ASPIRE #36 by AMSA International

C O N T N E T S

FOREWORD

EDITORIAL BOARD

05 07

CONTRIBUTORS

EXECUTIVE COMMITTEE

AMSA INTL ACTIVITIES

MEET THE EXPERT

HEALTH ISSUES

CLINICAL CHALLENGE

113

HOBBIES

115

CREATIVE CORNER

119

LETTERS TO JULIET

149

FEEDBACK SURVEY

153

MEDIA PARTNERS

154

FOREWORD Greetings, People of Tomorrow! AMSA International eNewsletter Editorial Board presents to you: ASPIRE #36: Brain and Sleep Awareness Week! After a long wait, this issue with its highly intriguing topic is finally published. In order to commemorate both Brain and Sleep Awareness Weeks happening in March, our team came up with this wonderful idea of incorporating these two topics for this issue, understanding that sleep is an essential portion of one’s daily life, and the brain is one of the many vital organs in our body that deserves its spotlight in our eNewsletter.

In this edition, you can find more than articles related to the theme, but also many beautiful artworks, literature pieces, and of course, recaps of events held by AMSA International. We are delighted to have received many submissions for this issue as well and would like to thank every single contributor and reader for their love and support. We hope that you would enjoy this eNewsletter. Do not forget to encourage your fellow AMSA friends to pay a visit! Virtus et Doctrina, Viva AMSA!

Best Regards, Kassie Gracella Putri Chief Editor of eNewsletter AMSA International

EDITO BOA

AMSA INTERNAT

AUSTRALIA

Kirsten Tsan

BANGLADESH

Nashita Nowshin

REPRE

ENGLAND Macy Au

HONG KONG Tania Chan

MALAYSIA

Hasanah N

PHILLIPINES

Lloyd Anicier B

MYANMAR Irene

NEPAL

Susmita K

CHAPTER INDIA

Samneet Singh

INDONESIA

Priscilla Sayogo

SEN

TATIVES

KYRGYZSTAN

Rahul Gautam

PAKISTAN Bisma Arif

SCOTLAND

Samantha Goh

TAIWAN

Wendy Liu

ORIAL ARD

ATIONAL 2021/2022

PROOF INDONESIA

Shafira Meutia

PHILLIPINES

Celestina Salvador

AUSTRALIA Justin Lee

M Raihan Ramdhan

INDONESIA

Gifta Hamiseno

READERS TEAM

LAYOUT INDONESIA

INDONESIA

Garry Soloan

INDONESIA Charlotte Lintang

INDONESIA Florentia Amanda

DESIGNERS

INDONESIA Jauda Hanoon

INDIA

Disha Suresh

CON

Anjali Mediboina AMSA India

Florentia Amanda AMSA Indonesia

Japmehr Kaur Sandhu AMSA India

Diya Bashetty AMSA India

Moses Reviano AMSA Indonesia

Benyapa Wongsaravit AMSA Thailand Kayshev Varman S AMSA Malaysia

Gifta Hamiseno AMSA Indonesia

B U TO Nur Hasanah AMSA Malaysia

Ting-Wei Kao AMSA Taiwan

TRI

Radhika Jalan AMSA India

Shafira Meutia N AMSA Indonesia

Shahriar Uddin Khan AMSA Bangladesh

Ellen Callista A AMSA Indonesia

Kirsten Tsan AMSA Australia

Jauda Hanoon AMSA Indonesia

Timothy Christian AMSA Indonesia

Nadira Tsurraya R AMSA Indonesia

ORS Bhumika Raisinghani AMSA Indonesia

Min-Hang Leng AMSA Taiwan

CON TR

Ria Raju AMSA India

Viddhya Pandhey AMSA India

Praveen Barath AMSA India

Tatyana Millenia AMSA Indonesia

Manahil Muqqadus AMSA Pakistan

Gilang Ignas R AMSA Indonesia

Shofia Nur Latifah AMSA Indonesia

Fata Imadudda’wah AMSA Indonesia

Lloyd Barba AMSA Philippines

Dr. Avi Singh AMSA India

Annete Claudia Keiko AMSA Indonesia Aramva Bikram Adhikari AMSA Nepal

Celestina Josefa Salvado AMSA Philippines Neha Ninad Shinde AMSA Indonesia

Manvi Lamba AMSA India

Garry Soloan AMSA Indonesia

Susmita Khatiwada AMSA Nepal Mahocca Carlo AMSA Indonesia

AMSA INTE

EXECUTIVE COMMI

ERNATIONAL

ITTEE 2021/2022

AMSA INTERNATIONAL activities

AMSA INTERNATIONAL ACADEMICS MASTERCLASS The AMSA Academics (AMSACAD) Masterclass was held on February 13th 2022. Titled ‘Academic Events: The Different Perspectives’, it broke down the academic event into three sections - brainstorming, preparation, and competition. Delegates also had the opportunity to work in teams to create public health posters on various topics and practice both design skills, and creative forms of public health education. The event was a collaboration with Lecturio, an online study tool with over 6,500 video lectures, 20,000 recall questions and 8,700 exam questions. They sponsored the prizes for the winning public health poster team during the event. Over 100 delegates attended the online event, which ran for approximately three hours (13.20 - 16.15 GMT+8).

event recap event recap

he event began with an icebreaker, where delegates described the weather in their home country and their previous experiences with academic competitions. The majority of delegates had never attended an academic competition prior to the event but were very excited to have their first experience later in the day.

presentation presentation Related to the event’s topic of brainstorming, the first session of the day was a talk given by Gunjan Kaur Malhotra, the National Director of Academics AMSA India, who provided an insight into the way AMSA India organises and conducts its academic events. The events themselves range from weekly activities to those conducted on a national scale. AMSA India programs that fall into the former category include ‘Saturday Night Trivia’ and ‘Wise Wednesdays’, and AMSA India’s national academic events include ‘Spin The Wheel’, ‘Hungmedicina’, ‘House of Medicine’, and ‘The Contagion’. These events were unique in the way that they were conducted and they all incorporated learning with games, creating a fun and engaging environment to foster the academics of the participants. Gunjan also went on to explain the planning protocol behind these events. This protocol involved brainstorming from the national officers, accommodation to a time frame, designing the event’s plan, delegating tasks amongst the academic team, and promoting the event through posters. The necessary logistics, including WhatsApp groups, Google forms, sponsorships and prizes were also carefully prepared, as well as the sending of certificates to participants.

As well as sharing her experiences in AMSA India, Gunjan also provided several recommendations for the participants to apply when planning their own academic events. This advice included properly conducting a division of labour prior to the event, anticip WhatsApp groups in advance, and maintaining clear communication with participants in a timely manner.

The presentation was concluded with a take-home message that highlighted that the events must be of interest to the target participants and must provide something new from previous academic events. Gunjan also advised that when planning events, you must be ready to face any difficulties that may arise, and most of all to stay calm and relax.

“ the events must be of interest to the target participants and must provide something new from previous academic events,

Following the presentation was an interactive question and answer session, where Gunjan provided further advice, from studying tips to her experiences carrying out the aforementioned national events. The next session was a presentation from Muhammad Raihan Tatroman, the Secretary of Academics in AMSA Indonesia, and Vicky Chiang, the National Director of Academics from AMSA Taiwan. They discussed how they prepare for academic conferences, before, during and after the event.

recommendations recommendations They had many recommendations for those who are interested in creating academic events. Firstly, the 5W1H rule: what, why, where, when, who, for 1 hour. In other words, a good strategy to create any event is to decide what it is, why it has been created, and what you would like to leave the audience with, and then work out the logistics and run the event for a maximum of 1 hour. Secondly, have a main theme and aim in the event that you run, and think of backup plans in case it doesn’t work out. It is also important to go through all the details of the event with facilitators prior and make a to-do list for the day to ensure everything runs smoothly. The third session of the masterclass divided the participants into breakout rooms, where participants had the opportunity to partake in a public poster

making competition, each group being supervised by experienced facilitators. The subjects of the poster revolved around health-related topics such as tips to achieve a healthy lifestyle, mental health during the pandemic, or a disease of the group’s choosing. The design of the poster itself was done through the platform Canva, and participants were provided with several templates as a foundation for their posters. The posters themselves were to be created in 30 minutes, after which each was presented in front of the other groups.

conclusion conclusion To conclude the event, the organisers Tai and Afaaf and the Director of Academics Mikail thanked the delegates for attending and encouraged them to utilise these tips for future events. The winners of the public health poster competition were Group 3, with the best poster, and Group 9, with the best presentation. The event was closed by Muhammad Mikail Athif Zhafir Asyura, the Director of Academics. All in all, it was a very successful event. The delegates enjoyed it thoroughly and left with a much-improved knowledge of the management of academic conferences.

P.S. Interested to forge everlasting friendships with AMSA International members of different chapters? Fill this penpal survey here https://bit.ly/AMSAInternationalPenpal and get started!!

Written by Kirsten Tsan eNewsletter Editorial Board 2020/2021

Jauda Hanoon eNewsletter Editorial Board 2020/2021

CONGRATU L A T I O N S to all the winners! BEST POSTER " HOW TO BE THE BEST VERSION OF YOU " Aramva Bikram Adhikari (AMSA Nepal) Siw Ming Huey (AMSA Malaysia) Hamnah Khalid (AMSA Kyrgyzstan) Abdullah Asy Syifa (AMSA Indonesia) Nathalia Angelina (AMSA Indonesia) Pia Nebrada (AMSA Philippines) Jauda Hanoon (AMSA Indonesia) Vicky Chiang (AMSA Taiwan)

BEST PRESENTATION "STAYING HEALTHY ONLINE WITH THE HABIT RULE " Josh Manalastas (AMSA Philippines) Sohaib Mukhtar (AMSA Kyrgyzstan) Ester Elita Emir (AMSA Indonesia) Emir Gibraltar Faisal (AMSA Indonesia) Cecilia Audie Sutedja (AMSA Indonesia) Kristen Tsan (AMSA Australia) Rainbow Wu (AMSA Australia)

AMSEP MASTERCLASS

2022 O

n 23 January 2022, AMSA International held their fourth masterclass of the tenure, the AMSEP Masterclass, with the theme ‘Forging ever-lasting connections with our Virtual/Physical counterparts across the globe’. The masterclass aims to give the delegates a glimpse of participating in an exchange, whether becoming an outgoing or a host. The masterclass was eventful as a lot of delegates from numerous chapters attended the event. It was held via Zoom Meeting and lasted for approximately three hours (13.00-16.00 GMT +8).

Introduction to the AMSEP Board 2021/2022 and Progress Report

he event started with an introduction to AMSEP. The International Director of AMSEP, Dr. Rahul Rangan, presented the AMSEP Board 2021/2022 to the delegates. He introduced his two secretaries, Ms. Nurul Ain Nadia as the Secretary of Documentation AMSEP Board 2021/2022 and Ms. Tatyana Milenia as the Secretary of Electives AMSEP Board 2021/2022. Dr. Rangan continued by introducing the National Directors of AMSEP in each chapter, which received a positive response from the audience as their DoAMSEPs are highly appreciated by Dr. Rangan. Then, Dr. Rangan presented the AMSEP, EAMSEP, and FAMSEP progress reports from 2018 to 2021. Overall, from the charts shown to the audience, AMSEP, EAMSEP, and FAMSEP showed an affirmative growth in terms of the number of delegates involved, contracts, and feedback.

Introduction to AMSEP

ext, Ms. Nurul Ain Nadia introduced the AMSEP subsidiary to the audience in more detail. She explained that AMSEP aims to provide opportunities for AMSA members to participate in student exchanges. Ms. Nadia also explained how AMSEP is conducted in a physical way and virtual way, and how they differ. This includes the minimum of hours per day the event should be conducted, contracts, payment fees, exchange forms, and amendments. Although the virtual and physical AMSEP differ from one another, they still cover the three important pillars of AMSEP, which includes academic, socio-cultural, and community service.

Conduction to AMSEP

s. Nadia continued by presenting on how to conduct an AMSEP to the delegates. She shared some tips that the delegates must pay attention to in order to host an AMSEP, which includes creating a central theme for the event, establishing a good two-way communication, creating fun and interactive sessions, and making the overall event beneficial and memorable. She also highlighted the important deadlines that must be kept in mind, such as the application forms as well as the post-exchange report. There are a few documents that must be completed when hosting an AMSEP as well. Overall, the information shared regarding conducting an AMSEP by Ms. Nadia was truly beneficial for the delegates.

Panel Discussion

sharing of experiences and insights then commenced through a discussion composed of four panelists, namely: Kayra Kapran (EMSA Yeditepe European Integration & Culture (EIC) Pillar Director 2020/2021); Loni Yike Ombara (Director of SCOPEFAMSA); Marjorie Ong (Director of AMSEP 2019/2020AMSA International); and Davyna Abysha (Director of AMSEP 2020/2021AMSA International). Kayra and Marjorie both shared that their most memorable moments in conducting exchanges happened in their first year. Kayra, who was then an assistant in his current position, recalled a certain exchange with IFMSA Rotterdam, saying, “That event made me who I am and who I wanted to be. I got the chance to see all of the experiences and all of the planning firsthand. It was hard but enjoyable at the same time.”

Marjorie, on the other hand, recalled her “pilot experience” which sparked her interest in leadership. On facing obstacles in conducting exchanges during the pandemic, Davyna believes the biggest hurdle is communication. “With the different time zones– my superiors or my exchange partners are at the other end of the world–, when things need immediate attention, this becomes a setback. It is important to be proactive and foresee possible setbacks and be ready to think of an action plan.”

Loni suggests further that it is about prioritizing, compromising, and understanding that everybody is busy with their lives. She adds that she has struggled in trying to explain to people that virtual exchange is just as beneficial as the physical one, in the context of Zoom fatigue. She, however, reiterated, “It’s about embracing a new culture and learning how to adapt which is something we had to do the last two years.” Marjorie also banks in, saying that finding a middle time zone and understanding relevant guidelines are ways that can ease communication.

In addition to communication, it is also challenging to ensure that virtual exchanges are as interactive as physical ones. But Davyna happens to have learned how to address that, saying she encourages her constituents to prepare a delegate bundle consisting of guidelines and protocols, as well as to conduct case discussions, games, and breakout room activities to enhance participation in virtual exchanges.

Towards the end of the panel discussion, each of the speakers gave their last piece of advice especially to those who are just starting out to partake in exchanges. For Marjorie, being a leader comes with responsibility, and it has a great domino effect if one is not responsible for a position. Loni, on the other hand, stressed the importance of communication, teamwork, attainable goals, and general respect for everyone with different cultures. Kayra encouraged forming an intimate bond with one’s team and emphasized the importance of delegates’ feedback. This was followed by Davyna further saying that it is important to listen to the delegates’ expectations and needs, whether in virtual or physical exchanges.

Written by Lloyd Barba eNewsletter Editorial Board 2020/2021

Gifta Hamiseno eNewsletter Editorial Board 2020/2021

Small Group Discussion

hortly after the panel discussion, the delegates were divided into small groups in breakout rooms to do a small group discussion. The topics discussed were in accordance with the masterclass’ theme. The delegates were given cases about problems that may be faced when conducting an AMSEP. One example is finding a solution when an AMSEP must be converted from physical to virtual due to the COVID-19 pandemic. The delegates were given

approximately 25 minutes to discuss and place the result in a PowerPoint file. Then, the delegates were given 3 minutes to present their presentation in the mainroom to all of the delegates. The SGD got a positive feedback from the delegates as Dr. Rahul Rangan gave his opinions regarding the presentations and highly praised the delegates.

All in all, the AMSEP masterclass went extremely well and the delegates were satisfied with the overall rundown. The delegates were able to meet new friends and gain new experiences through the

masterclass. The event was closed by Dr. Rahul Rangan himself as well as Ms. Nadia and Ms. Milenia. At the end of the day, the masterclass ended and the delegates took home a very useful knowledge.

Written by Annete Claudia Keiko AMSA-Indonesia University of Gadjah Mada

AMSAxEMSA ICCD 2022

Twibbon Challenge

s there is an ever-growing effort to raise awareness and recognise the detrimental effects of childhood cancer, AMSA International and EMSA decided to join forces and support International Childhood Cancer Day 2022. ICCD is a day that promotes appreciation and deeper understanding of issues and challenges relevant to childhood cancer and its impact on children or adolescents. With 2022’s ICCD theme being “better access to treatment and care for all children with cancer everywhere”, it spotlights the need for more equitable and fair access to care. We execute our week long online campaign consisting of various infographics and a twibbon challenge. A twibbon is a template design that can be overlaid on a picture or social media post in order to show support for a specific cause. Through this, we hope to showcase international support and increase the existence of ICCD. We thank everyone who has taken part in this twibbon challenge. Remember, big change comes from hundreds of tiny steps and they all matter. #ICCD2022 #AMSAxEMSA

MEET THE

EXPE

ERT

SLEEP

HOW IT IMPACTS

THE BRAIN

Greetings, People of Tomorrow! The AMSA International eNewsletter once again returns with the highly anticipated Afternoon Tea with AMSA: Instagram live session. This session is a two-hour talk show on the topic of brain and sleep, and how the two affect each other. The talk show was held on Saturday, 26 February 2022.

leep is presumably one of the most important aspects of human life. The average person would spend a total of 26 years sleeping throughout their life! This equates to approximately 2 2 7 , 7 6 0 hours! Multiple studies have s h o w n t h a t

during sleeping, the brain is actually very active in processing multiple information that was acquired during the day. Therefore, it is not surprising to see that sleep is linked to the various intricate functions of the human body such as memory, even other nonneurological functions such as immunity and hormone levels. During this session, the AMSA International E-Newsletter invites one of the renowned experts in the field of neurology to shed some information regarding the importance of sleep and how it affects our brain.

AFTERNOON TEA WITH AMSA: A Talk about the Brain The session was hosted by Garry Soloan and Celestina Salvador, the staff of the editorial board of the AMSA International eNewsletter. This Afternoon Tea with AMSA invites Dr. Deibby Mamahit, the Secretary-General of AMSA Alumni Club (AMSAAC), who is currently working as a Brain Consultant in Brainworks Singapore.

Sleep for Medical Students During the talk show, Dr. Deibby shared to us the importance of sleep, sleep cycle, as well as having a proper sleep schedule. Dr. Deibby highlighted the challenge of maintaining a sleep schedule, especially among medical students, who may be exposed to multiple tasks that can reduce the time they allocate to sleep. “Especially for students during the clinical years, it must be tough to maintain a proper sleep schedule with all the night shifts and mountains of work that you have” she further emphasized.

According to Dr. Deibby, sleep allows cells to repair, regrow and reorganize specifically our neurons. Toxins built up throughout the day are removed during sleep which allows our brain to really function well during the day. It definitely helps our memory, concentration and learning process as it replenishes energy sources in the brain that are depleted during wakefulness. She also agreed that lack of sleep has a negative effect on our mental health. With the accompanied stress as a medical student, it causes us irritability and unexplained exhaustion the whole time.

Tips However, Dr. Deibby did share some tips on how we can maximize sleep quality despite a busy lifestyle. One of which, is to minimize the time we spend on our gadgets during the night, as they prove to be a great distraction from our sleep, and more often than not, we are guilty of scrolling through our phones for multiple hours before we sleep, sacrificing the precious time we could have used to rest. Another is to have regular exercise, as it hastens the sleep onset and evidently enhances the quality of sleep. Melatonin supplements which are widely available may also be used to aid us in sleeping faster, this goes with the use of scented candles and essential oils.

Dr. Deibby advocated prioritizing sleep in order for our brains to function very efficiently.

Written by Garry Soloan eNewsletter Editorial Board 2020/2021

Celestina Josefa Beatrize Salvador eNewsletter Editorial Board 2020/2021

HEALTH I

H ISSUES

Written by: Anjali Mediboina AMSA India Alluri Sitarama Raju Academy of Medical Sciences

WHAT HAPPENS WHEN YOU DON’T SLEEP? Imagine all the things you could accomplish without sleep in the way. You could finish an entire TV series, get that last-minute assignment done... In theory, it sounds quite practical. But in reality (or in this case, physiologically), here’s what would actually happen:

■ In the first 24 hours, you’d be fine; sleeplessness would stimulate the mesolimbic pathway in the brain, which causes the release of dopamine. You’d feel happy and energetic. ■ After these 24 hours, your brain starts to slow down, and the parts of the brain responsible for decisionmaking and planning start to shut down, causing impulsiveness. Your movements would become exhausted, sluggish and lethargic and cognitive impairment would also occur.

■ At 48-72 hours of no sleep, glucose metabolism shuts down initially, followed by protein metabolism. Soon, all energy sources become depleted, and by the end of the third day, you’d start hallucinating. ■ By the second week, the immune system would become extremely weak, making you prone to infections, and by the third week, your organs would start shutting down, and death may occur due to heart failure[2].

It’s not uncommon to hear about people not getting enough sleep; according to a survey in 2018, 51% of adults worldwide did not get the required number of sleep[3]. In America, a study in the same year revealed that 73% adolescents also fail to meet the required hours of sleep[4]. Ironically, and unfortunately, we seem to have the tendency to associate less sleep with more productivity. Aside from having negative physical effects, sleeplessness also has a vicious cycle with mental health, either contributing to, or exacerbating mental health conditions. Insomnia has been linked to anxiety and depression; furthermore, sleeplessness has also been associated with obesity, cardiovascular diseases, diabetes and other comorbidities[1]. Thus, getting adequate sleep is incredibly vital to our mental and physical wellbeing. Sleeping on time, and waking up on time can help us be productive, happy and healthy.

So, get some sleep. The world can wait.

REFERENCES: 1.

What Are Sleep Disorders? [Internet]. Psychiatry.org. 2022 [cited 14 February 2022]. Available from: https://www. psychiatry.org/patients-families/sleepdisorders/what-are-sleep-disorders 2. Poll G. What Would Happen to Your Body If You Stopped Getting Any Sleep? [Internet]. INSH. 2018 [cited 14 February 2022]. Available from: https://insh.world/ science/what-would-happen-to-yourbody-if-you-stopped-getting-any-sleep/ 3. Stats: 51% of Adults Worldwide Don’t Get Enough Sleep [Internet]. Travel Agent Central. 2018 [cited 14 February 2022]. Available from: https://www. travelagentcentral.com/running-yourbusiness/stats-51-adults-worldwide-dont-get-enough-sleep 4. Is Your Teen Getting Enough Sleep? 73% Don’t. Here’s Why [Internet]. Healthline. 2018 [cited 16 February 2022]. Available from: https://www.healthline.com/healthnews/73-of-high-school-students-dontget-enough-sleep

Written by: Benyapa Wongsaravit AMSA Thailand College of Medicine, Rangsit University

HOW TO IMPROVE SLEEP QUALITY It is a well-known fact that medical students all around the world are notoriously known for their inconsistent sleeping schedules. Some may be stuck in the operating room with back-toback emergency cases while some may be on-call duties for the past 36 hours. Nevertheless, due to the unique nature of our profession in which a working 9 to 5 does not exist, we can all agree that most medical students do not get their standard 7 to 8 hours of sleep. As a result, medical students have developed various tips and tricks in order to improve their sleep quality even with 2 to 3 hours of sleep. As someone who has had insomnia since she was a child and is currently in her clinical years in medical school, I have created a well-developed routine that has helped reduce any sleeping problems I had over the years. Although everybody’s sleep routine is different and is individually tailored, I believe the fundamental of a

good bedtime routine is just simply one thing, which is a consistent nighttime routine or pre-sleeping habits. Pre-sleeping habits are crucial aspects in getting a good night’s sleep. Personally, I think developing consistent habits that are suitable to your needs will promote quality sleeping wherever you go. My tip for maintaining a consistent nighttime routine is to keep every step simple. For instance, my pre-sleep routine only consists of five steps which I start preparing one or two hours before sleeping. The first thing I recommend is to avoid having any food or sweets before bed for at least three hours. I like to avoid having any food before bed since this may lead to an upset stomach which affects my sleeping quality. The second tip is to start preparing and planning one hour prior before getting any sleep. What this means is if you know you want to sleep

in about an hour, start planning simple things beforehand like brushing your teeth, getting a cup of water, going to the bathroom ahead of time, or start packing for tomorrow’s activities. This is important since as soon as you are in bed, you can avoid things like getting up to get water or going to the bathroom, or even stressing about forgetting tomorrow’s agenda. The next step is to dim the lights as much as possible with the exception of a bedside lamp. The fourth tip is to eliminate stress and clear away any thoughts before bed. This may sound simple but it is in fact the hardest routine of them all. Over the years, I found out that if I have any thoughts bothering me, this will lead me to overthink everything which will interrupt my sleeping time. To resolve this issue, I found out that after I dimmed the lights, I like to listen to some soothing music whether it is instrumental, classical, or even ASMR videos. This tip has proven

very effective to me since the main point of this tip is to help eliminate any stress that will affect my sleeping quality. Last but not least, for people like me who can not avoid playing on their phone before bed, I recommend setting a timer of about 5 to 10 minutes to limit overplaying on the device. Although these tips may sound broad and simple, personally these techniques have helped me fall asleep faster. Not only has my sleeping quality improved, but I also have an easier time falling asleep in foreign places. Nevertheless, what works for one person may not work for another thus, these nighttime routines may not be for everyone. With that in mind, I hope that my tips and techniques may be helpful to everyone, especially to medical students like me who also seek to improve sleep quality in the future.

SLEEP HYGIENE

WHAT IT IS AND WHY IT MATTERS

ASPIRE 36

Written by: Diya Bashetty AMSA India Shri Atal Bihari Vajpayee Medical College and Research Institute

Let’s face it - all of us have at some point in time used the words “I am going to fix my sleep schedule from today”, haven’t we? I have, and many of the people around me have too. Many articles, especially these days, have spoken about the rise in sleep deprivation among young adults and associated stress or lack of proper “Sleep hygiene”. So, what is this sleep hygiene? And why haven’t we been taught about this in school along with brushing our teeth twice a day and taking a bath daily? Sleep hygiene, a lesser spoken about term in contrast to personal hygiene, is basically having a bedroom environment and daily routines that promote consistent, uninterrupted sleep. Ideal sleep hygiene more or less would look like keeping a detailed sleep schedule, setting up a comfortable bed with no distractions, following a calm pre-bed routine and cultivating healthy habits during the day that contribute to a good night’s sleep.[1] Well, why is sleep hygiene important? In a survey of 150 Indian medical students, 30.6% reported an ESS > 10, indicating daytime sleepiness; sleep quality in females was better than in males. Sleep and sleepiness were found to be worse for interns and postgraduate trainees than for medical students. [2] The Johns Hopkins Precursors Study, a long-term prospective study, was conducted on

1,053 men who provided information on sleep habits during medical school. This study advocated that insomnia in young men was indicative of a greater risk for subsequent clinical depression and psychiatric distress that continued for at least 30 years.[3] The correlation between sleep, lifestyle and mental health is pretty well established. According to a study done to assess sleep hygiene awareness and its relation to sleep quality, sleep hygiene awareness was moderate on the whole and significantly worse in young adults (compared to the other age groups).[4] Thus, being aware and having good sleep hygiene is very vital to improve the quality of life in all spheres (and even improve our academic performance!) So, before we get into how to practise good sleep hygiene it is important to know the signs of poor sleep hygiene. They include: ■ Having a hard time falling asleep ■ experiencing frequent sleep disturbances ■ suffering daytime sleepiness ■ An overall lack of consistency in sleep quantity or quality Finally, let’s get down to some actionable tips on developing good sleep hygiene.

1. Having a fixed wake-up time Although easier said than done, waking up at a fixed time every day (yes, even weekends) is vital for healthy sleep hygiene as it helps your body set into a consistent rhythm.

2. Prioritise sleep Another tip which is easier said than done, but important! Being a medical student and in a field where getting less sleep for studying is often glorified upon, it becomes necessary to consciously put an effort into prioritizing sleep and, more importantly not feeling guilty about it!

3. Having a pre-bed routine It’s important to trick your brain into thinking that it’s time to sleep- let’s start with the classic wearing pyjamas and brushing your teeth. But anything that helps you set into the mood of sleep time can be a part of your pre-bed routine.

4. Cutting down caffeine consumption in the afternoon and evening Coffee is a stimulant and it keeps your brain active even when it is tired, therefore disrupting your normal sleep-wake cycle. So, try to stay out of consuming too much caffeine after the afternoon.

5. Getting daylight exposure Did you know that light, especially sunlight, is one of the key drivers of circadian rhythms that can encourage quality sleep? Yes, you heard it right! However, exposure to light right before sleep isn’t a healthy thing to do as the light can hinder the production of melatonin, the sleeping hormone secreted by the pineal gland.

Other lifestyle modifications include: ■ Being physically active ■ Restricting smoking ■ Reducing alcohol consumption ■ Avoiding late dinner ■ Restricting in-bed activity Lastly, it is important to know that although the basic concept of sleep hygiene applies to everyone, an ideal sleep hygiene regimen can vary from person to person. Therefore, it is necessary to try out different techniques and figure out what works the best for you, because every human is unique!

REFERENCES

Suni E. Sleep hygiene [Internet]. US: Sleep Foundation; 2021 Nov 29 [cited 2021 Feb 18]. Available from: https://www. sleepfoundation.org/sleep-hygiene. 2. Giri P, Baviskar M, Phalke D. Study of sleep habits and sleep problems among medical students of Pravara Institute of Medical Sciences Loni, Western Maharashtra, India. Ann Med Health Sci Res. 2013;3:51–4. 3. Chang PP, Ford DE, Mead LA, CooperPatrick L, Klag MJ. Insomnia in young men and subsequent depression. The Johns Hopkins Precursors Study. Am J Epidemiol. 1997;146:105–14. 4. Voinescu BI, Szentagotai-Tatar A. Sleep hygiene awareness: its relation to sleep quality and diurnal preference. J Mol Psychiatr. 2015;3(1):1.

JUJUBE TEA : A Magic from Asia to Help Your Insomnia Written by: Florentia Amanda C AMSA Indonesia Faculty of Medicine, Sriwijaya University

Have you ever watched a Netflix series named Our Beloved Summer? For those who watched it may have known jujube tea as it was captured on some episodes to help Choi Ung, an architecture artist, to get rid of his insomnia. For those who haven’t watched the series yet, that’s ok, we aren’t going to talk about that, instead this article is about the jujube tea which could be a solution for those who are having insomnia and other sleep issues. Jujube seed (Ziziphus zizyphus) also known as Suan Zao Ren or Red Chinese dates, belongs to the Rhamnaceae family and it came from a small deciduous tree or shrub with thorny branches that grows 5 to 10 meters tall. The tree produces edible oval fruits which have dark red to purple-black color and wrinkle texture, also it contains a single hard seed inside. Jujube grows in Korea, Japan, China, India, and other Asian nations. For 2.500 years, traditional practitioners originally from China have extracted the seeds from jujube fruit and used them to alleviate stress and insomnia, also to appetite stimulants, digestive aids, antiarrhythmics, and contraceptives. A scientist called Michael Brus found that jujube contains a flavonoid compound, spinosin, which affects serotonin to trigger sleepiness. Beside the flavonoid, jujube extracts also have saponins. Some studies found that flavonoids and saponins extracted from jujube could reduce wakefulness, limited restlessness, and extended sleep duration. It also has an impact on the brain to decrease

activity of the hippocampus, where overexcitation can delay sleep onset. Other studies said that flavonoid and saponins extend Rapid Eye Movement (REM) and Slow-Wave-Sleep (SWS) in the night sleep cycle. Besides, it could calm the central nervous system and increase overall sleep duration. Not only do they have a positive impact on sleep and regulating the mood, jujube seeds also have some promising other health benefits. As it was mentioned before, jujube fruits contain flavonoid to help sleep issues, besides the fruits itself are rich in other antioxidant compounds, such as polysaccharides, triterpenic acids, and high level of vitamin C. Jujube polysaccharides can scavenge DPPH radical and OH radical. Those antioxidant compounds can prevent and reverse damage caused by excess free radicals, neutralize harmful cells, and decrease inflammation. Therefore, it can help prevent damage in the liver and Diabetes mellitus (Type 2 Diabetes). Some studies said that the vitamin C in the fruit has an anticancer component that could kill thyroid cancer cells in mice. Other researchers found that the extracts could kill several cancer cells in ovarian, cervical, breast, liver, colon, and skin. The vitamin C could also boost the immune system. Jujube fruits are high in fiber too! For those who have digestive problems, they may eat the fruit or make an extract of tea.

You have read all of the interesting benefits from jujube seeds, now let’s see the recipe of jujube tea!

To make the jujube tea you will need : 1. 2. 3. 4. 5.

4 ounces dried jujube 1 ounce peeled ginger, sliced thinly 6 cups of water 1 cinnamon stick Pine nuts, tips removed

These ingredients are worth 3-4 persons. If you only drink it for yourself, that’s ok, you can save the rest of the tea in the refrigerator to drink it later.

Now, let’s make the tea! 1. First, wash and clean the fruits in cold running water. You can rub the jujubes to make sure it’s clean enough. Then, drain the water. 2. Slice the jujubes into big portions (2 or 4 slices). 3. Boil the water in a glass kettle or stainless steel pot, then add the jujubes, ginger, and cinnamon stick. Boil it for 30 minutes on medium low heat. 4. Reduce the heat to low then simmer for 1 hour. After that, remove the pot from the heat. 5. Get a large bowl and strainer, then pour the boiled water into the bowl. Then, mash and press the condiments with a wooden spoon to get the jujube’s pulp. Make sure you mash and press it well, so there won’t be waste. 6. Discard the condiments. 7. Put the strained tea into the kettle or pot, then reheat. 8. Pour the tea into cups, sprinkle with some pine nuts, then voila!

The jujube tea is ready! Well, now you can make your own jujube tea and fall into your sweet dreams. May this article help, ciao!

REFERENCES: 1.

Drugs.com (2021). Jujube Uses, Benefits & Dosage - Drugs. com Herbal Database. [online] Drugs.com. Available at: https://www.drugs.com/npp/jujube.html. Maangchi (2022). Jujube ginger tea (Daechu-saenggangcha: 대추생강차) recipe by Maangchi. [online] www.maangchi.com. Available at: https://www.maangchi.com/recipe/daechusaenggangcha [Accessed 15 Feb. 2022]. Mahmoudi, R., Ansari, S., Haghighizadeh, M.H., Shakiba Maram, N. and Montazeri, S. (2020). Investigation the Effect of Jujube Capsule on Sleep Quality of Postmenopausal Women: A Double-blind Randomized Clinical Trial. BioMedicine, 10(4), pp.42–48. MOMENTOUS (2020). Improve Your Sleep with Wild Jujube Seeds – Momentous. [online] discover.livemomentous. com. Available at: https://discover.livemomentous. com/ar ticles/ improve -your-sleep -with-wild-jujube seeds/#:~:text=%E2%80%9CJujube%20contains%20a%20 flavonoid%20compound [Accessed 15 Feb. 2022]. Shergis, J.L., Ni, X., Sarris, J., Zhang, A.L., Guo, X., Xue, C.C., Lu, C. and Hugel, H. (2017). Ziziphus spinosa seeds for insomnia: A review of chemistry and psychopharmacology. Phytomedicine, [online] 34, pp.38–43. Available at: https: //www.sciencedirect.com/science/article/abs/pii/ S0944711317300788 [Accessed 2 Jun. 2021]. Shoemaker, S. (2019). What Is Jujube Fruit? Nutrition, Benefits, and Uses. [online] Healthline. Available at: https:// www.healthline.com/nutrition/jujube#benefits [Accessed 15 Feb. 2022]. Sobhani, Z., Nikoofal-Sahlabadi, S., Amiri, M.S., Ramezani, M., Emami, S.A. and Sahebkar, A. (2019). Therapeutic effects of Ziziphus jujuba Mill. fruit in traditional and modern medicine: a review. Medicinal Chemistry, 15. The Editors of Encyclopaedia Britannica (n.d.). jujube | Description, Tree, Fruit, & Species | Britannica. [online] www. britannica.com. Available at: https://www.britannica.com/ plant/jujube [Accessed 15 Feb. 2022].

SLEEPING VS. THE WORLD Written by: Gifta Marshanda Qanitah Hamiseno AMSA Indonesia Faculty of Medicine, Universitas Airlangga

Written by: Mahocca Carlo AMSA Indonesia Faculty of Medicine, Universitas Airlangga

WHAT THE FUDGE IS SLEEP? Sleep is an essential part of our lives. We need it to relax and recharge our body. It requires several brain functions to sleep, including hormonal patterns and the brain structures. The American Academy of Sleep Medicine recommends seven to nine hours of sleep daily [1]. By having a good night sleep, we would be able to function well throughout the day as it is strongly correlated with quality of life, physical and mental health, learning, memory forming, behaviour, and increased attention [2]. Therefore, it is important to have a good sleep every day.

There are a lot of factors that can affect our sleep. One example is our mood, an internal feeling that can impact our external aspects through our behaviour [3]. This includes how we treat other people, how we work, and how we sleep! What we feel actually affects our quality of sleep. On the other way around, sleep can also affect our mood the next day! Like feeling grumpy and tired when we don’t have a good sleep quality. Studies have shown this to be true, so let’s discuss the correlation between mood and sleep quality!

How do you stabilise your personal life with your sleeping quality? Humans are deprived of the intensity on the basis of quality and quantity of sleeping, it suggests a more impact on people’s daily activities. Being awake in a day is consuming so much energy that the body needs some time to recover. That is where your personal situations come into play. Humans cannot live without social interactions and relationships. Relationships determine how we feel towards ourselves and other people. Studies have shown that the quality of our social relationships affects our mood and eventually our quality of sleep. A 15year long study using the Pittsburgh Sleep Quality Index on the correlation between personal relationships and the quality of sleep underlined that people with healthy relationships tend to have better sleep compared to those with toxic relationships [4]. This study also pointed out that people who have not been in a close relationship for the past 12 months experienced lower quality of sleep. This indicates that they may experience loneliness, which affects their mood deeply. Another study found that loneliness is strongly correlated with sleepless nights [5]. From this, we can say that surrounding ourselves with positive people can improve our mood, leading to a peaceful sleep.

SLEEP AND MOOD If we call how mood affects our sleep as the ‘pre-event’ of sleep, then how sleep affects our mood would be the ‘postevent’. The duration of sleep that we have may significantly affect our emotions. Research stated that sleep is crucial for cognitive function so we can focus during the day [10]. Without sufficient sleep, we would not be able to concentrate well. This may be experienced by patients with mood disorders like anxiety, depression, bipolar, and so on. For instance, people with insomnia suffer from sleep deprivation and emotional instabilities the next day [9]. People who suffer from degenerative diseases like Parkinson’s can also suffer from mood instabilities. As a result, this takes away their sleep as their unstable mood disrupts it. A study mentioned that patients with Parkinson’s who are sleep deprived tend to suffer from Excessive Daytime Sleepiness due to anxiety and depression that they often experience at night [8]. This leads to lower quality of sleep and possibly increases the consumption of sleeping medications, which may not be good for the patient’s health.

#FUNFACT!

Did you know that using social media can affect our mood? Well now you know! Using social media makes us afraid of missing out on any latest information, known as ‘Fear of Missing Out’ or ‘FoMO’. As social media update themselves every second, we tend to stay on it to make sure that we are up to date with the current news. We tend to worry when we stay off of it. For this reason, it can take away our sleeping hours. A study confirmed that students who compulsively use social media tend to have sleepless nights as they constantly refresh their timeline [6]. Furthermore, another one found that 68 percent out of 93 percent of students who start their first lecture at 8 a.m. are sleep deprived due to late night social media use [7]. For this reason, it is important to use social media wisely so we do not give away our sleeping hours to it.

SLEEP VS. MEDICAL STUDENTS: HOW DO WE MAKE PEACE WITH IT? How do you sleep as a student? Studies presume on how sleep is affecting students’ activities during the day. Sleep quality should be an essential factor on how well students’ academic performance results. If students have a good sleep quality, it might help them on how well they receive materials given during classes. In an opposite factor, it might unease students to receive those materials given. As a medical student, how do you maintain a good and sustainable activity while stabilising your sleep quality? A question enacted on a daily basis of a medical student, more in the examination is pinpointed on how less sleep is taken during the day. More in which less is given a fact on how medical students are filled with agendas that consume day and night,

sometimes taking sleep hours of a normal person. Based on an article by Christodoulou et al. pinpointed on French medical students regarding their sleep quality. Using an MCQ method about basic sleep hygiene rules to students in the 4th, 5th, 6th, years of medicine, the results obtained from 177 participants included 49.7% with poor sleep. Based on sleep latency, 44.6% are students who have under 30 minutes to fall asleep at least once a week, around 26.5% slept 6 hours or less by night, and 42.4 % considered their sleep as ‘bad to very bad’. Other than that, the authors obtained an analysis regarding knowledge about basic sleep hygiene. Only 31% of the students were aware of good sleep habits [11].

HOW TO STUDY EFFECTIVELY WHILE NOT DISTURBING YOUR GOOD NIGHT SLEEP? 1. Take breaks when studying! Have you ever heard of the pomodoro technique? It is a common method that students use in order to study effectively while getting sufficient rest. Here, students must follow a strict time schedule when studying. The most common study-rest ratio used is the 25:5 ratio. Here, you allocate 25 minutes to fully focus on what you are studying (no distractions at all!). Once the time ends, you have 5 minutes to take a break without looking at the study materials at all. You can use this short time to stretch or grab some snacks. This way, your focus would not be altered so you can study more efficiently.

2. Make your study time more enjoyable! Try to maintain your study as a hobby! The ideology of a torture-mindset study is infectious that contradicts students true academic goal. The statement that supports this term is the fact that people still keep believing that studying is a struggle. For example, when people play video games they have their spirit to achieve the winnings without any exhaustion. This is because they are enjoying what they do. But in terms of studying, people get sleepy because of how unenjoyable people think studying is. We obtained the following steps to achieve on the basis of making your study enjoyable.

a. Implement your study with pop culture! These days, movies and TV may be a direct influence on society. Grey’s Anatomy, House M.D, The Good Doctor, and ER are people’s leading references on medical TV series. Many students take big inspiration from those shows. To make your study session more interesting, try to implement some of the pop culture references to your study. For example, when studying anatomy, imagine yourself as one of the doctors in ER. That would make your study more engaging.

b. Music If you find your study full of silence, you can cheer it up with some taste of music, or even try to make your study materials into lyrics of a song. By doing this, the materials you study can be easier to memorise. For example, there is this song called The Krebs Cycle song that can help you to memorise the steps of the Krebs Cycle.

c. Study in different vibes Places can have a major impact on people’s work, especially when it comes to studying. Just imagine, your workplace is your bedroom all of the time, no fresh air, not even a single moment to find yourself something new. All of this can lead to boredom in studying. Find a nice and comfortable cafe with a quiet situation. Your study experience will take you to a whole new level!

REFERENCES: 1.

Carley D, Farabi S. Physiology of Sleep. Diabetes Spectrum. 2016;29(1):5-9.

L. Bey, M.T. Hamilton Suppression of skeletal muscle lipoprotein lipase activity during physical inactivity: a molecular reason to maintain daily low-intensity activity. J. Physiol., 551 (2) (2003), pp. 673-682

Sekhon S, Gupta V. Mood Disorder [Internet]. Ncbi.nlm.nih.gov. 2022 [cited 19 February 2022]. Available from: https://www.ncbi.nlm.nih.gov/books/ NBK558911/

4. Stafford M, Bendayan R, Tymoszuk U, Kuh D. Social support from the closest person and sleep quality in later life: Evidence from a British birth cohort study. Journal of Psychosomatic Research. 2017;98:1-9. Available from: https://www.sciencedirect.com/science/article/pii/S0022399917303562 5.

Gordon A, Carrillo B, Barnes C. Sleep and social relationships in healthy populations: A systematic review. Sleep Medicine Reviews. 2021;57:101428. Available

from:

https://www.sciencedirect.com/science/article/pii/

S1087079221000137 6. Tandon A, Kaur P, Dhir A, Mäntymäki M. Sleepless due to social media? Investigating problematic sleep due to social media and social media sleep hygiene. Computers in Human Behavior. 2020;113:106487. Available from: https://www.sciencedirect.com/science/article/pii/S0747563220302399 7.

Lopes M, Gutierres G, Pavoni M, Mendes A, Campos M, Bastos I et al. Social media for students’ sleep health promotion – a health intervention report during COVID -19. Sleep Epidemiology. 2021;1:100018.

8. Palmeri R, Lo Buono V, Bonanno L, Sorbera C, Cimino V, Bramanti P et al. Potential predictors of quality of life in Parkinson’s Disease: Sleep and mood disorders. Journal of Clinical Neuroscience. 2019;70:113-117. Available from: https://www.sciencedirect.com/science/article/pii/S0967586819311294 9. Kaur H, Spurling B, Bollu P. Chronic Insomnia [Internet]. Ncbi.nlm.nih.gov. 2022 [cited 19 February 2022]. Available from: https://www.ncbi.nlm.nih. gov/books/NBK526136/ 10. Stepan M, Fenn K, Altmann E. Effects of sleep deprivation on procedural

errors.

Journal

2019;148(10):1828-1833.

Available

Experimental from:

Psychology:

General.

https://psycnet.apa.org/

doiLanding?doi=10.1037%2Fxge0000495 11. Christodoulou N, Maruani J, d’Ortho M, Lejoyeux M, Geoffroy P. Sleep quality of medical students and relationships with academic performances. L’Encéphale. 2021;. Available from: https://www.sciencedirect.com/science/ article/abs/pii/S0013700621002335.

TETRIS, SLEEP, AND ANESTHESIA

ASPIRE 36

Written by: Japmehr Kaur Sandhu AMSA India Government Medical College, Amritsar

Sleep is a natural form of the unconscious state while the anesthetic state is an artificial form of unconscious state. The shared characteristics range over the fact that the individual is unconscious, minimally sensitive to exogenous stimuli and presents resistance to the shift to consciousness while the difference revolves wholly around induction and intent. The kicker is that the state of anesthesia is also very similar to the NREM (Non–rapid eye movement) phase of sleep. The neurological mapping in both these states show immense similarities. Which leads up to the assumption that the phenomenon of dream formation may occur when the patient is under anesthesia too.

Stickgold et al [1] described something called a Tetris phenomenon which associated the content of dreams with the pre-dream episodic memory. Participants reported an obvious shift in dream content after playing the game Tetris continuously. Following this, experiments demonstrated a similar phenomenon when dreams were evoked with the help of suggestions immediately prior to anesthesia. These were not REM dreams like we are used to hearing about. Instead, they were what we call NREM dreams. The latter contain elements of episodic memory, usually related to the most recent events while the former has been linked more to old events or memories. It has been highlighted that the incidence of dreaming under anesthesia also depended on the choice of anesthetic agent with propofol use reporting a higher incidence than scopolamine [2].

Dreams under anesthesia are unlike REM dreams due to the lack of bizarreness in them. They are cinematic [3] and full of color and more in line with NREM mentation. In normal sleep dreams, we also observe contemporaneous sensory input being incorporated into the dream like being able to hear the alarm clock next to the sleeper. This is also seen in dreams under anesthesia in a slightly less uniform manner- there is still incorporation of the environmental stimuli but not in terms of the dream’s content.[4] But of course, there are criticisms to this theory. It has been argued before, that humans are unaware of dreaming during the actual sleep duration and simply have an ability to concoct the entire dream when transitioning from sleep to wakefulness. While such a claim is difficult to reject outright, it is highly unlikely that a vivid dream can be made up in a split second like that. If that were true, we would all be Kubricks and Scorseses. This has been defended by highlighting that the estimated dream durations have been matched to actual REM sleep durations in the past and physical motions of the dreamers have been linked to similar movements in their dream context.

Neuroimaging has also shown similar results when compared to actually performing an action in reality versus thinking of performing that action theoretically. EEGs look superficially the same for active waking and REM sleep.[5] A strong activation of the occipito-temporal visual cortex is also seen which corresponds to the vivid visual imagery of dreams. The consistency between a patient’s cognitive abilities and dreaming does not end here. Even in patients with neuronal deficits, their dreams will correspond to the same. This is why patients with impaired face perception do not dream of faces and blind people who lose their vision before the age of 5 do not see images in their dreams. The conclusion is simple and utterly mind-blowing. The human brain, when isolated from its surroundings (when under anesthesia), apparently has the ability to build an entire universe of conscious experiences on its own. Further, this inception may not be caused by perceptions, but rather from imagination and subtle persuasions. So perhaps Nolan was spot on when in the movie Inception, it is said “Reality is that which, when you stop believing in it, doesn’t go away”; In which case, we certainly mustn’t be afraid to dream a little bigger.

REFERENCES: 1.

Stickgold R, Malia A, Maguire D, Roddenberry D, O’Connor M. Replaying the game: hypnagogic images in normals and amnesics. Science. 2000 Oct 13;290(5490):350-3. doi: 10.1126/ science.290.5490.350. PMID: 11030656 Cascella M., Fusco R., Caliendo D., Granata V., Carbone D., Rosaria Muzio M., Laurelli G., Greggi S., Falcone F., Forte C., Cuomo A. Anesthetic dreaming, anesthesia awareness and patient satisfaction after deep sedation with propofol target controlled infusion: A prospective cohort study of patients undergoing day case breast surgery. Oncotarget. 2017; 8: 7924879256 Nofzinger, E. A. (2006). Neuroimaging of sleep and sleep disorders. Current Neurology and Neuroscience Reports, 6(2), 149–155.doi:10.1007/s11910-996-0038-3 Gyulaházi, J., Redl, P., Karányi, Z. et al. Dreaming under anesthesia: is it a real possibility? Investigation of the effect of preoperative imagination on the quality of postoperative dream recalls. BMC Anesthesiol 16, 53 (2015). https://doi. org/10.1186/s12871-016-0214-1 Nir, Y., & Tononi, G. (2010). Dreaming and the brain: from phenomenology to neurophysiology. Trends in cognitive sciences, 14(2), 88–100. https://doi. org/10.1016/j.tics.2009.12.001

Written by: Kayshev Varman Surendren AMSA Malaysia School of Medicine, International Medical University

Better Sleep by Improving Mental Health through Sahaja Yoga Meditation

There is a close relationship between sleep and mental health where poor sleep results in poor mental health and vice versa1. Therefore, by improving mental health, one’s sleep can also be improved. There are various methods to improve one’s mental health. This article focuses on the method of Sahaja Yoga meditation. Sahaja Yoga meditation was founded by Shri Mataji Nirmala Devi in 19702. Shri Mataji, who was the wife of Sir Chandrika Prasad Srivastava3 travelled a lot for Sahaja Yoga. In 1990, her travels (not including informal events in homes, airports, halls and schools) totalled more than 135,000 kilometres for scheduled talks that addressed the need for spiritual ascent4. Shri Mataji was also invited by the United Nations from 1990 to 1994 to speak about ways to achieve world peace5. In 1995, she was also the official guest of the Chinese Government to speak at the United Nations International Women’s Conference5. On the other hand, Shri Mataji’s life and work were also honoured by Mr Claes Nobel (grandnephew of Alfred Nobel) in a public speech at the Royal Albert Hall in 19975. At the 105th Congress (1997) and 106th Congress (2000) of the United States of America (USA), Congressman Eliot Engle also read an honorarium into Congressional Record to commend Shri Mataji on her work for humanity5. The foundation of Sahaja Yoga meditation is the awakening of the subtle energy that resides at the base of the spinal cord which is known in Sanskrit as the Kundalini6. This awakening which is known as selfrealisation is a spontaneous process that is centred on an individual’s choice to take it up and practice it6. No prior knowledge or spiritual practice is required to receive one’s self-realisation6. This self-realisation

facilitates the establishment of the state of ‘thoughtless awareness’, which is a state where the brain is at rest yet aware of the surroundings6. The establishment of ‘thoughtless awareness’ also occurs spontaneously and effortlessly and this is one of the factors that differentiates Sahaja Yoga meditation from other methods6. Furthermore, Sahaja Yoga meditation which is currently established in more than 95 countries does not charge any money for self-realisation or the teaching of Sahaja Yoga meditation7. Based on studies conducted, Sahaja Yoga meditation has benefits to one’s mental health. The first benefit is the changes in brain activity. In one study, electroencephalography (EEG) of Sahaja Yoga meditation practitioners showed increasing theta (θ) oscillating networks during meditation and this was correlated with joy experienced during 8 meditation . There was also lesser gamma (γ) synchronization in the EEG of Sahaja Yoga meditation practitioners when facing negative emotional stimuli which indicated lesser emotional workload among Sahaja Yoga meditation practitioners when

facing these situations8. The lesser emotional workload among Sahaja Yoga meditation practitioners can also be suggested by their reduced judgement of thoughts and other people9. Sahaja Yoga meditation practitioners also demonstrated larger grey matter volume (GMV) overall and this larger GMV was also associated in one study with usedependent enlargement with regular practice10,11. Sahaja Yoga meditation also helps in mental health disorders. In some studies, there was a reported reduction in anxiety and depression12,13. Sahaja Yoga meditation also reduces stress14. This was shown by decreased sympathetic activity (indicated by increased galvanic skin resistance) and a more relaxed state (indicated by decreased blood lactate and urinary vanillylmandelic acid [VMA] levels)14. A reduction in medication was also observed after Sahaja Yoga meditation15. In a study about attention deficit hyperactivity disorder (ADHD), of the 20 children who were receiving medication at the start of the research, 11 had r e d u c e d the dose during

Sahaja Yoga meditation treatment (two by less than half, six by half and three by more than half)15. In this study, the participants (children) also shared some comments on benefits of Sahaja Yoga meditation that they observed such as ‘relaxing’, ‘helps me with my headaches’, ‘getting into less of a panic’ and ‘I seem to be able to concentrate more’ 15. In conclusion, although each study explored above had its limitations, Sahaja Yoga meditation does improve a person’s mental health. Therefore, each individual should search for the method that works best for them and follow it once found to always maintain a state of better mental health. Thus, with an established state of better mental health, an optimal quality of sleep can be experienced daily.

REFERENCES: 1.

Harvard Health Publishing. (2021). Sleep deprivation can affect your mental health. Retrieved February 2, 2022 from https://www.health.harvard.edu/newsletter_article/ sleep-and-mental-health

Vishwa Nirmala Dharma. (2020). About Sahaja Yoga. Retrieved February 2, 2022 from https://www.sahajayoga.org/whatissy/default.asp

Sahaja Yoga World Foundation. (2022). A Noble Inheritance. Retrieved February 2, 2022 from https://shrimataji.org/a-noble-inheritance/

4. Sahaja Yoga World Foundation. (2022). Uniting the Nations. Retrieved February 2, 2022 from https://shrimataji.org/uniting-the-nations/ 5.

Sahaja Yoga World Foundation. (2022). Recognizing Her Work. Retrieved February 2, 2022 from https://shrimataji.org/awards/

6. Sahaja Yoga World Foundation. (2022). Self-Realization. Retrieved February 2, 2022 from https://shrimataji.org/self-realization/ 7.

Sahaja Yoga World Foundation. (2022). Shri Mataji Nirmala Devi: A Life Dedicated to Humanity. Retrieved February 2, 2022 from https://shrimataji.org/

8. Chung S. C., Brooks M. M., Rai M., Balk J. L. & Rai S. (2012). Effect of SahajaYoga Meditation on Quality of Life, Anxiety, and Blood Pressure Control. The Journal Of Alternative And Complementary Medicine. 18(6). 589–596. DOI: 10.1089/acm.2011.0038 9. Hendriks T., Pritikin J., Choudhary R. & Danyluck C. (2021). Exploring the Relationship Between Character Strengths and Meditation: a Cross-Sectional Study Among Long-Term Practitioners of Sahaja Yoga Meditation. International Journal of Applied Positive Psychology. https://doi.org/10.1007/s41042-021-00052-0 10. Hernández S. E., Dorta R., Suero J., Barros A. L., González J. L. M. & Rubia K. (2020). Larger whole brain grey matter associated with long-term Sahaja Yoga Meditation: A detailed area by area comparison. PLoS ONE. 15(12). e0237552. https://doi.org/10.1371/ journal.pone.0237552 11. Hernández S. E., Suero J., Barros A., González J. L. M. & Rubia K. (2016). Increased Grey Matter Associated with Long-Term Sahaja Yoga Meditation: A Voxel-Based Morphometry Study. PLoS ONE. 11(3). e0150757. https://doi.org/10.1371/journal. pone.0150757 12. Hendriks, T. (2018). The effects of Sahaja Yoga meditation on mental health: a systematic review. Journal of Complementary and Integrative Medicine, 15(3), 20160163. https://doi.org/10.1515/jcim-2016-0163 13. Morgan, A. (1999). SAHAJA YOGA: AN ANCIENT PATH TO MODERN MENTAL HEALTH? Retrieved August 9, 2021 from https://pearl.plymouth.ac.uk/bitstream/ handle/10026.1/1969/ADAM%20MORGAN.PDF;sequence=1 14. Panjwani U., Gupta H. L., Singh S. H., Selvamurthy W. & Rai U. C. (1995). EFFECT OF SAHAJA YOGA PRACTICE ON STRESS MANAGEMENT IN PATIENTS OF EPILEPSY. Indian Journal of Physiology and Pharmacology. 39(2). 111 – 116. Retrieved on August 9, 2021 from https://www.ijpp.com/IJPP%20archives/1995_39_2/111-116.pdf 15. Harrison L. J., Manocha R., Rubia K. (2004). Sahaja Yoga Meditation as a Family Treatment

Programme

for

Children

with

Attention

Deficit-Hyperactivity

Disorder. Clinical Child Psychology and Psychiatry. 9(4). 479-497. https://doi. org/10.1177/1359104504046155

Alteration of Circadian Blood Pressure Rhythm and Hypertensive Nephropathy Written by: Ming-Han Leng AMSA Taiwan National Taiwan University; National Taiwan University Hospital

ASPIRE 36

Written by: Ting-Wei Kao AMSA Taiwan National Taiwan University; National Taiwan University Hospital

Circadian rhythm is referred as the endogenous biological alterations which follow a 24-hour cycle and synchronized both by the central clock in the suprachiasmatic nucleus of the hypothalamus as well as peripheral clocks systemically [1,2]. Homeostasis of the host is pronouncedly regulated by the day-night chronobiology. Fluctuation in the blood pressure (BP) is among the manifestations exemplifying the impact of circadian rhythm. Disrupted circadian rhythm is associated with the compromise of morning BP surge (MBPS) and nocturnal dipping. Furthermore, the presence of abnormal circadian BP rhythm is prevalent in individuals with chronic kidney disease (CKD) and was suggested be associated with worse renal prognosis [3]. Detailed elucidations toward the mechanism of circadian BP rhythm and the attempts to offer appropriate BP management with concomitant renal insufficiency remained a clinical unmet need.

Both intrarenal renin–angiotensin activation system (RAAS) and its circulating components have been addressed as the cornerstone in the regulation of vascular pressure and sodium homeostasis. Ohashi et al studied the circadian rhythm of the intrarenal RAAS by assessing urinary angiotensin level [4]. Altered circadian rhythm of the intrarenal RAS was further demonstrated to independently bring about renal damage and hypertension in patients with CKD [5]. Two hypotheses were conceptualized to interrogate the circadian BP rhythm. One is the pacemaker theory which argues the natural rhythm is generated from oscillators within the central nervous system. The other asserted resonance phenomenon secondary to the baroreflex initiated by the inhibition of sympathetic tone after every increment in BP level [6]. Circadian BP rhythm is also orchestrated by the sodium sensitivity determined by the renal capacity for excretion. Sodium sensitivity is regulated by balance between glomerular filtration capability and rate of tubular sodium reabsorption. Accordingly, sodium sensitivity is amplified when glomerular filtration rate is reduced, e.g. CKD, and in the context of enhanced tubular sodium reabsorption, including primary aldosteronism (PA), diabetes mellitus, and metabolic syndrome. The nocturnal dipping in BP is blunted in patients with high sodium sensitivity, leading to the elevation of glomerular capillary pressure, albuminuria, and eventually aggravated to irreversible renal dysfunction [7]. PA is a classic example exhibiting the consequences of disorganized circadian BP rhythm in response to metabolic derangement. Aldosterone plays a crucial role in the maintenance of BP through adjustment of extracellular volume, vascular tone, and cardiac output. As the most common causes of secondary hypertension in young adults, PA is pinpointed to be intertwined with compromised hemodynamics parameters [8] and wide spectrum of target organ damage [9]. Early literature also indicated the circadian BP rhythm under PA shifts to a non-dipping pattern and would be restored after surgical removal of adrenal adenoma [10].

Obtuse or absence of nocturnal BP dipping is common in CKD, and the disrupted circadian BP rhythm is correlated with elevated all-cause mortality and increased risk of deterioration in renal function [11]. Etiologies of nondipping BP included activation of intrarenal RAAS, exacerbated sodium and fluid retention, impaired baroreceptor sensitivity, altered sympathetic nervous system activity, endothelial dysfunction, and escalated arterial stiffness [12]. Exaggerated MBPS is in conjunctionally a pivotal risk factor for CKD progression in patients with CKD and hypertension, regardless of baseline BP level and dipping pattern [13]. To facilitate the appreciation of circadian BP rhythm, accurate and chronological documentation of BP was highlighted. Taiwan Hypertension Society and Taiwan Society of Cardiology jointly proposed the “722” principle to guide home BP monitoring [14] (Figure). Additionally, 24-hour ambulatory BP monitoring (ABPM) is a key modality to inquire the daily fluctuation. As compared with office BP measurements, ABPM was illustrated to better predict clinical outcomes, classify hypertension, and evaluate treatment response upon subjects with CKD and poorly-controlled hypertension [15].

As for future therapeutic implications, chronotherapy emphasizes the significance of circadian BP rhythm in the timing to administer antihypertensive agents. Hermida et al demonstrated angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blockers (ARB) exerted more substantial BPlowering effects at asleep than awake BP, potentially due to the activation of RAAS during nocturnal sleep [16]. Aoki et al further proposed renal damage could be rescued with chronotherapy by suppressing intrarenal RAAS, especially in individuals with CKD in addition to nocturnal hypertension [17]. However, whether antihypertensive medications other than ACEi or ARB would exert the similar time-dependent therapeutic benefit remained elusive. In conclusion, BP is closely correlated with circadian rhythm. Specific daynight fluctuations of the BP level have been demonstrated to be associated with aggravated renal function decline in patients with CKD, potentially mediated by the activity of RAAS. Advocation of the “722” principle for the general public to record home and potentially with the incorporation of 24-hour ABPM will catalyze the generation of chronological BP database. Guidance of chronotherapy with antihypertensive agents by better comprehension of the BP rhythm is the ultimate goal to improve clinical prognosis and integrated care in such population.

Acknowledgement: nil. Disclosure: The authors declared no conflict of interests. Figure legend: The “722” principle for home BP monitoring. BP: blood pressure. (Derived from Taiwan Society of Hypertension and Taiwan Society of Cardiology)

[1] Costello HM, Gumz ML. Circadian rhythm, clock genes, and hypertension: recent advances in hypertension. Hypertension. 2021;78:1185-96. [2] Zhang J, Sun R, Jiang T, et al. Circadian blood pressure rhythm in cardiovascular and renal health and disease. Biomolecules. 2021;11:868. [3] Song J, Li Y, Han T, et al. The difference between nocturnal dipping status and morning blood pressure surge for target organ damage in patients with chronic kidney [4] Ohashi N, Isobe S, Ishigaki S, Yasuda H. Circadian rhythm of blood pressure and the renin-angiotensin system in the kidney. Hypertens Res. 2017;40:413-22. [5] Isobe S, Ohashi N, Fujikura T, et al. Disturbed circadian rhythm of the intrarenal renin-angiotensin system: relevant to nocturnal hypertension and renal damage. Clin Exp Nephrol. 2015;19:231-9. [6] Biaggioni I. Circadian clocks, autonomic rhythms, and blood pressure dipping. Hypertension. 2008;52:797-8. [7] Kimura G. Kidney and circadian blood pressure rhythm. Hypertension. 2008;51:827-8. [8] Kusunoki H, Iwashima Y, Kawano Y, et al. Circadian hemodynamic characteristics in hypertensive patients with primary aldosteronism. J Hypertens. 2018;36:2260-8. [9] Chan CK, Chang YY, Tsai YC, et al. Taiwan mini-frontier of primary aldosteronism: updating treatment and comorbidities detection. J Formos Med Assoc. 2021;120:1811-20. [10] Uzu T, Nishimura M, Fujii T, et al. Changes in the circadian rhythm of blood pressure in primary aldosteronism in response to dietary sodium restriction and adrenalectomy. J Hypertens. 1998;16:1745-8. [11] Velasquez MT, Beddhu S, Nobakht E, Rahman M, Raj DS. Ambulatory blood pressure in chronic kidney disease: ready for prime time. Kidney Int Rep. 2016;1:94-104. [12] Zhang J, Rao J, Liu M, et al. Abnormal circadian rhythm of urinary sodium excretion correlates closely with hypertension and target organ damage in Chinese patients with CKD. Int J Med Sci. 2020;17:702-11. [13] Liu X, Zhang T, Qin A, et al. Association of morning blood pressure surge with chronic kidney disease progression in patients with chronic kidney disease and hypertension. J Clin Hypertens. 2021;23:1879-86. [14] Lin HJ, Wang TD, Yu-Chih Chen M, et al. 2020 Consensus statement of the Taiwan Hypertension Society and the Taiwan Society of Cardiology on home blood pressure monitoring for the management of arterial hypertension. Acta Cardiol Sin. 2020;36:53761. [15] Huang QF, Yang WY, Asayama K, et al. Ambulatory blood pressure monitoring to diagnose and manage hypertension. Hypertension. 2021;77:254-64. [16] Hermida RC, Ayala DE, Fernández JR, Portaluppi F, Fabbian F, Smolensky MH. Circadian rhythms in blood pressure regulation and optimization of hypertension treatment with ACE inhibitor and ARB medications. Am J Hypertens. 2011;24:383-91. [17] Aoki T, Ohashi N, Isobe S, et al. Chronotherapy with a renin-angiotensin system inhibitor ameliorates renal damage by suppressing intrarenal renin-angiotensin system activation. Intern Med. 2020;59:2237-44.

REFERENCES

disease. J Clin Hypertens. 2020;22:2025-34.

SLEEP, STRESS, AND MEDICAL STUDENTS:

How Academic Stress Impacts Medical Students’ Sleep Quality and ViceVersa Written by: Moses Orvin Reviano AMSA Indonesia Faculty of Medicine, Universitas Airlangga

INTRODUCTION It’s a fairly known phenomenon, that medical students are highly stressed individuals. Most of their stressors, cause of stress, are due to the academic weight that they carry as scholars of medicine, one of the most stressful fields of education due to the increasing demand for excellence as a professional practising physician. It’s been proven that chronic mental stress in medical students can cause a few behavioural symptoms, such as sleep disorders and depression.1

WHAT ARE THE MAIN STRESSORS IN MEDICAL STUDENTS? Stressors for medical students come in many kinds and forms, but can be categorized into three different categories. There are academic stressors, psychosocial stressors, and lastly, health-related stressors. A few studies found that the main stressors in medical students are, unsurprisingly, academic stressors.1-2 Academic stressors are defined as academic-related demands that cause responses from the student’s body because they exceeded the student’s adaptive capability.3 In one study, the most commonly experienced academic stressors in medical students are caused by exam frequency and academic performance.1 This is also in line with another study which also found the main causes of academic stressors as academic overload, taking examinations, and also oral presentations, as well as lack of time to meet commitments.2

WHY SLEEP IS AFFECTED BY STRESS LEVELS? Sleep quality can be defined as a person’s general level of satisfaction with their sleep experience. Their satisfaction with their sleep experience is generally graded by a few marks, which are the quantity of sleep, their sleep continuity, and the revitalizing feeling after waking up.4 High levels of stress can impact sleep quality by impacting their sleep architecture, which is another way of saying how sleep is segmented into different stages. Stress can create a disparity between rapid eye movement (REM) and non-rapid eye movement (NREM) sleep.5 This statement can be supported by another study that found high levels of stressors can decrease REM sleep.6 The segment of the sleep cycle where the human mind goes to dream is called REM sleep. Dreaming during REM sleep has been shown to have a major part in processing negative experiences, i.e. stress.6

WHY SLEEP IS IMPORTANT? Studies show that a higher quality of sleep can impact a medical student’s day-to-day life, such as improving memory and cognitive abilities to perform better academically, reducing the risk for cardiovascular disease, and obesity, as well as improving moods.7-10 And it’s not just with sleep quality, a study about sleep quantity involving 3000 participants who are high school students, found that students who have better grades have more sleep quantity, earlier bedtimes on school nights, and lowered delayed sleep on weekends compared to that of students with lower grades.11 Which, for most medical students, better grades are the foremost goal in their academic years.

WHAT CAN MEDICAL STUDENTS DO TO HELP AID THEIR STRESS LEVELS? As medical students, it would make sense for them to want to lower or at least cope with their academic stressors. One of the best-proven ways of managing stress to help sleep quality is by practising good sleep routines. Sleep routines can be approached differently by many people, so here are a few proven ways that can help aid stress levels. Light physical activities, such as yoga, meditation, tai-chi, and qigong may help to unwind before bed.12 On the other hand, reducing screen time before bed also has been proven to help protect the circadian rhythm, the sleep-wake cycle, from interference by the blue light emitted from most electronic devices, such as televisions, smartphones, tablets, etc.13 A study found that overeating three hours before bedtime has been correlated to longer sleep latency, shorter sleep duration, and is more likely to wake up mid-sleep.14 However, some studies found that eating light, but highly nutritious snacks or some calming drinks, such as warm milk or chamomile tea would do the opposite effect.15-17 Moreover, aromatherapy has been proven to help some people to relax and unwind after a stressful day. Some of the essential oils that are used in aromatherapy are lavender oil, peppermint oil, basil oil, and helichrysum oil.18-19 Lastly, a study found that warm baths or showers lead to a moderate cooldown that mimics the body’s natural process of falling asleep. This activity can help to shorten the duration of falling asleep for some people.20

CONCLUSION In conclusion, academic stress is one of the main causes of poor sleep quality in medical students. This phenomenon can cause sleep disorders, depression, and lead to poorer performance academically, which ironically, is the cause of poor sleep quality, to begin with. So, it’s with utmost importance that as future physicians, medical students have to start practising good sleep routines in order to maximize their sleep quality and quantity to holistically be better physicians in general.

REFERENCES: 1.

Waqas A, Khan S, Sharif W, Khalid U, Ali A. Association of academic stress with sleeping difficulties in medical students of a Pakistani medical school: a cross sectional survey. PeerJ. 2015;3:e840.

Alsulami S, Al Omar Z, Binnwejim MS, Alhamdan F, Aldrees A, Al-Bawardi A, Alsohim M, Alhabeeb M. Perception of academic stress among health science preparatory program students in two Saudi universities. Adv Med Educ Pract. 2018;9:159.

Wilks SE. Resilience amid academic stress: The moderating impact of social support among social work students. Advances in social work. 2008;9(2):106-25.

Rachlin DJ. Encyclopedia of behavioral medicine. Reference Reviews. 2013; 27(7):40-1.

Vandekerckhove M, Wang YL. Emotion, emotion regulation and sleep: An intimate relationship. AIMS Neurosci. 2018;5(1):1.

Kim EJ, Dimsdale JE. The effect of psychosocial stress on sleep: a review of polysomnographic evidence. Behav Sleep Med. 2007;5(4):256-78.

Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL. Consensus statement of the American Academy of Sleep Medicine on the recommended amount of sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12(11):1549-61.

Owens J, Au R, Carskadon M, Millman R, Wolfson A, Braverman PK, Adelman WP, Breuner CC, Levine DA, Marcell AV, Murray PJ. Insufficient sleep in adolescents and young adults: an update on causes and consequences. Pediatrics. 2014;134(3):e921-32.

Lowry R, Eaton DK, Foti K, McKnight-Eily L, Perry G, Galuska DA. Association of sleep duration with obesity among US high school students. J Obes. 2012;2012:476914.

10. Fitzgerald CT, Messias E, Buysse DJ. Teen sleep and suicidality: results from the youth risk behavior surveys of 2007 and 2009. J Clin Sleep Med. 2011;7(4):351-56. 11.

Wolfson AR, Carskadon MA. Sleep schedules and daytime functioning in adolescents. Child Dev. 1998;69(4):87587.

12. Wang X, Li P, Pan C, Dai L, Wu Y, Deng Y. The effect of mind-body therapies on insomnia: a systematic review and meta-analysis. Evid Based Complement and Alternat Med. 2019;2019:9359807. 13. Wahl S, Engelhardt M, Schaupp P, Lappe C, Ivanov IV. The inner clock—Blue light sets the human rhythm. J Biophotonics. 2019;12(12):e201900102. 14. Chung N, Bin YS, Cistulli PA, Chow CM. Does the proximity of meals to bedtime influence the sleep of young adults? A cross-sectional survey of university students. Int J Environ Res Public Health. 2020;17(8):2677. 15. Kinsey AW, Ormsbee MJ. The health impact of nighttime eating: old and new perspectives. Nutrients. 2015;7(4):2648-62. 16. Valtonen M, Niskanen L, Kangas AP, Koskinen T. Effect of melatonin-rich night-time milk on sleep and activity in elderly institutionalized subjects. Nord J Psychiatry. 2005;59(3):217-21. 17. Chang SM, Chen CH. Effects of an intervention with drinking chamomile tea on sleep quality and depression in sleep disturbed postnatal women: a randomized controlled trial. J Adv Nurs. 2016;72(2):306-15. 18. Hamzeh S, Safari-Faramani R, Khatony A. Effects of aromatherapy with lavender and peppermint essential oils on the sleep quality of cancer patients: a randomized controlled trial. Evid Based Complement Alternat Med. 2020;2020:7480204. 19. Varney E, Buckle J. Effect of inhaled essential oils on mental exhaustion and moderate burnout: a small pilot study. J Altern Complement Med. 2013;19(1):69-71. 20. Haghayegh S, Khoshnevis S, Smolensky MH, Diller KR, Castriotta RJ. Before-bedtime passive body heating by warm shower or bath to improve sleep: A systematic review and meta-analysis. Sleep Med Rev. 2019;46:124-35.

Insomnia: Living with Insomnia

When Counting Sheep How often have you found yourself tossing and turning in bed, incapable of getting a wink of sleep? Time keeps ticking away but you remain wideawake. With each passing minute, the realization that you will soon have to get up for school or work grows. This is what insomnia looks like. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), insomnia is a sleep disorder characterized by “difficulty initiating sleep, difficulty maintaining sleep, and early-morning awakening with inability to return to sleep.” In other words, people with insomnia do not get enough sleep or have poor-quality sleep. The consensus is that children need 9 to 13 hours of sleep per night, whilst adults need 7 to 9 hours of sleep for optimal health. In addition to the aforementioned symptoms, the disorder causes fatigue, irritability, problems with concentration or memory, sleepiness during the day, and impaired work performance. Insomnia manifests itself in diverse ways and can be categorized into two groups: acute (short-term) and chronic (long-term). Acute insomnia typically stems from poor sleep hygiene, life stressors, and environmental factors that disrupt sleep, such as noise and an uncomfortable bed or pillow, and lasts for a few days or weeks, whereas chronic insomnia occurs due to medical conditions and medications. To be diagnosed with chronic insomnia, symptoms must be present for at least 3 nights a week for 3 months or more. As one of the most common health issues of modernity, insomnia greatly influences the lives of millions of people worldwide, ranging from 10% to 30% of the world population, and about 50% of which suffer from chronic insomnia. Its prevalence is higher in females, older adults, and individuals with medical conditions. WRITTEN BY : Neha Ninad Shinde AMSA Indonesia Faculty of Medicine, Universitas Airlangga

Consequences of Insomnia

p Doesn’t Work Before truly grasping the dangers of insomnia, we must first understand the importance of sleep. Sleep is a physiological process that allows the mind and body to rejuvenate. Although it appears to be a passive state, sleep involves a remarkably active interplay of brain circuits and plays a significant role in cognitive performance, productivity, and overall health and well-being. During sleep, nerve cells (neurons) reorganize to process information obtained during the day. Neurons also have toxic waste byproducts removed via the brain’s waste clearance system, called the glymphatic system. This helps maintain healthy brain functioning. Thus, when sleep is deprived, the brain’s glymphatic system is unable to perform its function efficiently, resulting in an accumulation of toxins in the cerebrospinal fluid, a liquid that surrounds the brain and spinal cord. These toxins then act on various areas of the brain, affecting memory, attention, behavior, decision-making, and physical coordination. When lost sleep adds up over time, the effects become progressively worse and may even cause severe brain injury. It can also increase the risk of certain brain diseases. For instance, Alzheimer’s disease and dementia are believed to be caused by the beta-amyloid protein, which is one of the metabolic waste products found in the brain. As the protein builds up, it clumps together to form plaques between neurons, and consequently blocks cell-to-cell communication at synapses. This is why insomnia is closely linked to neurodegenerative diseases—the toxic waste that ought to be cleared up ends up lingering in the brain, thereby reducing cognitive function. Apart from Alzheimer’s, insomnia is associated with several psychiatric illnesses. It often exists secondary to depression, anxiety, bipolar disorder, and attention deficit hyperactivity disorder (ADHD). Depression is the most common comorbidity, and insomnia serves as a diagnostic symptom for depressive disorders. Insomnia exacerbates depression by reducing the levels of serotonin, a happiness-boosting hormone, through changes in the sensitivity of its neurotransmitters in the brain. Mental disorders and insomnia tend to go hand-in-hand; living with a mental disorder aggravates the quality of your sleep, and poor sleep negatively impacts your mental health. It is a vicious cycle that is challenging to break, with many people failing to make improvements to their mental state despite undergoing standard treatments.

The first-line of treatment for acute insomnia is a type of behavioral intervention that involves cultivating good sleep hygiene. In short, sleep hygiene is a practice carried out to develop and maintain healthy sleeping habits aimed to boost sleep quality and overall health. It encompasses both habits and the environment. There are some routines that we can adopt to get the best sleep possible.

Unplug from electronics

Electronic devices emit blue light that restrains the production of melatonin, the hormone that controls your sleep-wake cycle, making it difficult to fall asleep.

Have a fixed sleep schedule

Waking up and going to sleep at the same time every day makes your brain familiar with the times it should release hormones that make you sleepy and awake. This maintains the timing of your biological clock.

Make yourself comfortable

Cool sheets, a comfortable mattress, and cozy pillows are critical to pain-free sleep and can deter you from tossing and turning all night.

Limit food intake before bedtime

Eating close to bedtime can cause indigestion and acid reflux. Both problems impede a good night’s rest and leave you exhausted in the morning.

Chronic insomnia is a more complex condition than acute insomnia because most cases of chronic insomnia are tied to an underlying medical condition, so diagnosing and treating the medical condition frequently relieves insomnia symptoms. Therefore, treatment is unique to each individual, but generally involves medications or therapy9. It is crucial to see a doctor for a proper assessment of your medical history to identify the cause of insomnia and select the most suitable treatment option for you.

Ceiling P

icture this. You’re in your well-lit bedroom, the clock hand showing 11 p.m. You just devoured a whole plate of lamb briyani for dinner 15 minutes ago because the Grab promotion seemed too tempting. Now, slumped against the pillow, you have your phone in one hand and a Starbucks tumbler in another featuring your favourite Butterscotch Latte. The K-drama you’re watching, Crash Landing On You - courtesy of the recent marriage announcement - never ceases to keep you on edge. One moment you’re laughing wholeheartedly at the drama; the next thing you know, you’re lamenting over the fact that it’s already three in the morning. I swear it was 11 p.m just 15 minutes ago. I have to leave the room by eight tomorrow, well I’m doomed! Now, guilt-stricken and irritated, you proceed to turn the lights out. After an eternity of tossing and turning, you’re wondering why you haven’t drifted off to sleep yet. There’s a cobweb floating near the corner of your ceiling, and the fan is screaming back at you, willing you to sleep…

Talks The next morning, you wake up to a different kind of alarm. The kind of alarm that takes the form of your roommate babbling about why you’re not up yet, and there are only 5 minutes left till 8 a.m. You force yourself out of bed to escape from the demon, determined not to repeat the same mistake. The following week, you try going to bed earlier, at least on some days. This time, you convince yourself to lay off the coffee and the drama (albeit not always). Yet, it still takes you more than an hour to fall asleep, and that’s not the only problem. When you do miraculously manage to sleep, you find yourself waking up several times at night, and it takes a while before you drift off again. Most of your days are spent in grogginess and fatigue, despite getting 8 hours of sleep. Often, you find yourself daydreaming and dozing off right in the smack of a lecture, and your friends no longer invite you to their study groups. Word has it; you’ve turned into a crocodile who snaps at anyone nearby. WRITTEN BY : Nur Hasanah AMSA Malaysia Kulliyyah of Medicine, International Islamic University Malaysia (IIUM)

All these problems stemmed from one thing: sleep. Or precisely, the lack of it. Let’s dissect the scenarios now, shall we? Earlier in the story, I depicted all the red flags contributing to a poor night’s sleep, which affected the sleep quantity. However, later, we see that our character has become remorseful and tries sleeping earlier, yet we’re still unable to get a proper night’s sleep with the constant waking up and grogginess the next day. This time, there is poor sleep quality. Briefly, the reasons for poor sleep quality include: • Poor sleep habits – irregular sleep schedule, screen time before bedtime, consuming caffeine and heavy meals less than 2 hours before bed • Stress and anxiety • Obstructive sleep apnea • Chronic health conditions – chronic lung diseases, acid reflux, renal disease and many more Luckily, improving sleep quality correlates heavily with improving one’s sleep hygiene. If one wishes to have sparkling, clean teeth, one should regularly brush and floss their teeth. Similarly, sleep hygiene involves a good sleeping practice that allows one to get good sleep on a common basis.

Personally, the best sleep I’ve had happened while I was quarantined in a building next to the forest. There was no WiFi, minimal human interaction, and the sounds of nature all around. Here, I was truly able to tick the checklist of things required to have a good night’s sleep.

At night, I would barely use my phone or laptop to save up on mobile data, which I would need for my classes during the day. Hence, I was able to shield myself from the blue light that the brain perceives as sunlight, and the melatonin is free to start kicking in.

Without the distracting WiFi, I was also able to go to bed earlier, ranging from 10 p.m. to 11 p.m. and wake up at 6 a.m. the next day. This gave me a solid 7-8 hours of sleep, which is adequate for our age since adults are recommended to get around 7-9 hours of sleep each day.

There are two types of people in this world. One, who is unwaveringly unaffected by coffee, and one who gets wiped out by the coffee. Fortunately, I belong to the latter. I say fortunate because it absolutely deters me from drinking coffee at night as one sip can last me till 3 a.m. in the morning. So, people, avoid your caffeine within five hours of bedtime and reserve it for the glorious morning.

Being in quarantine, there’s not much for you to do. Your everyday routine involves getting out of bed, showering, online classes, eating, and back to sleeping. However, it is the same routine that allows you to go to bed and wake up at the same time every day. With a consistent sleep schedule, the brain recognizes what time to sleep and what time to be awake (daydreaming not included).

Daily exercise is key for a good night’s sleep, as it tires you out in a proper way at night, letting you sleep earlier and giving you quality sleep. However, one should avoid exercising at night since it releases stimulating hormones like epinephrine and adrenaline. There have been cases of people exercising at night, where they suddenly collapse. Further investigations revealed that they’d been overworked during the day yet still forced themselves to exercise at night, and that put a strain on their heart. Therefore, time your exercises correctly.

I’m not usually one for a bedtime routine, and I’m glad to be in this position. A lot of websites recommend having a relaxing bedtime routine like listening to music or reading a book before bed, and many more. However, I find these activities to be mentally stimulating, prolonging the time needed to fall asleep. A discussion with my lecturer further reinforced this belief, where he also does not recommend reading before bedtime as it still gets your brain thinking, especially when you’re hooked onto the story. Instead, I prefer deep breathing exercises before lulling to sleep. However, this is just a personal preference; things may work differently for different people! Your sleep hygiene doesn’t just stop at night. It’s important to get at least 15-30 minutes of the morning sunlight to help you wake up and reset your circadian rhythm. In quarantine, I would quickly take a cold morning shower before soaking up that good morning glow, and it made me feel so alive.

These are briefly some of the tips that helped me to improve my sleep quality. Like most things, nature prevails. Run too far away from it, and you start to see the detrimental effects it has on you. For those living in the city, you might not always have the luxury to be protected by the conditions in pure nature, but you can try your best to simulate living in one. Cut off the WiFi near bedtime, listen to some nature sounds, and give your body the due rest that it deserves. You’ll always be grateful for it the next day, always.

References: • • •

https://www.sleepfoundation.org/sleep-hygiene/how-to-determine-poor-qualitysleep https://www.health.harvard.edu/newsletter_article/8-secrets-to-a-good-nights-sleep https://www.healthline.com/nutrition/17-tips-to-sleep-better#16.-Exercise-regularlybut-not-before-bed

Social Jetlag “Becoming weak Every week”

n a mundane Saturday in his hostel room, Aadil lumbers across his bed to reach for his mobile phone. The hovering clock on the screen tells him that it’s bordering on noon. Light from a screen isn’t usually the first thing to fall on his eyes on any given day, but Saturdays haven’t been the same since the fateful day he discovered movie nights on Fridays- an indispensable escape from the brutal, eternal routineness of life in a medical college. Aadil is far from your typical medical student, mind- he has a regular sleep schedule. He goes to bed as early as 9 pm every night. His curtains don’t let anything as a stray photon enter his room. His pillow is custom-made to perfection for his comfort, on his bed is the cosiest mattress money can buy. He makes sure any edible object with so much as a whiff of caffeine doesn’t get within a mile radius of him once the sun begins to set. He is the prototype morning lark. But he is tired. Even his favourite lectures can barely keep him from yawning every other minute. He is pretty sure he doesn’t snorehis roommates have never complained. And yet, he is tired. He almost feels jetlagged- like he has been to the other side of the world and back. At first, it was just the weekends. Late Friday nights would mean late Saturday mornings too. But

WRITTEN BY : Praveen Bharath S AMSA India KAP Viswanatham Government Medical College, India

Aramva Bikram Adhikari AMSA Nepal Institute of Medicine, Nepal

now the fatigue seemed perpetual and it wasn’t long before his general wellbeing was in jeopardy. His grades suffered and he was losing whatever was left of his social life. Even his mental health was on a downward spiral. Perplexed but in denial, he refused to seek professional help. He had so much confidence in his sleeping methods that he couldn’t even contemplate so much as giving the doctor a visit. Why would he? He couldn’t recall the last time he didn’t manage to get in at least 8 hours of sleep. Every sleep science article that had ever existed, occupied his browsing history. He was the sleep mogul. He had once conquered sleep but it was now bearing down on him. Then one day, something happened. A pandemic hit, the world stopped. People ceased going out and socialising.

It was as if someone had waved a magic wand on him. While everyone around him seemed to be losing all control over their circadian rhythm, his was improving. He had stuck to his immaculate sleep schedule, but the big difference now was that there were no movie nights for him anymore. His energy levels had now skyrocketed resembling his old, confident self. By the time normalcy came back around, he was a different man. Ironically, it was the lack of socialisation that had helped him get back his social life. Now that he had a more positive outlook on life altogether, he wanted to get to the bottom of the issue. So, he finally decided to take a bite off the humble pie and visited a sleep doctor who gave him a better insight into what happened to him.

THE LESSON LEARNT: The world has three different clocks:

The Sun Clock corresponds to the day-night cycle.

The Biological clock is our “internal setting” that controls when our metabolism acts.

Until the 19th century, People had their social lives consistent with the Day-night cycle. Humans had strong “zeitgebers” – environmental cues like sunlight and eating patterns - that helped maintain the biological clock in phase with their sun clock. Thus, all three worked without lags and allowed them to have a sound sleep. The modern lifestyle has brought us Daylight saving that has advanced our social clocks and artificial lighting throughout the day, leaving us with weaker zeitgebers and lagging our biological clocks. The resultant delay caused by this phase difference has led to the concept of “Social Jetlag”.(2) So what’s social in it?

The Social Clock, the “external influence” on our dayto-day functioning.(1)

We often categorise ourselves into Early larks and Late Owls depending upon our productive times in a 24H Cycle.(3) Consider Aadil, a certified Lark, who works well in the mornings and prefers to sleep in early. Due to social habits, he put his sleep schedule late and compensates his “sleep debt” by oversleeping the next day. Thus, his sleep quality gets weak every week. Aadil is lucky to compensate for his sleep debt as most larks are used to getting up early regardless of the time they get a shut-eye. They compensate by sleeping in earlier throughout the weekdays, thanks to their schedules being “Lark-Friendly”.

The fate of a late-night Owl isn’t the same. They love to work at night, but due to all of their schedules, are forced to get up early throughout the weekdays and accumulate a sleep debt to be repaid every weekend. Their sleep quality worsens throughout the week and they need a definite sleep day every week. Looking at most of our schedules, the late-night Owls lose more of their sleep owing to this social jetlag. Studies have shown that People with lesser hours of workday sleep have a higher mortality rate if they don’t have a weekend catch-up.(6)

Everyone who travels long distances experiences “Travel jetlag”. Our Biological clocks take a day to pass over each timezone crossed. Humans, when removed from all social inhibitions will resolve into their sleeping schedules. Which Aadil had experienced during the pandemic when time lost its essence. Before the pandemic, he was going through a “social jetlag” that has a causal relationship with bad academics, increased social habituations, clinical depression, altered diet and eating patterns, which is for obvious reasons due to social time constraints.(1,4,5) The brief removal of such constraints had helped him revert to his best self.

“SLEEP IS THE BEST MEDICATION – DALAI LAMA” Daylight saving: Setting the Clocks an hour earlier during the summer and reverting afterwards as an effort to save energy when industrialization started. Artificial Lighting Effect: Instead of basking under the sun, We live in enclosures with the same amount of electric lighting throughout the day except for when we sleep, unlike medieval times.

References:

1. Roenneberg T, Pilz LK, Zerbini G, Winnebeck EC. Chronotype and Social Jetlag: A (Self-) Critical Review. Biology (Basel). 2019 Jul 12;8(3):E54. 2. Wittmann M, Dinich J, Merrow M, Roenneberg T. Social jetlag: misalignment of biological and social time. Chronobiol Int. 2006;23(1-2):497-509. 3. Horne JA, Ostberg O. Individual differences in human circadian rhythms. Biol Psychol. 1977 Sep;5(3):179-90. 4. Antypa N, Vogelzangs N, Meesters Y, Schoevers R, Penninx BW. CHRONOTYPE ASSOCIATIONS WITH DEPRESSION AND ANXIETY DISORDERS IN A LARGE COHORT STUDY. Depress Anxiety. 2016 Jan;33(1):75-83. 5. Haraszti RÁ, Ella K, Gyöngyösi N, Roenneberg T, Káldi K. Social jetlag negatively correlates with academic performance in undergraduates. Chronobiol Int. 2014 Jun;31(5):603-12. 6. Åkerstedt T, Ghilotti F, Grotta A, Zhao H, Adami HO, Trolle-Lagerros Y, et al. Sleep duration and mortality - Does weekend sleep matter. J Sleep Res. 2019 02;28(1):e12712

Complex Inter

typical scenario seen among many students and full-time workers because of busy schedules and different commitments includes untimely meals, no proper diet, late nights with ever-changing bedtime, and relying on sweet treats to get through the day. Also, the ongoing pandemic has in many ways turned our eating habits and sleep patterns upside down. This has resulted in a vicious cycle of erratic diet, poor sleep, constant fatigue, and a lack of motivation from which there seems to be no escape. However, what one does not realize is that the solution to this situation is much easier than it seems. Both nutrition and sleep have an essential role in our health. However, many times the complex and dynamic relationships between them are overlooked. One’s eating habits influence the quality of sleep in a major way. Not only what one eats but also when one eats can make it easier or harder to get adequate sleep. Similarly getting enough sleep helps in maintaining a healthier body weight. Understanding the bidirectional relationship between sleep quality, and diet has implications for both public health and clinical practice.

Many different lifestyle habits affect sleep. Some of them include regular exercise, a fixed bedtime routine, and limiting screen time. However, one of the most important factors for poor sleep often missed is diet. Research has shown that the food you eat can affect how well you sleep, and your sleep patterns can affect your dietary choices. A study published in the Journal of Clinical Sleep Medicine has discovered that eating a large amount of saturated fat and less fibre led to a reduction in slowwave sleep which is a part of the deep restorative rest required by the body. Also consuming more sugar and simple carbohydrates such as bread, pastries, and pizza results in frequent nighttime awakenings. Also, the timing of meals plays a huge role in maintaining the circadian cycle. Mid-night meals disturb the body’s metabolism which delays the ability to fall asleep and prevents one from getting the much-needed rest. Dietary habits are also linked with causing sleep disorders. Unhealthy eating can result in obesity which is a key risk factor for obstructive sleep apnea. Also, alcohol can worsen sleep apnea by impairing muscle tone throughout the night.

raction Between

Sleep Patterns and Eating Habits This direct effect of food on sleep gives the old saying ‘you are what you eat’ a deeper meaning and has implications in such a manner normally not understood easily. Hence to improve the quality of sleep intake of complex carbohydrates containing high fibre must be increased. They maintain a more stable blood sugar level resulting in better sleep. Recent observational studies have also found out that following a certain dietary pattern such as the Mediterranean diet focusing on vegetables, fruits, whole grains, seafood, poultry, yoghurt, herbs, and olive oil, or the DASH diet which involves reduced salt and saturated fats and a greater emphasis on whole foods with high levels of fibre, magnesium, and potassium reduces the likelihood for insomnia and poor sleep. In addition, having dinner at least three hours before bedtime ensures the best quality of rest.

WRITTEN BY : Radhika Jalan AMSA India H.B.T Medical College and R.N Cooper Hospital, Mumbai

However, let’s not forget that the relationship between poor diet and bad sleep is like a double-edged sword. Epidemiological studies have shown that insufficient sleep is associated with a greater risk for obesity. Lack of sleep causes physiological changes, increasing cravings for foods high in added sugar, fat, and sodium. Clinical trials have shown that sleep deprivation causes increased consumption of calories and snacks throughout the day. Individuals with poor sleep experience more hunger and prefer more sweet foods.

This change in food preferences is because of a disproportion in the levels of appetite-regulating hormones. In men sleep deprivation stimulates increased secretion of ghrelin also known as hunger hormone from the enteroendocrine cells of the gastrointestinal tract which promotes greater appetite and desire to eat. While in women restricting sleep results in lower levels of Glucagon-like peptide 1 causing low satiety. Sleep limited to four hours a night for a week also leads to changes in the brain. There is greater activation in reward centres of the brain such as the ventral striatum and nucleus accumbens to junk food compared to healthy alternatives. Hence sleep deprivation is a proven recipe for weight gain. Despite feeling full, one still wants to eat more. Dieting while not getting adequate sleep is also futile since the weight is lost from the lean body mass and not the fat.

A research study conducted at King’s College London in 2018 had shown that proper sleep even after just five nights can increase one’s willpower to avoid unhealthy foods and help make improvements in diet. Getting enough hours of sleep thus reduces overeating and contributes to weight loss. The main gist is that diet and sleep are interwoven intricately. Focusing on one will automatically improve the other and vice versa, resulting in a positive feedback loop where they sustain one another. Recognizing this connection creates opportunities to achieve good health optimally through both a healthy diet and healthy sleep.

References: 1. Frank S, Gonzalez K, Lee-Ang L, Young MC, Tamez M, Mattei J. Diet and sleep physiology: Public health and clinical implications. Front Neurol. 2017;8:393. 2. Berkley C. What you eat can sabotage your sleep [Internet]. Atlanta: WebMD; 2004 [cited 2022 Feb 6]. Available from: https://www.webmd.com/sleep-disorders/features/ food-sabotage-sleep 3. DiGiulio S. How what you eat affects your sleep [Internet]. Washington DC: NBC News; 2017 Oct 19 [cited 2022 Feb 6]. Available from: https://www.nbcnews.com/better/ health/how-what-you-eat-affects-how-you-sleep-ncna805256 4. O’Connor A. How foods may affect our sleep [Internet]. US: The New York Times; 202Dec 10 [updated 2021 Jan 1; cited 2022 Feb 9]; Available from: https://www.nytimes. com/2020/12/10/well/eat/sleep-foods-diet.html

Knowing the Sleep Disorders:

Narcolepsy sy and Insomnia WRITTEN BY : Shafira Meutia Nadhifa AMSA Indonesia Faculty of Medicine, Universitas Indonesia

What is

narcolepsy & insomnia? Narcolepsy is a lifelong neurological disorder affecting an individual’s sleep-wake cycle that intrudes into wakefulness. Narcolepsy is characterized by pathognomonic signs of excessive daytime sleepiness (EDS), hallucinations (hypnogogic and/or hypnopompic), sleep paralysis, and cataplexy (sudden loss of muscle tone).(1)

In contrast, the term “insomnia” refers to a disorder of hyperarousal throughout the entire day, shown by a state of daytime hypervigilance and nighttime difficulty of sleep initiation and maintenance. The conditions are often associated with difficulty falling asleep, frequent or regular nighttime awakenings with problems returning to sleep, or awakening much earlier than desired. A person with insomnia may suffer from fatigue, mood disturbances, and impairment in functioning, particularly cognitively. As a consequence of sleep deprivation at night, daytime sleepiness may occur –which might slightly resemble narcolepsy to a certain degree.(2)

Are

narcolepsy & insomnia The incidence rate of narcolepsy is estimated to be more or less 1/100.000 per year. The prevalence seems to vary based on ethnicity and gender. Cases of narcolepsy are more likely to be found in males, and the prevalence rate of narcolepsy in Japan is relatively higher (accounting for 0.16%) than in the Middle East and European countries. However, these estimated rates might be affected by other factors as well, such as study designs, age groups, or any factor that might be different in collecting the data.(3)

common?

On the other hand, the prevalence of insomnia is significantly higher, approximately accounting for 30% to 43% of reports of at least one episode of insomnia, with most reports proposing the estimated prevalence rates to be 5% to 15% in general.(2) Age, gender and comorbidities are likely to be associated with the condition. Researchers suggest that insomnia is more common in the elderly and both menopause women as well as women in the onset of menses. Additionally, among all insomnia patients, almost half of them are present with coexisting psychiatric conditions, with depression as the most prominent disorder.(4)

What causes

narcolepsy & insomnia?

Causes of narcolepsy Despite ongoing research, several studies proposed that genetic basis influences the occurrence of narcolepsy to a certain extent. Cases of familial clustering suggest that first-degree relatives of narcolepsy patients have a greater risk of approximately 10-40 times higher compared to general populations.(4) Furthermore, certain HLA haplotypes are observed to be more vulnerable to narcolepsy. Over 85% of narcolepsy with cataplexy patients have HLA DQB1*0602 along with HLA DR2 (DQB1*0602). However, it may not necessarily be a useful diagnostic test as these alleles are not limited to narcolepsy only.(3)

In addition to HLA haplotypes, hypothalamic neuropeptides known as hypocretins or orexins also play essential roles, as these molecules are responsible for sleep-wake cycle regulations, along with food intake and pleasure-seeking behaviour controls. Several brain regions produce hypocretins while corresponding to the secretion of other major neurotransmitters such as norepinephrine, dopamine, serotonin, and histamine. Research suggests that hypocretin deficiency may result in the malfunctioning of brain activities involved, thus leading to REM sleep disturbances and excessive daytime sleepiness.(3) Apparently, the combination of hypocretin deficiency, gene mutations, and loss of hypocretin-producing neurons along with HLA antigens are often associated with autoimmune aetiology. These ideas originated from the presence of motor complex disruption by autoantibodies which proved the autoimmune nature of narcolepsy. Other studies also discovered T-cell polymorphism along with an increase of several cytokines in patients suffering from narcolepsy with cataplexy. (3)

Causes of insomnia As sleep-wake traits are heritable and associated with innumerable genes, studies suggest that heritability and multigene involvement highly correlate to the pathophysiology of insomnia. Several genes that may be involved include the HLA DBQ1*0602, Apoε4, PER34/4, 5-HTTLPR, and Clock gene 3111C/C. A study also found a significant association of single-nucleotide polymorphisms involved in neuroplasticity, stress reactivity, and mental well-being.(2)

Interestingly, corticotropin-releasing factors (CRFs) involved in depression also implicate insomnia. Abnormal regulation of CRF leads to vulnerability to both conditions, hence explaining the reasons for their interlinked emergence.(4)

On a molecular level, insomnia hyperarousal is linked to neurophysiologic and physiologic factors, including hypocretins or orexins (the same signalling molecule involved in narcolepsy), histamine, and catecholamine responsible for wakefulness, as well as GABA, serotonin, melatonin, and prostaglandin D2, which promote sleep. Increased neuronal firing in the wake-promoting/sleep-suppressing region and inhibition of the sleep-promoting/ wake-suppressing region is one possible mechanism leading to insomnia.(2)

Can

narcolepsy & insomnia While there is no definite cure yet, treatments are available to treat or relieve the symptoms of narcolepsy. In the United States, only five medications have been indicated to treat narcolepsy, as researchers are still investigating some drugs to widen the treatment options.(1) Although only showing Level III to Level IV evidence, using caffeine as a stimulant was considered the earliest medication used. However, caffeine consumption should be monitored appropriately as cardiovascular risks may arise when used at a higher dose. Besides medications, nonpharmacological therapies including regular naps and hypnotherapy also showed Level III and Level IV evidence, respectively.(3)

be cured?

Meanwhile, a number of pharmacological therapies for insomnia have undergone trials in real patients. The medications include benzodiazepines, z-drugs, H1 antagonists, melatonin receptor agonists (MT1/MT2), orexin antagonists, antidepressants, antipsychotics, anticonvulsants, and non-selective histamines. Among these drugs, many have shown promising efficacy for insomnia treatment in both younger and older adults. (5) Nonpharmacological therapies available for insomnia also cover a wide range of methods, such as relaxation techniques, sleep restriction –as excess time in bed leads to fragmented sleep–, and controlling stimulus, as conditioned arousal is considered an essential factor in triggering insomnia.(5) As both narcolepsy and insomnia may influence not only the physical but also the mental and social well-being of an individual, psychological therapies along with counselling may be necessary to ensure that patient’s life quality may be maximized to the fullest.(1)

References

1. Barker EC, Flygare J, Paruthi S, Sharkey KM. Living with narcolepsy: current management strategies, future prospects, and overlooked real-life concerns. Nat Sci Sleep. 2020; 12: 453-66. 2. Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest. 2015; 147(4): 11792. 3. Akintomide GS, Rickards H. Narcolepsy: a review. Neuropsychiatr Dis Treat. 2011; 7: 507-18. 4. Roth T. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007; 3(5 Suppl): S7-S10. 5. Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. World Psychiatry. 2019; 18(3): 337-52.

DON’T MESS WITH SLEEP! WRITTEN BY : Shahriar Uddin Khan AMSA Bangladesh Capital Medical University

“You go to the gym and do the most awesome workout possible, meal prep all your macros in every meal, and take all the overpriced supplements you found on a fitness Instagram, yet even though you seem to be doing everything right, your buddy, who started getting in shape about the same time as you, is still getting better result. And he or she does the same workouts but hardly meal preps while eating the occasional pizza and ice cream, and the only supplement he’s taken is a protein shake he bought on sale. So how is this possible? Well, what you didn’t realise is that your buddy is doing better at the number one most important thing outside of exercising than you are. While you’re binge-watching new TV series, or playing a videogame for hours, or even just staying up doing whatever you might be doing on the internet, your buddy is hard at work… sleeping.”

elieve it or not, sleep may be the exact reason why others seem to progress much faster than you are. Or why you just aren’t seeing the results you were hoping for despite putting in the work. We already know how important sleep is just for the sake of survival, after all, all animals have to sleep sometime. When it comes to increasing your gains, sleeping is pretty important.

The Effect of Sleep on Muscle Growth

Sleep helps prevents muscle breakdown and promotes fat loss Although the mechanisms behind this are relatively unclear, a recent 2018 paper helps shed some light on the topic. Researchers analysed the effects of one night of no sleep on 15 young men. Here’s what their bodies experienced after that one night: • their muscles already showed signs of increased protein breakdown • their fat tissue had elevated levels of proteins and metabolites that are involved in promoting fat storage

Sleep plays a crucial role in balancing hormones

When we sleep, our body releases a high amount of muscle anabolic hormones (Testosterone, Growth hormones IGF-1). A study found that subjects suffering from sleep apnea had lower levels of overall testosterone. Sleep also lowers muscle breaking hormones, catabolic hormones (Myostatin, Glucocorticoids, and Cortisol). Cortisol remains elevated when you don’t get a good night’s rest. Without proper sleep, there’s an increased risk of muscle loss and a decrease in the hypertrophic stimulus.

Sleep affects your workout performance

Not only does sleep affect your body on a cellular/hormonal level, but also significantly affects your workout performance. In fact, research has shown that when sleep-deprived, the body tends to give up when it would otherwise normally be physically capable of pushing further. Effects on performance from being sleep deprived include: • Slower reaction time, lower mental and motor capacity • Decrease mood to workout with sleep restriction • Decrease effort, motivation and concentration • Increase the number of mistakes, leading to a possible increase in injuries • Get tired easily, as the body has trouble metabolising glucose at sleep-deprived state

As far as actual performance, sleep deprivation doesn’t really affect your peak capabilities, meaning you still can push heavy weights or perform at a high intensity, but… you’ll get tired quicker.

How Much Sleep Do You Need To Build Muscle? Although this will vary individually, multiple studies have suggested that you aim to get roughly 7 to 9 hours of sleep. With more active individuals required closer to the higher end or even slightly above this range. So if you haven’t been sleeping enough according to this, I’d highly suggest you make an effort to do so for the reasons previously discussed.

What about Naps? Although research does suggest that daytime naps may be beneficial to increase total sleep duration during periods where inadequate sleep is unavoidable, they should not be used as a regular substitute for night-time sleep since it just doesn’t provide quite the same effects.

Improving Sleep Quality & Total Sleep Duration

Improve Your Sleep Hygiene

Coming in on top is improving your sleep hygiene. Quite a few studies have shown this to be effective at reducing the time required to fall asleep and improving sleep quality. Some recommended strategies include: • avoiding any electronic use for at least 30 minutes before bed • using your bedroom strictly for sleep • sticking to a consistent sleep/wake schedule every day.

Avoid Caffeine Within 6 Hours Before Bed

You’ll want to avoid ingesting caffeine shortly before bed. One recent 2013 study actually found that moderate caffeine ingestion 6 hours before sleep reduced total sleep time by 41 minutes. And moderate caffeine ingestion just 3 hours before sleep reduced total sleep time by 63 minutes.

Exercise improves sleep

Evidences suggest that regular exercise pattern helps people improve their sleep quality as well as boost the immune system. Personally, I love doing a bit of light exercise before bed, it does help me fall asleep faster, but results can be different for other individuals.

It is unclear how sleep influences hypertrophy directly, but there are many indirect effects of poor sleep on muscle hypertrophy. Negative effects are exacerbated by chronic sleep deprivation. But all in all, the biggest takeaway from all of these studies is that nothing beats making sure your head is on your pillow for enough hours each night. So although you may get by just fine on less-than-optimal sleep, you’re likely doing a disservice to your hard-earned gains in the gym.

So moral of the story is “Don’t mess with SLEEP” Get your sleep, and get enough of it!

References 1. https://www.science.org/doi/10.1126/sciadv.aar8590 2. https://pubmed.ncbi.nlm.nih.gov/23974210/ 3. https://journals.lww.com/acsm-csmr/Fulltext/2017/11000/ Sleep_and_Athletic_Performance.11.aspx#R6-11 4. https://pubmed.ncbi.nlm.nih.gov/27031035/ 5. https://pubmed.ncbi.nlm.nih.gov/27574901/ 6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3564638/ 7. https://pubmed.ncbi.nlm.nih.gov/19849803/ 8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC535701/ 9. https://pubmed.ncbi.nlm.nih.gov/12952360/ 10. https://pubmed.ncbi.nlm.nih.gov/2657963/ 11. https://pubmed.ncbi.nlm.nih.gov/20370472/ 12. https://pubmed.ncbi.nlm.nih.gov/7761740/ 13. https://pubmed.ncbi.nlm.nih.gov/7199438/ 14. https://pubmed.ncbi.nlm.nih.gov/6822642/

Exercise and S Do you ever thought of doing light exercise after having sleep disturbance or your health professional suggest to exercise as nontherapeutic treatment of Insomnia? Have you been questioning yourself how exercise induce sleep? Then follow me till the end of article, I can probably help you with this query.

xercise has been associated with better sleep. And also proper night sleep cause memory consolidation, clearance of brain metabolites, and restoration of nervous, immune, skeletal, and muscular systems. This bidirectional relationship between sleep and exercise has been proven by several studies. It is found that an acute bout of moderate-intensity aerobic exercise, but not high-intensity aerobic exercise or high-intensity resistance exercise, improved sleep compared to a baseline night in some adults. 30-min increase in the time to fall asleep associated with a 1-min decrease in next-day exercise duration, a 10% increase in sleep efficiency associated with a 5.4% increase in nextday moderate to vigorous exercise activity time. In contrast, some researcher found no relationship between single sessions of moderate-intensity aerobic exercise and sleep during the corresponding night.

Physiologically, sleep is an internally and externally controlled process structured by an interaction of circadian clock and homeostatic mechanism. Daily exercise is quite hard for beginner because of more breakdown of ATP and more release of Adenosine which bind to Adenosine receptor in the brain and give the feeling of tiredness and daytime sleepiness. But the continuous exercise downregulate the Adenosine receptor in the brain and increase the daytime activity level. Exercise increases the sympathetic activity which make us alert. Sleep is a glycogenetic process that replenishes glucose stores in neurons while the awake cycle is designed for repetitive glycogen breakdown. Some authors suggest that patterns of neural oscillations observed during sleep stimulate the neurobiological processes associated with synaptic plasticity and long-term potentiation.

The process of sleep affects the brain at an endocrine level independent of the hormonal regulation of metabolism and waste removal at the cellular level. Furthermore, quality sleep is the possible result of body temperature changes, cytokine concentration changes, increased energy consumption/metabolic rate, central nervous system fatigue, changes in mood and anxiety symptoms, changes in heart rate and heart rate variability, changes in growth hormone secretion, changes in brain-derived neurotropic factor secretion, improved fitness level, and changes in body composition.

Sleep Relation WRITTEN BY : Susmita Khatiwada AMSA Nepal MBBS 2nd year Maharajgunj Medical Campus

Studies have found that nightly variations in various sleep parameters (i.e., sleep quality, subjective sleep latency, and actigraphic sleep efficiency) predict physical activity behavior the following day. Virtually all bodily systems are impacted by poor or inadequate sleep, and chronic sleep disturbance predisposes an individual to cardiovascular disease, metabolic dysfunction, psychiatric disorders, and early mortality. Aerobic exercise training in a sample of older adults with insomnia significantly improved sleep quality while also reducing daytime sleepiness and depressive symptoms. This investigation reported that daily exercise of moderate intensity had differential effects on circadian melatonin rhythm, rectal temperature during nocturnal sleep, sleep stages, and heart rate variability depending on the time of day the exercise is performed. The interpretation of these results suggests that the timing of exercise is important for sleep quality. But it is still the subject of research whether the late night exercise disturbs the sleep?

What is the minimal dose and maximal dose of exercise for quality sleep and health?

But we can conclude that daily light physical exercise help with insomnia and sleep disturbance due to Apnea. So let’s do exercise and be physically and mentally healthy.

Reference

1. Christopher E. Kline, Ph.D. The bidirectional relationship between exercise and sleep: Implications for exercise adherence and sleep improvement. https://www.ncbi.nlm. nih.gov/pmc/articles/PMC4341978/ 2. Brett A. Dolezal1 Eric V. Neufeld1 David M. Boland1 Jennifer L. Martin2,3 and Christopher B. Cooper1 https://www.researchgate.net/publication/315659606_Interrelationship_between_Sleep_and_Exercise_A_Systematic_Review

Listen to You It Urges You

Reasons Why Sleep Deprivation May L

our body wants you to sleep. Contradictory to the famous catchphrase, sleep is not only for the weak. Sleep actually helps you become stronger. It is the time of the day for your body to relax and recover after a long day of work for the cells and tissues. Therefore, sleep is such an important daily activity for human beings. In this article, we will discuss the importance of sleep for our heart health and also some tips for you to have better quality and quantity of sleep in order to become stronger.

“Do our bodies really need to sleep? How much time exactly do I need to sleep every day? What if I can’t sleep?”, as one might ask. It is a very common question, especially for medical students who not only need to study but also sleep. Not only that, this pandemic that is still going on is causing people to sleep less for countless reasons. The answer to these questions is a straightforward “yes!”. There are many benefits to sleeping for your body. It enables them to recharge and regenerate from stress while performing their own tasks. Remember which organ always works every day to sustain our lives? It is our hero – heart. Our heart never stops pumping blood through your blood vessels to every corner of your body so oxygen and nutrients can be delivered. Only by sleeping does your body allow your heart to work lighter and recover quicker.

ur Heart, to Sleep

WRITTEN BY : Timothy Christian AMSA Indonesia Faculty of Medicine, Universitas Padjadjaran, Indonesia

Lead to Heart Problems During the night when we sleep, our metabolic activity is reduced, blood pressure is lowered, and our heart rate is slower. All of these reduce your heart’s workload, but it can only be achieved through a good quality and quantity of sleep (1). According to the American Academy of Sleep Medicine and the American Heart Association, seven to eight hours of sleep per night is an ideal duration of sleep for optimal health (2). However, people have become more and more insufficient in their sleep time. This happens due to advancements in current technologies, as they can work, study, and connect with other people anywhere and anytime, even during their nighttime when they are supposed to sleep. The usage of electronic devices before sleep may also change the body’s own perceptions of sleep. Nowadays, the COVID-19 pandemic also triggers various stresses that may disturb sleep.

Many observational and experimental studies have found that both lack of sleep and fragmented sleep are associated with heightened cardiovascular risk. According to current research, insufficient sleep duration (≤6 hours per day) poses significant risks to cardiovascular function, possibly through increased cardiac stimulation caused by the buildup of plasma and urinary norepinephrine, a chemical that activates our “fight or flight” response. Lack of sleep also causes early damage to the blood vessel’s structure and function. Another thing is that lack of sleep also triggers prolonged inflammation, potentially causing heart problems through plaque formation and hardening of the arteries as it disturbs the perfusion of the heart. Do not forget to mention that lack of sleep also reduces glucose metabolism and insulin sensitivity, causing disruption in hormone regulation that leads to metabolic negative consequences. All these mechanisms amplify the risk of hypertension, coronary heart disease, stroke, heart failure, and arrhythmia (3).

In order to have a healthy life and also a healthy heart, living a healthy lifestyle, controlling risk factors, and having a good quality and quantity of sleep are the keys. Here are some short tips for you to sleep better that you can easily implement in your daily life:

Have a quiet time before bed.

Stop any use of electronic devices 1 hour before sleep, as it can disturb the sleep-wake rhythm in your brain. Avoid consuming caffeine in the evening and limit alcohol consumption. You may choose to read books (physical ones, not electronic ones) or drink herbal tea to help you sleep easily.

Preserve the purpose of your bedroom, especially your bed.

Your bed is only for sleep. Do not do other activities in your bed. By preserving the purpose of your bed, your brain sends you a signal to sleep every time you go to bed. To help you sleep, adjust your bedroom with nice and comfortable pillows, dim lights, a suitable temperature, slow music, and a calm scent, as they might entice you to sleep sooner than you thought.

Be consistent with your sleep schedule.

From the text above, you know that you need to have an ideal duration of sleep time to become healthier. Set your own sleep time; 7-8 hours is the recommendation. Sleep and wake up at the same time each day so you become fresher to start your productive day and have no trouble when you need to sleep or wake up.

Live with healthy habits.

Choose what to eat wisely. Healthy food gives you the most benefits. Be physically active by doing exercise. Not only does exercise during the day make your body more fit and ready to function, but it also helps you sleep easily at night (4,5).

If you have any sleeping disorder, such as insomnia or obstructive sleep apnea, you might need other treatment as well. However, use of sleep medication needs to be consulted with the doctor, especially if you already have heart problems or are on heart medications. This is to prevent any unwanted side effects (5). A personal message from the writer to all the readers: stay safe and stay healthy at these tough times. Do not forget to sleep, as this activity is very crucial. Invest in your own health so you can get through each day better.

References:

1. Suni E, Callendar E. How Sleep Deprivation Affects Your Heart [Internet]. 2020 [cited 2022 Feb 18]. p. 11. Available from: https://www.sleepfoundation.org/sleep-deprivation/how-sleep-deprivation-affects-your-heart 2. Heart Foundation. How does sleep affect your heart rate? - Harvard Health [Internet]. 2021 [cited 2022 Feb 18]. p. 3. Available from: https://www.heartfoundation.org. nz/about-us/news/blogs/how-does-sleep-affect-your-heart 3. Covassin N, Singh P. Sleep Duration and Cardiovascular Disease Risk. Sleep Medicine Clinics [Internet]. 2016 Mar;11(1):81–9. Available from: https://www.ncbi.nlm.nih. gov/pmc/articles/PMC4791534/ 4. Suni E, Vyas N. Sleep Hygiene [Internet]. 2021 [cited 2022 Feb 18]. p. 6. Available from: https://www.sleepfoundation.org/sleep-hygiene 5. Heart Foundation. Dealing with Sleep Problems [Internet]. 2021 [cited 2022 Feb 18]. p. 2. Available from: https://www.heartfoundation.org.nz/your-heart/post-heart-attack/sleeping

INFOGRAPHICS

Sleep is of paramount importance in our life. A sound sleep is essential to keep us sane and healthy. Scientific evidence has proven that sleep impairment can lead to the deterioration of mental health and stress if not properly managed can hamper sleep.

Created by: Manahil Muqqadus AMSA Pakistan CMH Institute of Medical Sciences, MULTAN

ASPIRE 36

ASPIRE #36

CLINICAL CHALLENGE

BRAIN & SLEEP ACROSS 3. Another name for REM sleep (1 word) 5. The rhythm or process that regulates the sleep-wake cycle every 24 hours (1 word) 6. Brain activity that has a frequency of 14Hz and greater (1 word) 7. The 1st phase of sleep and also known as slow wave sleep (1 word) 9. Common sleep disorder where you could not fall asleep, no matter how desperately you try to (1 word) 10. Hormone that promotes the wake state of the brain and inhibits REM sleep (1 word) 11. Small endocrine gland located in the centre of the brain which produces a serotonin derivative related to sleep (1 word) 12. An unpleasant dream characterised by vivid detailed imagery with good recall (1 word)

DOWN

1. Excessive and uncontrollable daytime sleepiness. May occur anywhere and in any circumstance (1 word) 2. Method or diagnostic test used to record the brain’s spontaneous electrical activity (1 word) 4. A condition when your breathing suddenly gets interrupted while sleeping, which often leads to you waking up (1 word) 8. The hormone that is responsible and affects the modulation of sleep-wake pattern (1 word)

Submit your answers here: http://tiny.cc/ClinChal36

HOBBIES SECTION

Law School (K-drama): Review

South Korean series entitled “Law School” is a legal drama that aired on JTBC and Netflix. The story started with a murder case of one of the “Guest” Professors named Professor Seo Byung-Ju during the first mock trial held in Hankuk University Law School, making a Professor named Yang Jong Hoon and his students suspected of murder. Professor Yang is a former prosecutor known as “Yangcrates” due to his teaching style, which resembles the Socrates method. He is straightforward, tends to unleash biting remarks, and does not care about his students’ opinions regarding his teaching. Instead, Professor Yang focused on cultivating personnel for the law field, members who will contribute meaningfully. Professor Kim Eun-Sook, the only colleague who Professor Yang can speak openly with, in Hankuk University Law School. Kang Sol A, Han Joon-Hwi, Kang Sol B, Seo Ji-Ho, Jeon Ye Seul, Yoo Seung-Jae, Min BokKi, Jo Ye-Beom are first-year law school student who is also Prof. Yang’s students and assigned together as a study group.

From the first episode until the mid-episode, explained why everyone could be a suspect, the reason to rebuttal suspicion, and each suspect’s problem. Interestingly, they pictured each suspect and made the viewers think, “OK, this person could be the murderer”. In the forensic investigation, I was fond of how they find et causa of death, such an explanation through legal and medical perspective. In the middle until the last episode, the mastermind behind the whole cases related to each other is revealed. They wrapped up the series exceptionally tremendous and satisfying in the final episode. The OST for drama is not as much as other drama I have watched, but still good to listen and suitable. Despite those positive arguments, several scenes are illogical, such as the scene where the students, the dean, and the professor were having a meal together after the trial.

In conclusion, it is worth watching the series because they emphasize the legal profession differently. Furthermore, the crew researches a lot about legal and medical facts. You will undoubtedly learn a lot from this series.

By: Tatyana Millenia AMSA Indonesia Faculty of Medicine Universitas Padjajaran

CREATIVE CORNER

THY BRIEF ESCAPE POETRY

Created by : Bhumika Raisinghani AMSA Indonesia Faculty of Medicine, Pelita Harapan University

Godlike languor sifts thee to darkness falling unto familiar slumber— thy love for nightly lull as summery as winterly mull. Beyond mind, body but a timeless shift— neither existing nor not infinitely floating, as naught. Utopia, here thy disciple to sight thy kingdom come; florid, bizarre, suave— sporadic visits of familiar faces glee fades in oft cases. Gloomy glum downs on thee as dawn crawls unto thy crib— fresh daybreak sets foot, thy yearn for snooze toots.

THE OTHER SIDE PHOTOGRAPHY

“Seeing is believing, believing is knowing, and knowing beats unknowing and the unknown” - Philip Roth

This is one of the most famous Torii gates in Itsukushima, Japan. Its presence marks the transition of the human world to the otherworldly, sacred place. I took this photo in a hurry since the sun was setting and my group had to hurry to the meeting point for our next destination. The photo came out great, but I just realized there’s a significant warmth contrast on both sides of the photo unintentionally. As if... There are two different worlds, captured in a moment, clashing with each other with the Torii as its entrance. I wonder what is it like on the other side?

Created by : Ellen Callista Angelica AMSA Indonesia Faculty of Medicine, Sriwijaya University

FICTIONAL WRITING

dent when I was a kid; but all I want now is to return to that womb again. It was dark, soft and warm. I must’ve felt safe there. Nevermind, as my mother’s womb sounds just like my bed. A place where I would love to escape.

Dear pages,

Unfortunately, we meet again. Today when I woke up, I thought I was dead. The lights in my room flashed through my eyes like God in heaven. You know, the first dilemma I had was,” what did I do to end up in heaven?” Wait, let me start from the beginning. One hell of a ride! So I was going through a rough patch lately. Things between Sean and I are a little bit bumpy. Hospital is throwing innumerable traumas, stresses and breakdowns towards me. I don’t know who to blame. Probably my covid job, or my parents who recently got infected; or maybe it’s all happening because I don’t know how to be an adult. It’s such hypocrisy right? I wanted to grow up and be indepen-

Covid was rising again. I was posted in covid ward for 12 hours. My days went by wearing plastic for 10 hours, 2 hours grooming. And even still the time allotted seemed too less to attend the infected. The crowd was getting hefty with each passing day. Sean also got absorbed in his job, his experimental agony of constantly teasing me. God these men!! They cannot understand how stressful this torture is! I used to come back home drained and he wants to make love! How can a human manage to gather the strength to start working at dawn till dusk and then get aroused at midnight? But I love him. So I never refused. For a month, I compromised my sleep for him. Almost everyday. I used to sleep around 3, go to work at 8 and return from my crusade at around 10. This cycle kept repeating and I was overwhelmed.

My health seemed to deteriorate. I was never attentive, caught dozing during work, lost 5 pounds of mass, even slept while cooking once and burnt my hand. My skin lost its texture and my face, it’s spark. I was getting hideous with each passing day, until I died. Yeah I actually did die. I was driving back home. It was past 10. All I remember was that I drove over the barricade and my car fell off the cliff. Luckily there was a huge tree to secure me from falling. I don’t know, I took a pill in the evening that promised me a constant supply of energy. My fatigue was hampering my ability to work. A bystander saw this and immediately rushed to the scene. He called 911 and soon enough I was saved. Unfortunately. They should have let me die. The only way to put an end to my never-ending trauma was for me to take my final breath. Light flashed on my eyes after 35 hours. I was unconscious and non responsive before that. The doctor dealing with me thought I slipped into a coma. Sean was optimistic though. He didn’t leave the premises until he

was convinced that I was okay. He held my hand and cried for an hour. Kept blaming himself even though I was trying my best to comfort him. Truth be told, I liked him tearing himself apart over me. I would have handled the stress if not for him. Hospital gave me a week’s recovery time. I was referred to the same hospital where I have my job for further evaluation of my condition. Strange thing is I don’t remember what exactly happened that night. It all feels like I was drunk driving. I just came back after being discharged from the hospital and can’t wait to tell you what happened. Sean tucked me in. Kissed my forehead. He’s treating me like his baby girl

now. He asked me to sleep, which I will be doing soon. But you know, just a little secret between you and I; I will ask him to make something for me to eat. I am starving. The accident suddenly activated my hunger centres and now all I want is food, netflix and Sean cuddling me. But wait, Pages, can it be my sleep? Or lack of sleep? Causing all the trouble since the beginning. Maybe it was my head that night, banging the doors of my cortical receptors to depress the reception of these pathological photons and sound waves. Maybe it was causing him more harm than good. Or perhaps I had a seizure because of all those blinding disco headlights falling on my eyes. But I am sure I was dead living before it. I

remember bits and pieces of everything that’s happened before it. I feel so alive now. Clinical evaluation came normal after I gained consciousness. This thought is really troubling me. I overburdened myself which led to a fatal accident. I could have died just because I sacrificed sleep. But people do it all the time! They lack sleep for stupid reasons, atleast I have an answerable one! Maybe I am different. Maybe my body cannot handle the stress. Okay, in my time at the hospital, I did some research because I was completely jobless. Shorting yourself on shut-eye chronically may cause hypertension, diabetes, heart attack, heart failure or stroke. What I fear the most are obesity, depression, infections and lower sex drive. Well I was indeed repelling Sean! It might increase cortisol levels in the body which can break down collagen, the protein that keeps skin smooth. Yeah I am talking about wrinkles and dark circles!

Ufff the truth is really traumatizing. The more I think about it, the more agonizing it gets. Nevermind, let me go bother Sean into making some cheese quesadillas with mexican dip for me, he will make you smack your lips I bet! And pucker them later LOL. But I promise I will sleep and take complete bed rest. Goodbye Pages, until we again. Your architect Melanie.

Created by : Manvi Lamba AMSA India Maulana Azad Medical College Delhi University

meet

BRAINSTORM ILLUSTRATION Created by : Dr. Avi Singh AMSA India Government Medical College Amritsar

The greatest debate to dominate, between our right and left brains, ‘an epiphone of the souls’ there ain’t anything as breathtakingly creative as an equation of physics constructed by the right mindand yet, understandable if you know the language-unlike a great piece of art; concealing a perpetual supply of perception beyond the comprehension of greatest left minds alone. Neuronal firing: Your skull is the battleground, but no deathbed; Among the chaos: the left upgrades while the right blossoms

WANDERING IN THE DARK ILLUSTRATION

In search of unknown mystery that lies beyond the endless walls full of mystical existence

Created by : Nadhira Tsurraya R AMSA Indonesia Faculty of Medicine, Sriwijaya University

WEEK DEEPS IN SEMESTER POETRY

9 AM Woke up to a class that started 5 minutes ago Better than my usual fare, where the night flits by without sleep I’d even gotten a good 15 minutes of drowsy attention before caving in

3 PM Here comes the first meal of the day Never have I paid any mind, the hunger Though the amount of time I take to eat worries me

12 AM Still feel the hangover from my lecture naps It’s not even the emotional bursts that bother me most It is the awareness that none of these lectures made way to my mind

6 AM After a night of distraction I finally finish it Drawings of slides due earlier this midnight

6 PM 9 PM All the sudden, a day is gone At this moment my senses came back I am finally awake

Midnight A game is still running on my tablet A practical report sleeps on my now blank laptop screen I, on the other hand, am trying my best to soothe my raging girlfriend “Would you still love me if I were a rat?!” she asks, tears in her eyes

Oh, how I miss a good night’s sleep

Created by : Gilang Ignas Raharjo AMSA Indonesia Faculty of Medicine, Nursing, and Public Health Universitas Gadjah Mada

TIME TO COUNT SHEEP ILLUSTRATION

Created by : Florentia Amanda C AMSA Indonesia Faculty of Medicine, Sriwijaya University

FOR THE REST REQUIRED FICTIONAL WRITING Darkness embraced Alisa. She shut her eyes and dived into the imagery of a lake. Tranquil, still, as she lay afloat and let everything loose. Her face slackened. Her shoulder relaxed. Tension slithered off her neck, her arms, her legs and feet. The water nibbled. It pressed her, caressed her until there was nothing, nothing.

to sleep despite everything was getting her frustrated. That frustration only made it more difficult to fall asleep, which raised her frustration which made it even harder to sleep.

But a sense of hyperawareness.

“Come on Alisa, don’t give up,” she murmured to herself. No time to wallow in a perpetual negative feedback loop. Mom bought her a bottle of earplugs last year. She had dismissed them and stored them somewhere. Was it in the drawer?

Alisa jolted awake. Rumbling engines and passing vehicles laughed goodbye as they faded into silence. With a disgruntled sigh, Alisa felt around the bedside table. She needed music. She would take the brief blue light phone exposure to drown the low murmurs and occasional booms. It was impossible to sleep as it was. However, even soft ambience music was not enough to lull her asleep. Alisa flipped her pillow – It was too warm – and pulled up the blanket – It was too cold. Her lips felt dry, so she reached over for a glass of water. When that wasn’t enough, she reached to the floor for a water bottle. Thirst satiated, she tried to sleep again. Except now she had to go to the bathroom. Her eyes burst open. Five minutes later, Alisa returned and ruffled her hair in annoyance. She had planned for perfection. Finishing works early, turning the internet off, all so she could have a stress-free rest. Her failure

A motorcycle revved past her window. Alisa hopped upright and took a deep breath.

Alisa turned on the light. She found the box of her phone and a watch she thought she had lost, but no earplugs. Alisa frowned. Did she put it in the donation box? Ugh. The box under the bed was supposed to be donated six months ago, but she forgot to give it away. Alisa held back the urge to scream when she pulled the box out. Cobwebs clung to her fingers, sticky like glue. She disliked spiders. Gritting her teeth, she persisted through the icky feeling as she dug through old items, through dust and wispy webs creeping over her hands. She could only pray that the threads were all she felt. Webs and dust, and not something else crawling. Then, at the bottom of the box, she saw it. A pill bottle filled with colourful foam

earplugs. “Got it,” she whispered, elated. Alisa pulled the bottle out. Then, she felt something burst under her thumb. It was a soft lump attached to the pill bottle. It was squishy. Satiny, like silk. Like spiderweb. Time was as if frozen. Alisa wanted time to stop. Then, tingly sensations crawled over her hand; Tiny, many crawling legs. “AAAAAAAH!” Alisa screamed. She tossed the pill bottle, shaking her hand as if her life depended on it. Tens of little critters flew with every jerk of her hand. Alisa only turned paler. She ran out of her room, frantically patting her clothes and hair to remove any lingering spiders. “What’s wrong?!” “EEK!” Alisa screamed again and stumbled sideways. At the stair, looking worried, was a face she found familiar. “Mom, don’t surprise me like that!” Her heart still raced as Alisa complained. “I found spiders.” “Surprise you? You screamed so loudly even the neighbours hear them.” Mom

Created by : Fata Imadudda’wah AMSA Indonesia Faculty of Medicine, Universitas Padjajaran

looked at the dark curtains and squinted. “Why are the curtains closed? And why are you in pyjamas?” Alisa flushed. “The band Geta is streaming live at three in the morning tomorrow. I want to sleep early so I don’t oversleep, but I can’t.” “Ay, this girl! It’s two in the afternoon; of course you can’t sleep. Just sleep at eight and set up an alarm. And you still have to help make dinner. No.” “But Mom!” “Go down and eat. I’ll wake you at that time. There’s a football match I want to watch at that hour.” Alisa’s face brightened. “Thanks, Mom!” She ran downstairs in a hurry. Mom could only shake her head. While she was upstairs, she should remove the spider Alisa mentioned. Or did she say spiders? Moments later, a horrified scream came from Alisa’s room.

A DAY IN A LIFE SOMEONE WITH NARCOLEPSY ILLUSTRATION

Created by : Nadhira Tsurraya R AMSA Indonesia Faculty of Medicine, Sriwijaya University

Shofia Nurul Latifah AMSA Indonesia Faculty of Medicine, Sriwijaya University

Narcolepsy is a chronic sleep disorder that disrupts the normal sleep-wake cycle. It’s characterized by overwhelming daytime drowsiness and sudden attacks of sleep. Narcolepsy may be accompanied by cataplexy (sudden muscle weakness) or not. The etiology behind it is the destruction of hypocretin-producing neurons by body’s immune cells.

STANDING BY THE GRAVE AND MUSING POETRY

Created by : Ris Raju Kappilparambil

Life is momentary Unpredictable Just like a wisp, It evanesces. Leaving no trace, Into the unknown It goes. And The only thing It Leaves behind Is memories. “ Dead men receive more flowers than the living ones because regret is stronger than gratitude”

Tis the ugly truth of life. Wish I could show my love Show my care To the ones who are here and now. Wish I could Forget all the strife Clear all the misunderstandings And Just run into the arms of the people I once loved And cleanse the pain in our hearts. But damn this ego. This insane war against ego.

THE NIGHT POETRY

I don’t know what wakes me up the midnight, was it the clasp within me or outside. I can’t figure out what it was, but I know it totally took all the joy inside me. The world around me was full of laughter, joy, fulfillment with emptiness within me. I wait for around an hour restlessly to fall asleep but anxious, totally anxious. I can’t see any good sign ahead or behind me which can terminate unease within me. I can’t call for help too, as I know it’s hard to make someone understand me. The night again clarify the loneliness in a crowd, discomfort in comfort, unloving in the love, fear of failure of failure in the success. But the number of unanswered things are a lot more than the untangled one and they are in the queue to make more horrible nights.

Created by : Susmita Khatiwada AMSA Nepal MBBS 2nd year Maharajgunj Medical Campus

RED BICYCLE PHOTOGRAPHY Three red bicycles standing still near the Osaka castle

Created by : Nadhira Tsurraya R AMSA Indonesia Faculty of Medicine, Sriwijaya University

About Importance&nbsp;of Sleep and allocated hours of sleep for different&nbsp;age groups

Created by : Viddhya Pandey MBBS, 2nd Year, 40th Batch IOM, Mahargunj Medical Campus

LETTERS TO JULIET

Dear Juliet, I am a second-year medical student and a paying student, and the word ‘paying’ is taking away my individuality. I am from India, however, since my mother is from Nepal, my father felt that it will be good if I studied here, and it has changed everything for me. I left my hometown, my country, and now, I am here in Nepal. It is not that I don’t like this place, but there is a thing called ‘Emotional Attachments’, and I am a fool who tends to trust people and get attached to areas quickly - including my hometown, and now, Nepal. I am also an introvert, which basically means I do talk, but with those who I feel comfortable. I am insecure about everything, I guess, to be frank. However, I don’t regard myself as a bad friend. Initially, I faced an amount of culture shock when I came to Nepal. I did not know any of their party songs, food cuisines, or even their history. However, as time passed by, I fell in love with the people and the atmosphere here. The question, however, is whether this feeling will last. I understand that one day, I have to return to my place of origin, and in the middle of the way now, I am surrounded by sadness as I will always be reminded that everything is temporary here. This is the reason why I did not want to be attached to too many people. I do not consider myself as a social butterfly – I don’t know any of my seniors, and I’m not a part of any clubs in college as well. I don’t think anyone knows me either – I am often lost in crowds. The two years I have spent here, however, made me experience many things – I made friends, I saw their truest selves, and I learned a lot as well. I feel lost, dear Juliet. However, I never was a quitter, and I’ll never be. I’m going to rise again all strong. This isn’t a pity story of an introverted, shy person, but a tale that has just begun. I hope that the next time I write to you, I’ll find my purpose here. Till then, it was good to have someone to whom I can just rant about.

Hello to my dear anonymous friend, Firstly, I want to assure the brave, brave soul that you are that everything is okay, everything is going to be okay. To leave your country and everything you know for the purpose of education is a gargantuan step, something that requires a great deal of courage and something which you have already done. I understand that starting your life anew in a different country and environment can be very nerve-wracking but it should not stop you from living your life to the fullest. Let go of your inhibitions and enjoy the rest of your time there. Do not be scared of making new friends and experiencing new things because the connections and memories that you make are gonna last you a lifetime. College is an experience of a lifetime and one should do their best to enjoy every last second of it. Try to live your life free of inhibitions. You are amazing and I’m sure you are going to destroy every challenge that comes your way. You are going to become a doctor that’s going to save many, many lives. Believe in yourself and be confident. Love, Juliet

FEEDBACK Your opinion is important to us! Scan the QR code below to share your feedback about this issue.

ASPIRE #36

Articles inside

ASPIRE #36