014 ‹http://www.youtube.com/watch?v=3HtCjGNERKQ›.

In the years surrounding the turn of the millennium, there emerged an assemblage of American and Spanish horror films fixated on uncanny child characters. Caught in the symbolic abyss between death and life, these figures are central to the films’ building of suspense and Gothic frisson—they are at once familiar and unfamiliar, vulnerable and threatening, innocent yet unnervingly inscrutable. Despite being conceived and produced in two very different cultural climates, these films construct the child as an embodiment of trauma in parallel ways. In turn, these Gothic children express the wavering of narratives of progress which suffused the liminal moment of the millennial turn. Steven Bruhm suggests that there is “a startling emphasis on children as the bearers of death” (author’s emphasis 98) in popular Gothic fiction at the turn of the new millennium, and that this contemporary Gothic “has a particular emotive force for us because it brings into high relief exactly what the child knows ... Invariably, the Gothic child knows too much, and that knowledge makes us more than a little nervous” (103). A comparative analysis of trans-millennial American and Spanish supernatural horror films reveals the specifically threatening register of the Gothic child’s knowledge, and that the gradual revelation of this knowledge aestheticizes the mechanics of trauma. This “traumatic” aesthetic also entails a disruption to linear progress, exposing the ways in which Gothic representations of the child’s uncanny knowledge express anxieties about the collapse of temporal progress. The eeriness associated with the child’s knowledge is thus tied to a temporal disjuncture; as Margarita Georgieva explains, child-centred Gothic fiction meditates on the fact that “childhood is quickly lost, never regained and, therefore, outside of the tangible adult world” (191). American films such as The Sixth Sense (M. Night Shyamalan, 1999) and Stir of Echoes (David Koepp, 1999), and Spanish films The Nameless (Jaume Balagueró, 1999) and The Devil’s Backbone (Guillermo del Toro, 2001), and also American-Spanish co-productions such as The Others (Alejandro Amenábar, 2001) and Fragile (Jaume Balagueró, 2005), expose the tangle of contradictions which lurk beneath romanticised definitions of childhood innocence and nostalgia for an adult’s “lost” childhood. The child characters in these films tend to be either ghosts or in-between figures, seemingly alive yet acting as mediators between the realms of the living and the dead, the past and the present. Through this liminal position, these children wreak havoc on the symbolic coherence of the films’ diegetic worlds. In so doing, they incarnate the ontological wound described by Cathy Caruth in her definition of trauma: “a breach in the mind’s experience of time, self, and the world” caused by an event that “is experienced too soon, too unexpectedly, to be fully known and is therefore not available to consciousness until it imposes itself ... repeatedly ... in the nightmares and repetitive actions” (4) of those who have experienced trauma. The Gothic aesthetic of these children expresses the ways in which trauma is locatable not in the original traumatic past event, but rather in “the way it was precisely not known in the first instance”, through revealing that it is trauma’s unassimilated element which “returns to haunt the survivor later on” (Caruth, author’s emphasis 4). The uncanny frisson in these films arises through the gradual exposition of the child character’s knowledge of this unassimilated element. As a result, these children trouble secure processes of symbolic functioning, embodying Anne Williams’ suggestion that “Gothic conventions imply a fascination with … possible fissures in the system of the symbolic as a whole” (141). I suggest that, reflecting Bruhm’s assertion above, these children are eerie because they have access to memories and knowledge as yet unassimilated within the realm of adult understanding, which is expressed in these films through the Gothic resurfacing of past traumas. Through an analysis of two of the most transnationally successful and influential films to emerge from this trend—The Sixth Sense (1999) and The Devil’s Backbone (2001)—this article explores the intersecting but tellingly distinctive ways in which the American and Spanish horror films figure the child as a vessel for previously repressed trauma. In both films, the eeriness of the children, Cole and Santi respectively, is associated with their temporal liminality and subsequent ability to invoke grisly secrets of the past, which in turn unsettles solid conceptions of identity. In The Sixth Sense, as in other American ghost films of this period, it is an adult character’s subjectivity which is untethered by the traumas of the uncanny child; Bruhm suggests that the contemporary Gothic “attacks adult self-identity on multiple fronts” (107), and in American films the uncanny child tends to launch this traumatic assault from within an adult character’s own psyche. Yet in the Spanish films, the Gothic child tends not to threaten an individual adult figure’s self-identity, instead constituting a challenge to secure concepts of socio-cultural identity. In The Sixth Sense, Cole raises a formerly repressed trauma in the mind of central adult character Malcolm Crowe, while simultaneously disturbing the viewer’s secure grasp on the film’s narrative world. Ultimately, Cole raises Freudian-inflected anxieties surrounding childhood’s disruption to coherent adult subjectivity, functioning as a receptacle for the adult’s repressed secrets. Cole’s gradual exposure of these secrets simulates the effects of trauma for both Malcolm and the viewer via a Gothic unsettling of meaning. While The Sixth Sense is set in the present, The Devil’s Backbone is set during the Spanish Civil War (1936-39)—a violent and traumatic period of Spain’s history, the ramifications of which have been largely unexplored in Spanish popular culture until very recently as a result of forty years of strict censorship under General Franco, whose dictatorship eroded following his death in 1975. Unlike Cole, Santi does not arouse a previously submerged trauma within an adult character’s mind, instead serving to allegorically raise socio-cultural trauma. Santi functions as an incarnation of Gilles Deleuze’s “child seer”, a figure who Deleuze claims first emerged in Italian neo-realist films of the 1940s as a response to the massive cultural rupture of World War II (3). The child seer is characterised by his entrapment in the gap between the perception of a traumatic event, and the understanding and subsequent action required to move on from it. Thus, upon experiencing a disturbing event, he suffers a breach in comprehension which disrupts the typical sensory-motor chain of perception-understanding-action, rendering him physically and mentally unable to escape his situation. Yet in experiencing this incapacity, the seer gains a powerful insight beyond the limits of linear temporality. On becoming a ghost, Santi escapes coherent space-time, and invokes the repressed spectre of Spain’s violent Civil War past, inciting an eerie collision of past and present. This temporal disruption has deep allegorical implications for contemporary Spain through the child’s symbolic status as vessel for the future. Santi’s embodiment of cultural trauma ensures that Spain’s past, as constructed by the film, eerily folds into the nation’s extra-diegetic present. The Sixth Sense In The Sixth Sense, adult protagonist Malcolm Crowe is a child psychiatrist, thus unravelling the riddles of the child’s psyche is positioned as the central quest of the film’s narrative. The dramatic twist in the film’s final scene reveals that the analysis of the child Cole’s “phobia” has in fact exhumed dormant spectres within Malcolm’s own mind, exposing the Gothic mechanisms whereby the uncanny child becomes conflated with the adult’s repressed trauma. This impression is heightened by the narrative structure of The Sixth Sense, in which the twist in the final scene shifts the meaning of all that has happened before. Both the audience and Malcolm are led to assume that they have uncovered and come to terms with Cole’s secret once it becomes clear two-thirds into the film that he “sees dead people”. However, the climactic twist exposes that Cole has in fact been hiding another secret which is not so easily ameliorated: that Malcolm is one of these dead people, having died in the film’s opening sequence. If the film’s narrative “pulling the rug out” from under the audience functions as intended, at the climax of the film both Malcolm and viewer simultaneously become privy to a layer of Cole’s secret previously inaccessible to us, both that Malcolm has been dead all along and that, subsequently, the hidden quest underlying the surface narrative has been Malcolm’s journey to come to terms with this disturbing truth. Thus, the uncanny child functions as a symbolic stage for the adult protagonist’s unassimilated trauma, and the unsettling nature of this experience is extended to the viewer via the gradual exposure of Cole’s secret. Further intensifying the uncanny effects of this Gothic disruption to adult knowledge, Cole also functions like a reincarnation of the crisis which has undermined Malcolm’s coherent identity as a successful child psychiatrist: his failure to cure former patient Vincent. Thus, Cole is like uncanny déjà vu for Malcolm and the viewer, an almost literal re-evocation of Malcolm’s past trauma. Both Vincent and Cole have a patch of grey hair at the back of their head, symbolising their access to knowledge too great for their youth, and as Malcolm explains, “They’re both so similar. Same mannerisms, same expressions, same things hanging over their heads.” At the opening of the film, Vincent is depicted as a wretched madman. He appears crying and half naked in Malcolm’s bathroom, having broken into his house, before shooting Malcolm and then turning the gun on himself. Thus, Vincent is an abject image of Malcolm’s failure, and his taunting words expose a rupture in Malcolm’s paternalistic, professional identity by hinting at his lack of awareness. “You don’t know so many things” Vincent remarks, and sarcastically undermines Malcolm’s “saviour” status by taunting, “Don’t you know me, hero?”. Functioning as a repetition of this trauma, Cole provides Malcolm with an opportunity to discover the “so many things” that he does not know, and also to once again become a “hero”. Cole functions as a literalisation of Malcolm’s compulsion to repeat the trauma which has exposed a breach in his sense of self, and to gain mastery over it. On first viewing, the audience is led to believe that this narrative is the primary one in the film, and that the film is wrapped up when Malcolm finally achieves his goal and becomes Cole’s hero. However, the final revelation that Cole has been keeping yet another secret from Malcolm—that Malcolm has been dead all along—reveals that this trauma is actually irrevocable: Malcolm was in fact killed by Vincent at the beginning of the film, thus the adult’s subjective breach (symbolised by his gunshot wound, which he suddenly notices for the first time) cannot be filled or repaired. All Malcolm can do at the close of the film is disappear, as a close-up of his face fades into the mediated image of him, now his only form of existence in the world as we know it, on the home videotapes of his wedding which play as his wife sleeps. Thus, Cole evokes the experience of a violent, unassimilated trauma which is experienced “too soon, too unexpectedly to be fully known in the first instance” (Caruth 4), a breach in subjectivity which has only become consciously known to Malcolm through the “nightmare repetition” figured by Cole. This experience of a traumatic disruption to the wholeness and coherence of subjective reality is echoed by the viewer’s own experience of The Sixth Sense, if the twist-narrative functions as intended. While on first viewing we are led to believe that we are watching a straightforward ghost story about a paternalistic psychologist helping a young child with an uncanny gift, we learn in the final scene that there has been an underlying double reality haunting the surface narrative all along. Central to this twist is the recognition that Cole was always aware of this second reality, but has been concealing it from Malcolm—underscoring the ways in which Malcolm’s trauma is bound up largely with what he was unable to comprehend and assimilate when the traumatic event of his death first occurred. The eerie effects of Malcolm’s traumatic confrontation with the child’s Gothic knowledge is extended to the viewer via the film’s narrative structure. Erlend Lavik discusses The Sixth Sense and other twist films in terms of a particular relationship between the syuzhet (the way in which a story’s components are organized) and the fabula (the raw components which constitute the story). He explains that in such films, there is a “doubling of the syuzhet, where we are led to construct a fabula that initially seems quite straightforward until suddenly a new piece of information is introduced that subverts (or decentres) the fictional world we have created. We come to realize the presence of another fabula running parallel to the first one but ‘beneath’ it, hidden from view” (Lavik 56). The revelation that Malcolm has been a ghost all along shatters the fabula that most viewers construct upon first viewing the film. The impression that an eerie, previously hidden double of accepted reality has bubbled to the surface of our perceptions is deeply uncanny, evoking the experience of filmic déjà vu. This is of course heightened by the fact that the viewer is compelled to re-watch the film in order to construct the second, and more “correct”, fabula. In doing so, the viewer experiences a “narrative bifurcation whereby we come to notice how traces of the correct fabula were actually available to us the first time” (Lavik 59). The process of re-watching the film in an attempt to solve the riddles of Malcolm’s existence reveals the viewer’s compulsion to undergo their own “detective work” in a parallel of Malcolm’s analysis of Cole: the exposure of the child’s secret turns a mirror upon the protagonist and audience which exposes a fracture in the adult’s subjectivity. Discussing the detective story, Slavoj Žižek explains that “the detective's role is ... to demonstrate how ‘the impossible is possible’ ... that is, to resymbolize the traumatic shock, to integrate it into symbolic reality” (58). On first viewing, this detective work is realized through Malcolm’s quest to comprehend Cole’s secrets, and then to situate the abject ghosts the child sees into a secure framework whereby they disappear if Cole helps them. The compulsion to re-watch the film in order to better understand how Malcolm experiences time, consciousness and communication (or lack there-of) represents an analogous attempt to re-integrate the traumatic shock raised by the twist-ending by imposing more secure symbolic frameworks upon the film’s diegetic world: to suture the traumatic breach in meaning. However, there are many irremediable gaps in Malcolm’s experiences—we do not actually see him trying to pay for the bus, or meeting Cole’s mother for the first time, or pondering the fact that no other human being has spoken to him directly for six months apart from Cole—fissures which repeat viewings cannot repair. The Devil’s Backbone The Devil’s Backbone is set in the final years of the Civil War, a liminal period in which the advancement of Spain’s national narrative is disturbingly uncertain. The film takes place in an orphanage for young boys from Republican families whose parents have been killed or captured in the Civil War. In the middle of the orphanage’s courtyard stands an unexploded bomb, an ominous and volatile reminder of the war. As well as being haunted by this unexploded bomb, the orphanage is also haunted by a child ghost, Santi, a former inhabitant of the orphanage who disappeared on the same night that the bomb landed in the orphanage’s grounds. We learn mid-way through the film that Santi in fact drowned in the orphanage’s cavernous cistern: after being struck on the head by the angry groundskeeper, Santi was left unable to swim, and is shown sinking helplessly into the water’s murky depths. Thus, Santi’s death represents the ultimate extreme of the child seer’s traumatic entrapment between perceiving and understanding the traumatic event, and the physical action required to escape it. Both the ghostly Santi and the unexploded bomb exude an eerie power despite, and perhaps because of, their apparent physical incapacity. Such corporeal powerlessness is the defining feature of Deleuze’s “child seer”, as the breach in the sensory-motor chain comes to imbue the child who encounters trauma with a penetrating gaze which sees beyond temporal borders. Once he becomes a ghost, Santi escapes the bounds of linear time altogether, becoming forever fused to the moment of his drowning. Santi’s spectral presence warps the ether around him as if he is permanently underwater, and the blood from his head wound constantly floats upwards. The sensory-motor chain becomes completely severed in a cinematic moment which can be likened to Deleuze “crystal of time”. Like the dual layers of narrative in The Sixth Sense, this crystal of time sparks a moment of Gothic frisson as linear time collapses and dual modes of temporality are expressed simultaneously: the chronological moment of Santi’s death—a ‘dead’ present that has already passed—and the fractured, traumatic memories of this past which linger in the present—what Deleuze would call a ‘virtual’ past which “coincides with the present that it was” (79). The traumatic effect of this collapse of temporal boundaries is enhanced by the fact that the shot of Santi drowning is repeated multiple times throughout the film—including in the opening minutes, before the audience is able to comprehend what we are seeing and where this scene fits into the film’s chronology. Ultimately, this cinematic crystal symbolically ungrounds linear narratives of Spanish history, which position the cultural rupture of the Civil War as a remnant of Spain’s past which has successfully been overcome. Through uncanny repetition, Santi’s death refuses to remain lodged in an immobilized “historical” past—a present that has passed—but remains forever alongside the present as an ethereal past that “is”. Santi’s raising of Gothic knowledge incites the wavering of not an adult character’s self-identity, as in The Sixth Sense, but a trembling in conceptual models of linear cultural progress. As a ghost, Santi is visually constructed as a broken porcelain doll, with cracks visible all over his body, emphasising his physical fragility; however, in his ghostly form it is this very fragility which becomes uncanny and threatening. His cracked body fetishizes his status as a subject who is not fully formed or complete. Thus, the film presents the post-Civil War child as a being who has been shattered and broken while undergoing the delicate process of being formed: an eerie incarnation of a trauma that has occurred “too soon” to be properly integrated. Santi’s broken body visualises the mechanisms whereby the violent conditions and mentalities of war permeate the child’s being in irreversible ways. Because he is soldered to the space and time of his death, he is caught forever as an expression of trauma in the inescapable gap between perception, assimilation and action. His haunting involves the intrusion of this liminal space onto the solid boundaries and binaries of the diegetic present; his abject presence forces other characters, and viewers, to experience the frisson of this previously concealed traumatic encounter. In so doing, Santi allegorically triggers the irruption of a fissure in the progression of Spain’s socio-cultural narrative. He embodies the ominous possibility that Spain’s grisly recent past may return within the child mutated by wartime trauma to engulf the future. The final scene of the film ideates the threshold of this volatile future, as the orphaned children stand as a group staring out at the endless expanse of desert beyond the orphanage’s bounds, all the adult characters having killed each other in a microcosm of the Civil War. Ultimately, both Cole and Santi enforce an eerie moment of recognition that the previously unassimilated traumas of the past live on within the present: a Gothic drawing forth of buried knowledge that exposes cracks in coherent meaning. In The Sixth Sense, Cole reveals the extent to which trauma is located in “the way it was precisely not known in the first instance” (Caruth 4), haunting Malcolm with his previous failure before exposing the all-encompassing extent to which this past trauma has fractured Malcom’s subjectivity. Santi of The Devil’s Backbone alludes to the ways in which this process of eliding past trauma extra-diegetically haunts contemporary Spain, particularly because those who were children during the Civil War are now the adult filmmakers, political leaders and constituents of Spanish society. These disturbances of historical and personal progress are rendered particularly threatening emerging as they do at the millennial turn, a symbolic temporal threshold which divides the recent past and the “new” present. The Gothic child in these contexts points to the danger inherent in misrecognizing traumatic histories—both personal and socio-cultural—as presents that have long-since passed instead of pasts that are. ReferencesBruhm, Steven. “Nightmare on Sesame Street: or, The Self-Possessed Child.” Gothic Studies 8.2 (2006): 98-210. Caruth, Cathy. Unclaimed Experience: Trauma, Narrative and History. Baltimore: Johns Hopkins University Press, 1996. Deleuze, Gilles. Cinema 2: The Time-Image. London: Continuum Books, 2005. The Devil’s Backbone. Dir. Guillermo del Toro. Perf. Fernando Tielve, Junio Valverde and Eduardo Diego. El Deseo S.A., 2001. Georgieva, Margarita. The Gothic Child. Basingstoke: Palgrave Macmillan, 2013. Fragile. Dir. Jaume Balageuró. Perf. Calista Flockhart, Richard Roxburgh and Ivana Baquero. Castelao Producciones, 2005. Lavik, Erlend. “Narrative Structure in The Sixth Sense: A New Twist in ‘Twist Movies?’” The Velvet Light Trap 58 (2006): 55-64. The Nameless. Dir. Jaumé Balaguero. Perf. Emma Vilarasau, Karra Elejalde and Tristán Ulloa. Filmax S.A., 1999. The Orphanage. Dir. Juan Antonio Bayona. Perf. Belén Rueda, Fernando Cayo and Roger Príncep. Esta Vivo! Laboratorio de Nuevos Talentos, 2007. The Others. Dir. Alejandro Amenábar. Perf. Nicole Kidman, Alakina Mann and James Bentley. Sociedad General de Cine, 2001. The Sixth Sense. Dir. M. Night Shyalaman. Perf. Haley Joel Osment, Bruce Willis and Toni Collette. Hollywood Pictures, 1999. Stir of Echoes. Dir. David Koepp. Perf. Kevin Bacon, Zachary David Cope and Kathryn Erbe. Artisan Entertainment, 1999. Williams, Anne. Art of Darkness: A Poetics of Gothic. Chicago: University of Chicago Press, 1995. Žižek, Slavoj. Looking Awry: An Introduction to Jacques Lacan Through Popular Culture. Cambridge: MIT Press, 1991.