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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Effect of Sleep Deprivation on Mood States of Junior Residents in Obstetrics and Gynaecology Department: A Prospective Observational Study
Correspondence Address :
Dr. Raksha Jaipurkar,
Professor, Department of Physiology, Armed Forces Medical College, Solapur Road, Pune, Maharashtra, India.
E-mail: rakshukarade@gmail.com
Introduction: Junior residents of highly demanding clinical specialties, like, Obstetrics and Gynaecology, are an integral part in the functioning of hospitals. They work round the clock donning the role of caregiver as well as learner and are in a constant state of stress. Any alteration in mood while working in intensive set ups like labor room and operation theatre can adversely affect not only the physician’s performance but also patient safety.
Aim: To evaluate the effect of sleep deprivation on mood states of junior residents in Obstetrics and Gynaecology Department during call duty.
Materials and Methods: This prospective observational study was conducted in Department of Obstetrics and Gynaecology at Armed Forces Medical College (tertiary care hospital), Pune, Maharashtra, India, from march 2019 to august 2019. The study included 37 junior residents of Obstetrics and Gynaecology Department, between age range of 25-40 years. Sleep diary was used to record resident’s sleep patterns, Karolinska Sleepiness Scale (KSS) was used to assess the day time sleepiness. Profile of Mood States (POMS) score was calculated during pre-call and post-call duty. This data was used to ascertain any changes in mood post-call due to sleep deprivation. Statistical analysis was done using paired Student’s t-test and Wilcoxon Signed Rank test and p-value <0.05 was considered as significant.
Results: Out of 37 participants, 21 were males and 16 females. There was a significant worsening of post-call POMS score (5.24±27.82) from pre-call score (-6.86±23.70) following call duty associated with a decrease in mean night time sleep (p-value<0.001). Likewise increased KSS score was also noted after call duty (pre-call score was 3.03±1.65 vs post-call score was 5.73±2.05; p-value<0.001). This signifies that mood states are adversely affected by sleep deprivation in these residents.
Conclusion: The study showed that there was a significant worsening of mood states due to sleep deprivation during call duties. This also mandates review of efficacy and feasibility of current policy regulating work hour schedule of junior residents in India.
Cognitive dysfunction, Mood disorders, Patient safety, Shift work schedule
Sleep is vital for sustaining normal functioning of human body, emotional experience and a host of complex cognitive processes. Numerous scientific studies have put forth debates that without adequate sleep nearly every aspect of waking life becomes more arduous, laboured and emotionally less fulfilling (1),(2),(3),(4). Insufficient sleep is often the norm among many professionals, including medical professionals where the residents face the maximum burnt (5). Long shift works and on call duties have been an integral part of training program of junior residents, especially of the clinical specialties like Obstetrics and Gynaecology, Medicine, Surgery, Paediatrics and Anaesthesia. The residents play the dual role of caregiver and learner, assisting in the functioning of hospitals round the clock (6),(7) .
Repeated shift work and long working hours increase the risk of sleep deprivation, sleep disturbance and poorer sleep quality in residents of clinical specialties as compared to residents of specialties which do not have so many on call duties (8). Despite researches on effect of sleep deprivation on other medical specialties, there has been very little done in case of Obstetrics and Gynaecology, a specialty that demands round the clock surveillance and surgical procedural intervention (9),(10),(11).
Although few studies have been conducted in Western and Middle Eastern countries, (7),(8),(9) the effect of sleep loss on mood in junior residents is still an unexplored territory in Indian subcontinent.
Even though there is general awareness regarding negative impact of sleep loss, the potential problems and extent of it on the mood states is yet to be defined in detail for residents working in clinical branches in various healthcare facilities of India. Keeping in mind the significance of the mood states of resident doctors while performing duties of patient care in intensive set up such as Intensive Care Unit (ICU), labour room and operation theatre, this study was designed to explore the effect of sleep deprivation on mood states of junior residents in Obstetrics and Gynaecology Department during call duty using Profile of Mood States (POMS) score, sleep diary and Karolinska Sleepiness Scale (KSS). This study aimed to measure variety and intensity of moods experienced by the junior residents during on call duties and to know if the resident doctors are performing their duties in intensive set up in altered mood states.
This prospective observational study was conducted in Department of Obstetrics and Gynaecology at Armed Forces Medical College (tertiary care hospital), Pune, Maharashtra, India, from March 2019 to August 2019. The study was approved by Institutional Ethics Committee (Ethical committee approval No: IEC/Oct/2018). Written informed consent was taken from all voluntary participants and complete confidentiality was maintained. The procedures followed were in accordance with the ethical standards of the institutional committee on human experimentation and with the Helsinki Declaration of 1975 (12). Total 37 eligible junior residents, as per inclusion criteria, were included as it was a pilot study in a tertiary care hospital.
Inclusion criteria: All junior residents in the department of Obstetrics and Gynaecology, between age group 25-40 years were included in this study.
Exclusion criteria: Any cases with known history of sleep disorders, pregnant or breast feeding female resident doctors and residents with history of alcohol ingestion 24 hours prior to study were excluded.
Data collection: Equipment were self-filled questionnaires - POMS (13), KSS (14) and sleep diary (15). The presentation order of tests included sleep diary followed by KSS and POMS which lasted for 8-10 minutes.
Procedure
The participants were evaluated on two occasions i.e., pre-call (previous day of call duty) and post-call day (day after call duty) after a call duty of 24 hours. Data was filled by the residents themselves and was collected between 10 am to 4 pm. Sleep diary was filled to assess sleep accumulated on both days. KSS was filled to assess day time drowsiness on pre-call and post-call day. POMS questionnaire was filled to assess alterations in mood state and to compare the mood state during pre-call and post-call.
Participants were divided in to three subgroups:
• First year Junior Resident (JR1)= 12 residents
• Second year Junior Resident (JR2)= 12 residents
• Third year Junior Resident (JR3) = 13 residents
Each resident was evaluated only once.
Profile Of Mood States (POMS)
The questionnaire is a checklist consisting of 65 adjectives which are rated on a 5-point scale that ranges from not at all to extremely (16). The modified POMS, which is a short form of the POMS, was used in this study. This modified version of the POMS questionnaire contains 40 self-report items measuring the subscales of depression (7), anger (6), tension (6), confusion (5), fatigue (5), esteem related affect (6) and vigor (5) to which the participants respond using a 5 point Likert Scale which ranges from 0 (not at all) to 4 (extremely) (13).
The higher the score the worse are the subscales. However, in case of vigor and esteem related affect, the higher the score the better is the feeling. Total mood disturbance score is calculated by adding up the scores obtained for depression, anger, tension, confusion, fatigue and then subtracting the vigor and esteem related affect score. An increment in Total Mood Disturbance (TMD) score is an indication of worsening mood. The higher the TMD score, the worse is the mood status (13).
Karolinska Sleepiness Scale (KSS)
This scale measures the subjective level of sleepiness at a particular time during the day. With this scale the subject reflects the psychophysical state experienced in last ten minute. Basically, it measures situational sleepiness which is subject to fluctuations. It is a 9-point Likert scale which ranges from extremely alert to very sleepy. The modified KSS has another additional item i.e., extremely sleepy, falls asleep all time (Score ranging from 1-9). Scores on KSS increases with longer periods of wakefulness and strongly correlates with time of the day. In this study the original KSS has been used for assessing day time sleepiness (Table/Fig 1) (14).
Sleep diary
The sleep diary used in present study was developed by Lough Borough sleep research Centre (15),(17). The format of sleep diary used for this study is a pen and paper questionnaire where the subject fills the data for the last night’s sleep. The data contained in this diary require manual aggregations and calculations. This sleep diary contains eight items that are considered to represent different critical parameters i.e., the time of getting into bed, sleep onset latency, number of awakenings during night, duration of awakenings, time of final awakening, final rise time, duration of total night time sleep and sleep quality which was evaluated using a Likert scale ranging from very poor (1) to very good (5). All the parameters were used to calculate the total night time sleep. Total night time sleep is calculated by subtracting total duration of sleep disturbance from total time spent in bed.
Statistical Analysis
All data were analyzed using the Statistical Package for the Social Sciences (SPSS) software package, version 20.0. Data was presented as mean±SD. Normality of the data was checked using Shapiro Wilk test. Paired Student’s t-test was performed for parametric and Wilcoxon signed rank test was used for the non parametric results to compare the mean. A p-value of less than 0.05 was considered as an indication of statistical significance. Association between sleep and day time sleepiness, between sleep time and mood scores were determined by using Spearman’s correlation coefficient. Subgroup analysis was done between JR1, JR2 and JR3 using Friedman’s test.
Out of 37 participants, 21 were male and 16 were female. The demographic data of the study population is summarised in (Table/Fig 2).
The duration of total night time sleep was evaluated in minutes during pre-call (330.73 ± 85.14) and post-call (153.32 ± 64.35). It showed notable decrease in night time sleep during post-call (p-value<0.001). Post-call alertness also remarkably decreased as was evident by increase in KSS score from pre-call value of 3.03±1.65 to post-call value of 5.73±2.05 (p-value<0.001). The total mood disturbance score was found to be significantly higher on post-call day (5.24±27.82) than pre-call day (-6.86±23.70); (p-value= 0.004) (Table/Fig 3).
Variations observed in different sub scores of POMS revealed that sub scores like fatigue (p-value <0.001), confusion (p-value=0.007) and depression (p-value <0.001) showed significant increase in post call score. On the other hand, there was a decrease in vigor (p-value=0.007) and esteem related affect score (p-value=0.013) as compared to pre-call score (Table/Fig 3).
Spearman’s correlation coefficient showed a negative correlation of sleep time with KSS score (p-value= 0.36; r-value= -0.15) and sleep time with TMD score (p-value= 0.30; r-value= -0.33) during pre-call. However, this negative correlation was not statistically significant. On the other hand, a statistically significant negative correlation was found between post-call sleep time with KSS and TMD scores (p-value=0.02; r-value= -0.385 and p-value=0.04; r-value= -0.34 respectively). These findings show worsening of mood with increased TMD score and decreased night sleep time (Table/Fig 4).
On subgroup analysis, a decrease in total night time sleep was observed in JR1, JR2 and JR3 with mean sleep time of 111.67 minutes, 156 minutes and 144.17 minutes on post-call day, respectively. There was an increase in post-call TMD score from pre-call TMD score for all the subgroups. The KSS score also showed similar increase in values on post-call day compared to pre-call day. However, when compared among three groups for post-call duty, there were no significant difference. (KSS score, p-value=0.674; TMD score, p-value=0.24 and total night time sleep, p-value=0.119) (Table/Fig 5).
This study investigated the effect of sleep loss on impairment in mood states among junior residents posted at Obstetrics and Gynaecology Departemnt of a tertiary care hospital. The present study confirms that sleep deprivation has significant adverse effects on mood states in residents. It reports significant changes in fatigue, depression, confusion, esteem related affect and vigor as well as TMD scores on a post-call day after night call shift. Total sleep time during on-call duty is significantly less and it is affecting the mood states of residents on post-call day. This quantification of sleep for Obstetrics and Gynaecology residents has not been reported in any other prior study as per literature review. The increased KSS score indicates that the residents experience marked increase in day time sleepiness as compared to pre-call day as night time sleep significantly decrease during on call. On subgroup analysis, no significant changes were found in the parameters between JR1, JR2 and JR3 which implies sleep deprivation is affecting all the junior residents irrespective of their residency years.
A study conducted by Martini S et al., reported that Obstetrics and Gynaecology residency have the highest prevalence of burn out of any specialties (18). The period of sleep deprivation and long night call duties are unavoidable consequences of medical residency training regime of Obstetrics and Gynaecology.
Studies have shown wide range of cognitive decline associated with sleep deprivation such as reduced ability to concentrate, slowing of reaction time, decreased memory, decreased ability to learn new skills. This along with mood disturbances and increased fatigue can lead to injuries and on job errors (19),(20),(21). It has been demonstrated in various research that prolonged wakefulness can cause performance and cognitive impairments equivalent to alcohol intoxication of 0.1% which is beyond legally permissible limits (22). In a meta-analysis of studies related to sleep deprivation it was noticed that mood was the most affected aspect of cognitive functions (23). Altered mood of residents may have an adverse effect on colleagues, staff, patient as well as his own personal life. Anger and depression arising from fatigue has been documented to cause detachment and lack of sympathy for the patients. This can also cause strain in family and interpersonal relationships. Alteration in mood can reduce concentration and impinges the decision-making skills of the residents (23).
The elevation in TMD and KSS score observed in this study are consistent with adverse effects of sleep deprivation previously reported in healthcare professionals and residents. A study conducted by Reddy R et al., reported that residents working in intensive care units and intense work setups experience severe sleepiness on post-call day (24). The contribution of sleep induced fatigue to accidental errors has been increasingly recognized in general population. However, sleep deprivation related distress may have more serious implications for physicians than general population. Fatigue-induced mood impairments can affect task motivation, increased perceived effort required for task completion and the ability to communicate efficiently (25). A study in Dutch physicians showed that almost half are suffering from work related fatigue and burnout which decrease their work ability (26). A study by Saadat H et al., on Anesthesiologists revealed that all aspects of mood and cognitive tasks are clearly affected after night on call duty (27). A similar study by Barger LK et al., showed increased risk of accidents due to sleep deprivation in interns (19).
It is well known that effective performance by residents of Obstetrics and Gynaecology require higher level of concentration, rapid judgment, immediate decision making and fine motor skills. Wali SO et al., conducted a study on residents from clinical specialties which included Obstetrics and Gynaecology, and reported worsening of mood on post-call day compared to pre-call day as indicated by increase in TMD score and day time sleepiness (7). A study by Kalmbach et al supported the findings of negative mood and its links to insufficient sleep-in residents and interns (28).
Restrictions on working hours of residents are in place in various countries including United Kingdom (since 1996) and United States of America (since 2003) (29),(30). Similarly, Supreme Court of India has passed a judgment in writ petition no. 348-352 in 1985 that “junior doctors should ordinarily work for 48 hours per week and not more than 12 hours at a stretch”. However, this is not implemented strictly in many parts of India resulting in prolonged work hours for Gynaecology residents without adequate sleep. This leads to accumulation of sleep debt and fatigue forcing them to work on altered mood States in intense work set-ups. Acute sleep deprivation related to on call shift work results in dose dependent impairments of mood States and increased day time sleepiness and fatigue making this population more vulnerable to depression as evident in increased post-call depression sub score.
Limitation(s)
The study was conducted in a single-centre, hence the sample size was limited. Recall bias regarding previous night’s sleep may be another limitation for the study. The questionnaires are subjective tools, and hence, less reliable than polysomnography.
The present study highlights the various negative mood effects due to sleep deprivation after on call duty in Obstetrics and Gynaecology residents. The gradual decrease in night time sleep duration from pre-call to post-call day is reflected in increased total mood disturbance score and increased Karolinska sleepiness score. It is suggestive of a positive correlation between altered mood states and day time sleepiness. More longitudinal multicentric studies are needed to investigate the impact of altered mood states on their performance and its potential effects on patient safety and healthcare delivery to minimise unwarranted fatigue related errors. This study also mandates for need of reassessment of efficacy and feasibility of current policy regulating work hour schedule of junior residents by capping the duration of working hours and increasing number of residents working which will ensure circadian synchronisation and a better healthcare delivery.
DOI: 10.7860/JCDR/2022/55170.16822
Date of Submission: Jan 27, 2022
Date of Peer Review: Mar 03, 2022
Date of Acceptance: Jun 10, 2022
Date of Publishing: Sep 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: No
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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