A study of more than 270,000 people, published online recently in the journal Diabetes Care, also found that the more nights employees work, the greater their odds of having the disease, whether they are genetically predisposed to it or not.Healthcare workers, security guards and other employees who periodically work the night shift are significantly more likely to have Type 2 diabetes than workers who work only days, according to a sweeping new study by researchers from CU Boulder and Brigham and Women’s Hospital (BWH) in Boston.

“Work, particularly night shifts, disrupts social and biological rhythms, as well as sleep, and has been suggested to increase the risk of metabolic disorders, including Type 2 diabetes,” said co-first author Celine Vetter, Director of the Circadian and Sleep Epidemiology Laboratory ( CASEL) at CU Boulder. “Our study is one of the first to show a dose-response relationship, where the more often people work nights, the greater their likelihood of having the disease.”

About 15 million Americans work permanent night shifts, rotating shifts or shifts with irregular schedules. Recent studies have found associations between such shift work and cardiovascular disease, diabetes and cancer, but few have looked specifically at how different work schedule characteristics impact risk. For the study, Vetter worked along with co-first author Hassan S. Dashti and collaborators at BWH, the Broad Institute of MIT and Harvard, and Manchester University, to examine data from participants 38 to 71 years old in the UK Biobank.

Participants had provided detailed information on lifestyle, health status and present work schedule; 77,000 also provided in-depth lifetime employment information, and a subgroup of 44,000 provided genetic information. Participants also provided information about their “chronotype,” or whether they were a morning person or night person. Nearly 7,000 people had Type 2 diabetes.

The researchers found that those who worked irregular or rotating shifts that included night shifts were 44 percent more likely overall to have Type 2 diabetes than those who never worked nights. The odds of a person having diabetes rose with nights worked. For instance, those who worked eight or more night shifts per month were 36 percent more likely to have diabetes than day workers.

Notably, those who in their current schedule worked only at night showed no increased incidence of diabetes. This could be because those who tolerate nightshift work better tend to gravitate toward night jobs (permanent night-shift workers were twice as likely to have a “night owl” chronotype). But Vetter also notes that over time, some people may partially adapt to working nights. “If you rotate through a schedule that is always changing between day and night shifts it makes it hard to adapt and you can end up with a chronic misalignment between your lightdark cycle, your sleep-wake schedule, your meal timing, and your physical activity timing.”

Previous research at CU Boulder and by corresponding co-senior author Dr. Frank Scheer, director of the Medical Chronobiology Program and associate professor of medicine at Harvard Medical School, has shown that both sleepdebt and body-clock misalignment can impair glucose tolerance and insulin sensitivity—a precursor to diabetes.

Vetter notes that while people may not be able to avoid working nights, maintaining a healthy weight and diet, and taking care to get enough exercise and sleep, is likely to mitigate its health risks. This was the first study to look at the genetic predisposition to Type 2 diabetes and its potential modification by shift work, and more studies are needed to replicate those findings.

The authors hope that the research will also inform efforts by employers to help their workers be as healthy as possible.

“Our study findings represent another puzzle piece in this quest towards healthier work schedule design,” they conclude.

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Hitting newsstands in the United States of America and India simultaneously, A New Book–Planning and Designing Healthcare Facilities: A Lean, Innovative and Evidence based approach by Dr V.K. Singh and Prof. Paul Lillrank call for a fresh approach in designing new age hospitals in the wake of emerging new normal in the healthcare sector.

Authors say modern medicine is founded on the scientific pursuit for knowledge about the human body and its pathologies. Science builds theories and tests them against evidence. The scientific method should now be applied to the design of hospitals and health service systems. This is the rationale for evidence – based design.

According to authors, lean and innovation complement each other. Lean means creating more value for customers with fewer resources. Innovation is a process of translating an idea into goods or services that create value for which customer is ready to pay. The General Hospital is still a valid concept and is not going to disappear anytime soon, particularly in parts of the world where public health is poor, resources are scarce, and a majority of people is underserved. While visions are always welcome, the task at hand, and the theme of this book, is to improve on the Dominant Design, the standard General Hospital.

Evidence-based design (EBD) emphasizes credible evidence to influence design. It works on well-defined problems, applies a multidisciplinary perspective, involves users and customers, establishes quantitative performance measures for critical variables, and uses tests and simulations throughout the design process.

Prof. Lillrank along with Riikka-Leena Leskelä and Olli Tolkki say the hospital has traditionally been seen as a production site like a factory where flows of material, people, energy and information combine with fixed assets. In modern manufacturing, the factory has evolved into supply networks. In a similar vein, the modern hospital is seen as a node in a regional service system. A hospital design initiative should therefore begin with a master plan that defines the hospital’s place and role in a broader health service system.

Dr. Singh in a chapter on ‘Patient First, Functions Next and Design Later’ along with Mr. S K Biswas says the evolution of hospital design principles has gone through stages.

The first was ‘functions follow design’, as services had to be adapted to whatever structures were available. Next came ‘design follows functions’. Various professional groups lined out their requirements in terms of floor space and layout. More recently, the concept ‘Design follows first patients, then functions’ has been adopted. The emphasis now is on integrating the needs of patients, hospital functions, and functionaries in hospital design.

In a chapter, ‘Green Hospitals and Sustainable solution to Healthcare Facility’, Mr. Rajeev Boudhankar says as important parts of the modern urban landscape, hospitals must adopt environmentally friendly and sustainable designs and technologies. Green hospitals use energy, water, materials and land more efficiently than conventional buildings.

With more natural light and better air quality, green buildings contribute to improved health, comfort, and productivity. The LEED 2009 for Healthcare Green Building Rating System is a set of performance standards for certifying healthcare facilities.

In ‘Designing a Patient-centric Healthcare Facility Using Lean Methodology’, Mr. John Gallagher, Kim Chaney and Ron Kwon say 2P (Process Preparation) is a Lean design tool that helps to organize the flow of activity in a way that results in the least amount of waste. This chapter details how it worked when Concord Hillside Medical Associates, a multi-specialty group practice part of Harvard Vanguard Medical Associates near Boston, applied it in a major facility design project.

Likewise, in an article on ‘Creating safer healthcare environments using an evidence-based design process, Dr. Anjali Joseph, Ellen Taylor and Xiaobo Quan say a growing body of research shows that the healthcare built environment impacts safety outcomes such as infections, medication errors, falls, and staff injuries. Latent conditions that adversely impact patient safety are built into the physical environment during the planning, design, and construction phases. Design decisions should be proactively evaluated by engaging users from different disciplines such as infection control, nursing, risk managers, and environmental services. Emerging tools such as the Safety Risk Assessment (SRA) toolkit provide a structured way to apply evidence-based design to improve patient safety.

Dr. Singh and Dr. Biswas in another chapter on ‘Evidence Based Design in Hospitals – Theory to Implementation’ opine that the principles of Lean Healthcare support Evidence Based Design. Lean calls for the identification of all major stakeholders and specifying what they consider valuable. Stakeholder value can be grouped into the basic categories tangibility, reliability, responsiveness, assurance and empathy. When these requirements are not met, processes create waste.

EBD analyze the constraints that need to be addressed. The design process covers several stages, initial hypothetical design, process design, service design, and empirical design. These principles are detailed in a case in a hospital in Kolkata.

On Virtual Hospitals of Future, IT expert Sachin Gaur says the Information and Communication Technologies (ICT), particularly smart and wearable devices, have the potential to break constraints of time and location. Physical installations may turn virtual, and centralized services may be decentralized. Assessing the potential of new technologies, the CIMO -methodology of Evaluation Science can be employed. It asks the questions, what is the context in which technology is applied through what kinds of interventions, and which mechanisms are activated to produce which outcomes?

On ‘Redefining Healthcare of Tomorrow in Smart City’, Dr Singh and Ms. Nimisha Singh say the three pillars of the smart city are-people, process, technology, and the information flows that bind them together as an optimized whole. The Smart Cities Mission under the leadership of Prime Minister Narendra Modi is an initiative towards urbanization. Smart cities require smart healthcare.

With the Internet of things (IoT), layers of smartness are being added to the hospitals, such as remote monitoring, chronic disease management, medication management, patient self-management, and workflow management.

In a Chapter titled ‘Delivering Inclusive Intelligent Healthcare’ by Innovative and Comprehensive e-Health System, Dr. Kuo Shou-Jen and Lai Chien-Wen aver that the chapter is based on a case study of Changhua Christian Healthcare System (CCH), Taiwan. CCH has been a pioneer in implementing sophisticated new technologies. The case emphasizes the importance of the combination of high tech with human touch.

In a chapter on ‘Planning Safe Hospitals’, Ms. Sushma Guleria says that the Hyogo Framework for Action 2005-2015 (HFA) spells out the challenge to substantially reduce the impact of disasters and to make risk reduction an essential component of development policies and programs. Risk reduction planning should be integrated into the health sector to make hospitals safe from disasters and strengthen their capacity to remain functional in disaster situations. Hospitals need to have disaster management plans and to evaluate their performance by implementing the Hospital Safety Index used widely to gather information for sound decision making.

In an article on ‘Designing Innovative Facilities: Contamination & Security Hazards at Hospitals’, Dr. Singh along with Dr. Raman Chawala emphasis on the danger of chemical, biological, radiological, nuclear and explosive (CBRNE) related terrorism which pose a contamination threat to healthcare institutions. Designing innovative resilience can provide long term and effective solutions by establishing a rigorous framework that can accelerate adaptation and ability to recover from any known and unknown contamination security and safety hazards.

‘Adapt or Obsolesce: The evolution of the Singapore Health System’, Matthew Saunders said Singapore is an advanced country of small size with a single party dominated political system. This has made it agile and able to respond quickly to changing circumstance in ways that differ from larger and more complex polities. Singapore faces the same challenges as other developing countries, including ageing society, non-communicable diseases and healthcare cost inflation, while it is well positioned to implement advanced technologies, such as electronic patient records and smart solutions. Singapore highlights the systemic nature of healthcare, where service production, facility design, finance, and regulation require innovative approaches to integration.

Dr. B. R. Shetty, Founder and Chairman, NMC Healthcare, Abu Dhabi, United Arab Emirates in his foreword said, “The book is a timely effort to discuss various concepts and tools to reduce delivery costs and maintain high quality by the means of planning a hospital with an eye on operations. It details experiences from around the globe. The authors strive to integrate several strains of thought: Lean, Innovation, Patient Centricity, and Evidence–based designs. This is what the healthcare industry needs.

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InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz
InnoHEALTH Volume 2 Issue 1 (January to March 2017) – https://goo.gl/DEyKnw
InnoHEALTH Volume 2 Issue 2 (April to June 2017) – https://goo.gl/Nv3eev
InnoHEALTH Volume 2 Issue 3 (July to September 2017) – https://goo.gl/MCVjd6
InnoHEALTH Volume 2 Issue 4 (October to December 2017) – http://amzn.to/2B2UMLw
InnoHEALTH Volume 3 Issue 1 (January to March 2018) – https://goo.gl/fksdQx
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Over the years, several measures have been launched to overcome the problem including imposition of ban on alcohol sale and setting up of de-addiction centres to help the drinkers.

A group of researchers drawn from several national and international institutions have now found that it is possible to address the issue in a significantly effective manner at low costs. They have found that lot of benefit can be derived by merely equipping public health workers with different counselling techniques.

The study was conducted at 10 public primary healthcare centres in Goa. A total of 377 heavy drinkers in the age group of 18 to 65 years were enrolled. They were randomized into two groups- one receiving just the routine care and the other who also received counselling for two months. Their alcohol use was measured after 12 months.

In the group that received counseling, as much as 68 per cent of the men were found to have reduced their consumption to the safe level, as against 40 per cent in the case of the group that received only the routine care. The counselling programme was also not too intense. It consisted of just one to three sessions.

The counselors were also just non-specialist health workers. They had no prior professional training or qualification in the field of mental health. However, they were given rigorous training on various aspects of counselling and they gave advice on how to deal with craving and motivated patients to quit drinking.

Speaking to India Science Wire, Vikram Patel, professor at the Department of Global Health and Social Medicine of the Harvard Medical School, Boston, Massachusetts in USA, who was the corresponding author for the study, said, “Given the great social and health harms associated with heavy drinking in India, and the effectiveness of this relatively brief and cheap treatment to reduce drinking levels,the government needs to scale up this treatment by training primary care health workers across the country”.

Besides Dr. Patel, the study team included Abhijit Nadkarni, Helen A Weiss, Benedict Weobong, David McDaid, Daisy R Singla, A-La Park, Bhargav Bhat, Basavaraj Katti, Jim McCambridge, Pratima Murthy, Michael King, G Terence Wilson, Betty Kirkwood, Christopher G Fairburn, and Richard Velleman.

National Institute of Mental Health and Neurosciences (NIMHANS) in Bengaluru and Sangath, a NGO in Goa participated in the study. They collaborated with the London School of Hygiene and Tropical Medicine, University of Oxford, University of Bath, University of York, University College London and London School of Economics and Political Science in United Kingdom, University of Toronto in Canada, Rutgers University in New Jersey, and Harvard Medical School in United States of America. The Indian Council of Medical Research gave the ethical approval for conducting the trial.

(Article shared from India Science Wire)

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InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2 
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz 
InnoHEALTH Volume 2 Issue 1 (January to March 2017) – https://goo.gl/DEyKnw 
InnoHEALTH Volume 2 Issue 2 (April to June 2017) – https://goo.gl/Nv3eev
InnoHEALTH Volume 2 Issue 3 (July to September 2017) – https://goo.gl/MCVjd6
InnoHEALTH Volume 2 Issue 4 (October to December 2017) – http://amzn.to/2B2UMLw
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Life on Earth is adapted to the rotation of our planet. For many years we have known that living organisms, including humans, have an internal, biological clock that helps them anticipate and adapt to the regular rhythm of the day. But how does this clock actually work? Jeffrey C. Hall, Michael Rosbash and Michael W. Young were able to peek inside our biological clock and elucidate its inner workings. Their discoveries explain how plants, animals and humans adapt their biological rhythm so that it is synchronized with the Earth’s revolutions.

Using fruit flies as a model Honored for their discoveries of molecular mechanisms controlling the circadian rhythm organism, this year’s Nobel laureates isolated a gene that controls the normal daily biological rhythm. They showed that this gene encodes a protein that accumulates in the cell during the night, and is then degraded during the day. Subsequently, they identified additional protein components of this machinery, exposing the mechanism governing the self-sustaining clockwork inside the cell. We now recognize that biological clocks function by the same principles in cells of other multi-cellular organisms, including humans.

With exquisite precision, our inner clock adapts our physiology to the dramatically different phases of the day. The clock regulates critical functions such as behavior, hormone levels, sleep, body temperature and metabolism. Our wellbeing is affected when there is a temporary mismatch between our external environment and this internal biological clock, for example when we travel across several time zones and experience “jet lag”. There are also indications that chronic misalignment between our lifestyle and the rhythm dictated by our inner timekeeper is associated with increased risk for various diseases.

Our inner clock

Most living organisms anticipate and adapt to daily changes in the environment. During the 18th century, the astronomer Jean Jacques d’Ortous de Mairan studied mimosa plants, and found that the leaves opened towards the sun during daytime and closed at dusk. He wondered what would happen if the plant was placed in constant darkness. He found that independent of daily sunlight the leaves continued to follow their normal daily oscillation (See figure). Plants seemed to have their own biological clock.

Other researchers found that not only plants, but also animals and humans, have a biological clock that helps to prepare our physiology for the fluctuations of the day. This regular adaptation is referred to as the circadianrhythm, originating from the Latin words circa meaning “around” and diesmeaning “day”. But just how our internal circadian biological clock worked remained a mystery.

Identification of a clock gene

During the 1970’s, Seymour Benzer and his student Ronald Konopka asked whether it would be possible to identify genes that control the circadian rhythm in fruit flies. They demonstrated that mutations in an unknown gene disrupted the circadian clock of flies. They named this gene period. But how could this gene influence the circadian rhythm?

This year’s Nobel Laureates, who were also studying fruit flies, aimed to discover how the clock actually works. In 1984, Jeffrey Hall and Michael Rosbash, working in close collaboration at Brandeis University in Boston, and Michael Young at the Rockefeller University in New York, succeeded in isolating the period gene. Jeffrey Hall and Michael Rosbash then went on to discover that PER, the protein encoded by period, accumulated during the night and was degraded during the day. Thus, PER protein levels oscillate over a 24-hour cycle, in synchrony with the circadian rhythm.

A self-regulating clockwork mechanism

The next key goal was to understand how such circadian oscillations could be generated and sustained. Jeffrey Hall and Michael Rosbash hypothesized that the PER protein blocked the activity of the period gene. They reasoned that by an inhibitory feedback loop, PER protein could prevent its own synthesis and thereby regulate its own level in a continuous, cyclic rhythm.

The model was tantalizing, but a few pieces of the puzzle were missing. To block the activity of the period gene, PER protein, which is produced in the cytoplasm, would have to reach the cell nucleus, where the genetic material is located. Jeffrey Hall and Michael Rosbash had shown that PER protein builds up in the nucleus during night, but how did it get there? In 1994 Michael Young discovered a second clock gene, timeless, encoding the TIM protein that was required for a normal circadian rhythm. In elegant work, he showed that when TIM bound to PER, the two proteins were able to enter the cell nucleus where they blocked period gene activity to close the inhibitory feedback loop.

Such a regulatory feedback mechanism explained how this oscillation of cellular protein levels emerged, but questions lingered. What controlled the frequency of the oscillations? Michael Young identified yet another gene, double time, encoding the DBT protein that delayed the accumulation of the PER protein. This provided insight into how an oscillation is adjusted to more closely match a 24-hour cycle.

The paradigm-shifting discoveries by the laureates established key mechanistic principles for the biological clock. During the following years other molecular components of the clockwork mechanism were elucidated, explaining its stability and function. For example, this year’s laureates identified additional proteins required for the activation of the period gene, as well as for the mechanism by which light can synchronize the clock.

Keeping time on our human physiology

The biological clock is involved in many aspects of our complex physiology. We now know that all multicellular organisms, including humans, utilize a similar mechanism to control circadian rhythms. A large proportion of our genes are regulated by the biological clock and, consequently, a carefully calibrated circadian rhythm circadian biology has developed into a vast and highly dynamic research field, with implications for our health and wellbeing.

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Read all the issues of InnoHEALTH magazine:
InnoHEALTH Volume 1 Issue 1 (July to September 2016) – https://goo.gl/iWAwN2 
InnoHEALTH Volume 1 Issue 2 (October to December 2016) – https://goo.gl/4GGMJz 
InnoHEALTH Volume 2 Issue 1 (January to March 2017) – https://goo.gl/DEyKnw 
InnoHEALTH Volume 2 Issue 2 (April to June 2017) – https://goo.gl/Nv3eev
InnoHEALTH Volume 2 Issue 3 (July to September 2017) – https://goo.gl/MCVjd6
InnoHEALTH Volume 2 Issue 4 (October to December 2017) – http://amzn.to/2B2UMLw
InnoHEALTH Volume 3 Issue 1 (January to March 2018) – https://goo.gl/fksdQx

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