[show abstract][hide abstract] ABSTRACT: Insomnia is a common, often chronic medical disorder with significant medical and socioeconomic repercussions. However, unlike other medical conditions, there is intense debate as to whether the long-term treatment of insomnia is clinically appropriate. The perceived deleterious side effect of sedative-hypnotic medications may result in patients remaining untreated or undertreated. This review proposes that a more subtle approach needs to be taken in the management of patients with chronic insomnia and that long-term use of the newer sedative-hypnotics may be a feasible and effective treatment option when used in conjunction with thorough medical assessment and regular patient follow-up. This review discusses these issues and discusses the pros and cons of long-term sedative-hypnotic use.
[show abstract][hide abstract] ABSTRACT: Women constitute about half the work force, and women shift workers warrant special attention given the different physiological needs of women, their reproductive status, and the added burden of family responsibilities. There is increasing evidence that women have greater difficulty adjusting to shift work compared to their male counterparts and that sleep problems may in large part account for this difficulty. The purpose of this article is to review the existing literature to highlight the differential negative impact of shift work on sleep and other health issues in women and as part of a needs assessment to promote research in female shift workers by developing and prioritizing research questions in this field. The literature suggests that women shift workers report poor sleep quality and experience reproductive disturbances, an increased risk of breast cancer, and a greater risk of metabolic and cardiovascular disorders.
Journal of Women s Health 08/2009; 18(7):965-77. · 1.42 Impact Factor
[show abstract][hide abstract] ABSTRACT: Obstructive sleep apnea (OSA) is present in a significant proportion of the population, but the majority of patients remain undiagnosed. It is crucial that anesthesiologists and surgeons recognize the increased perioperative risks associated with undiagnosed OSA. We present a systematic review of the literature on the perioperative management of surgical patients with OSA.
The scope of this review is restricted to publications in all surgical specialties and in the adult patient population. The main search key words were: "perioperative care," "sleep apnea," "obstructive sleep apnea," "perioperative risk," and "perioperative care." The databases Medline, Embase, Biological Abstract, Science Citation Index, and Healthstar were searched for relevant English language articles from 1966 to March 2007.
The literature supports an increased perioperative risk in OSA patients. The American Society of Anesthesiologists guidelines support the routine screening for OSA during preoperative assessment, and methods of OSA screening are discussed in this review. This review suggests a number of perioperative management strategies to reduce surgical risk in patients with OSA. However, apart from the consensus-based American Society of Anesthesiologists guidelines, it is important to note that evidence-based recommendations are lacking in the literature.
This review suggests ways to screen for OSA in the preoperative setting and proposes perioperative management strategies. The ultimate goal is to reduce the perioperative risk of OSA patients but, to realize that goal, research will be needed to determine whether screening for OSA and/or adapting specific perioperative management approaches translates into a lessening of adverse events in surgical patients with undiagnosed OSA.
Anesthesia and analgesia 12/2008; 107(5):1543-63. · 3.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: Because of the high prevalence of obstructive sleep apnea (OSA) and its adverse impact on perioperative outcome, a practical screening tool for surgical patients is required. This study was conducted to validate the Berlin questionnaire and the American Society of Anesthesiologists (ASA) checklist in surgical patients and to compare them with the STOP questionnaire.
After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. The scores from the Berlin questionnaire, ASA checklist, and STOP questionnaire were evaluated versus the apnea-hypopnea index from in-laboratory polysomnography. The perioperative data were collected through chart review.
Of 2,467 screened patients, 33, 27, and 28% were respectively classified as being at high risk of OSA by the Berlin questionnaire, ASA checklist, and STOP questionnaire. The performance of the screening tools was evaluated in 177 patients who underwent polysomnography. The sensitivities of the Berlin questionnaire, ASA checklist, and STOP questionnaire were 68.9-87.2, 72.1-87.2, and 65.6-79.5% at different apnea-hypopnea index cutoffs. There was no significant difference between the three screening tools in the predictive parameters. The patients with an apnea-hypopnea index greater than 5 and the patients identified as being at high risk of OSA by the STOP questionnaire or ASA checklist had a significantly increased incidence of postoperative complications.
Similar to the STOP questionnaire, the Berlin questionnaire and ASA checklist demonstrated a moderately high level of sensitivity for OSA screening. The STOP questionnaire and the ASA checklist were able to identify the patients who were likely to develop postoperative complications.
[show abstract][hide abstract] ABSTRACT: Obstructive sleep apnea (OSA) is a major risk factor for perioperative adverse events. However, no screening tool for OSA has been validated in surgical patients. This study was conducted to develop and validate a concise and easy-to-use questionnaire for OSA screening in surgical patients.
After hospital ethics approval, preoperative patients aged 18 yr or older and without previously diagnosed OSA were recruited. After a factor analysis, reliability check, and pilot study; four yes/no questions were used to develop this screening tool. The four questions were respectively related to snoring, tiredness during daytime, observed apnea, and high blood pressure (STOP). For validation, the score from the STOP questionnaire was evaluated versus the apnea-hypopnea index from monitored polysomnography.
The STOP questionnaire was given to 2,467 patients, 27.5% classified as being at high risk of OSA. Two hundred eleven patients underwent polysomnography, 34 for the pilot test and 177 for validation. In the validation group, the apnea-hypopnea index was 20 +/- 6. The sensitivities of the STOP questionnaire with apnea-hypopnea index greater than 5, greater than 15, and greater than 30 as cutoffs were 65.6, 74.3, and 79.5%, respectively. When incorporating body mass index, age, neck circumference, and gender into the STOP questionnaire, sensitivities were increased to 83.6, 92.9, and 100% with the same apnea-hypopnea index cutoffs.
The STOP questionnaire is a concise and easy-to-use screening tool for OSA. It has been developed and validated in surgical patients at preoperative clinics. Combined with body mass index, age, neck size, and gender, it had a high sensitivity, especially for patients with moderate to severe OSA.
[show abstract][hide abstract] ABSTRACT: The Berlin questionnaire (BQ) has been used to help identify patients at high risk of having sleep apnea in primary care and atrial fibrillation patients. The BQ may be a useful adjunct in sleep medicine and research, but it has never been validated in a sleep clinic population. The aim of the study is to determine the specificity and sensitivity of the BQ compared to the respiratory disturbance index (RDI) values obtained from two nights of polysomnographic recording in a sleep clinic population. This is a retrospective chart review study of 130 sleep clinic patients. Patients' demographics, BQ scores, RDI measurements, and sleep study parameters were extracted from the patients' chart. Of the 130 charts reviewed, the BQ identified 76 (58.5%) as being at high-risk of having sleep apnea, but overnight polysomnography found only 34 of the 130 patients (26.2%) had an RDI > 10. The BQ performed with 0.62 sensitivity and 0.43 specificity at the RDI > 10 level. Due to the low sensitivity and specificity as well as the large number of false negatives and positives, the Berlin questionnaire is not an appropriate instrument for identifying patients with sleep apnea in a sleep clinic population.
Sleep And Breathing 03/2008; 12(1):39-45. · 2.26 Impact Factor
[show abstract][hide abstract] ABSTRACT: Increased physical activity is important given the concern over the growing rates of obesity. The aim of this study is to conduct a controlled investigation of the effects of bright light therapy and exercise on weight loss and body composition in overweight and obese individuals.
Twenty-five overweight and obese subjects were assigned to 6 weeks of moderate exercise with or without bright light treatment. Outcome measure included changes in body mass and body composition and ratings of mood, seasonality, and sleep.
Body weight decreased significantly with exercise in subjects in the light and non-light treatment groups, but the change was not significantly different between the groups. Similar results were found for BMI. With exercise, body fat decreased significantly only in the light treatment group. There was a significant effect of the interaction of group by time on body fat composition, but the group by time interaction failed to reach statistical significance for body weight and BMI. Mood scores improved significantly with exercise in the light group, but no significant changes were noted regarding sleep.
This preliminary study is the first to show that addition of bright light treatment to a 6-week moderate exercise program can alter body composition by significantly reducing body fat. The reduction in body fat mass is of particular importance, because visceral fat has been particularly implicated as a major factor in the development of the metabolic syndrome. This study is an important step toward finding ways to maximize the effects of exercise.
[show abstract][hide abstract] ABSTRACT: To investigate continuous positive airway pressure (CPAP) compliance after one versus two nights of CPAP titration.
A chart review and a telephone questionnaire interview were conducted in 110 sleep apnea patients who received one or two nights of CPAP titration. Of these patients, 78 followed through with phone interview.
There was no difference in CPAP compliance between those who had one or two nights of CPAP titration. The titration pressures on the first and second nights were not significantly different. But there was significant improvement in sleep efficiency from the first to the second diagnostic night.
One versus two nights of CPAP titration did not affect CPAP compliance, but sleep efficiency improved on the second diagnostic night and an extra titration study may be necessary for some patients, especially those with only one diagnostic night.
Behavioral Sleep Medicine 02/2007; 5(2):117-29. · 1.13 Impact Factor
[show abstract][hide abstract] ABSTRACT: Shift work is a ubiquitous phenomenon and its adverse effects on workers' physical and mental health have been documented. In the sleep literature, differentiating between the symptoms of fatigue and sleepiness, and developing appropriate objective and subjective measures, have become very important endeavors. From such research, fatigue and sleepiness have been shown to be distinct and independent phenomena. However, it is not known whether shift work differentially affects fatigue and sleepiness. In an attempt to answer this question, 489 workers from a major Ontario employer completed a series of subjective, self-report questionnaires, including the Fatigue Severity Scale (FSS) and the Epworth Sleepiness Scale. Workers were separated into four groups based on the frequency with which they are engaged in shift work (never, fewer than four times per month, 1-2 days per week, 3 days or more per week). The frequency of shift work was found to have a significant effect on subjective fatigue, but not on subjective sleepiness. Compared with the subjects who never had a shift schedule, those who worked in a shift for 3 days or more had significantly higher mean score of the FSS. In agreement with previous results, a low correlation was found between workers' subjective fatigue and sleepiness scores, providing further support for the concept of fatigue and sleepiness as distinct and independent phenomena. Future research should address the possibility of using the FSS as an indicator when the frequency of shift work has become high enough to adversely affect work performance or cause health problems.
Journal of Sleep Research 04/2006; 15(1):1-5. · 3.04 Impact Factor
[show abstract][hide abstract] ABSTRACT: This study aimed to characterize the effects of mirtazapine on polysomnographic sleep, especially slow wave sleep (SWS) and rapid eye movement (REM) sleep, as well as its effects on clinical symptoms in patients with major depressive disorder (MDD).
Sixteen MDD patients were treated with mirtazapine 30 mg taken 30 minutes before bedtime. Polysomnographic and subjective sleep, as well as other clinical data, were collected at baseline and on Days or Nights 2, 9, 16, 30, and 58 during treatment. We used repeated measures analysis of variance, including pairwise comparison, to analyze data statistically.
Mirtazapine administration increased total SWS and the SWS in the first sleep cycle, but not SWS in the second sleep cycle. The medication increased REM latency and the duration of the first REM episode; it also decreased the number of REM episodes. Simultaneously, mirtazapine significantly reduced wake-after-sleep onset and scores on the Athens Insomnia Scale. After patients took the medication, scores on the Hamilton Depression Rating Scale-17 (HDRS-17) decreased rapidly and continuously. The changes on the Beck Depression Inventory-II were consistent with those on the HDRS-17. The medication has a tendency to increase weight.
Mirtazapine significantly improved sleep quality, reversed sleep markers of depression, and reduced depressive symptoms in this group of MDD patients.
Canadian journal of psychiatry. Revue canadienne de psychiatrie 02/2006; 51(1):27-34. · 2.48 Impact Factor
[show abstract][hide abstract] ABSTRACT: The management of persistent symptoms during acid suppression therapy in patients with gastroesophageal reflux disease or dyspepsia might be improved if patient-physician communication regarding the presence and character of these persistent symptoms were facilitated.
To validate a short, simple questionnaire (the Proton pump inhibitor [PPI] Acid Suppression Symptom [PASS] test), in English and French, to identify patients with persistent acid-related symptoms during PPI therapy and document their response to a change in therapy.
Patients with persistent acid-related symptoms on PPI therapy were interviewed to produce a draft, five-item questionnaire; content validity was evaluated by focus groups comprising English- and French-speaking patients. Psychometric validity was subsequently evaluated in a multicentre, family practice-based study of English- and French-speaking patients with persistent acid-related upper gastrointestinal symptoms despite PPI therapy. The PASS test, Global Overall Symptom scale, Gastrointestinal Symptom Rating Scale (GSRS), Quality of Life in Reflux and Dyspepsia questionnaire and Reflux Disease Questionnaire were completed at baseline and repeated after one week while patients continued their original PPI therapy. All patients then received esomeprazole 40 mg once daily for four weeks, after which all questionnaires and an evaluation of overall treatment effect were completed.
Content validity was established in 20 English- and 16 French-speaking patients. Psychometric validation in 158 English- and 113 French-speaking patients revealed good-to-excellent test-retest reliability coefficients: 0.76 for English; 0.68 for French. For construct validity, the PASS test showed moderate-to-high correlation with the GSRS scale (0.51 for English; 0.43 for French). After four weeks of therapy, the PASS test score fell to zero in 30% of English- and 33% of French-speaking patients, while the Global Overall Symptom score fell to one (no symptoms) in 32% of patients (English- and French-speaking); the PASS test demonstrated good responsiveness in comparison with the GSRS, Reflux Disease Questionnaire and Quality of Life in Reflux and Dyspepsia questionnaire.
The five-item PASS test is a valid tool for the evaluation of persistent acid-related symptoms in patients receiving PPI therapy. It demonstrates good content validity, test-retest reliability, responsiveness and construct validity in both English and French forms. The PASS test is a simple, clinically applicable tool for the identification of patients with persistent acid-related symptoms during therapy and the assessment of their responses to a change in therapy.
Canadian journal of gastroenterology = Journal canadien de gastroenterologie 07/2005; 19(6):350-8. · 1.53 Impact Factor
[show abstract][hide abstract] ABSTRACT: Sleep apnea is being studied as a risk factor for hypertension. This observational chart review was conducted to determine the long-term effects of continuous positive airway pressure (CPAP) treatment on blood pressure (BP) in a sample of sleep apnea patients from urban and rural populations.
This study was conducted using data from 180 clinical charts from 1995 to 2002. Patients were identified as hypertensive or normotensive by their initial BP values before they were diagnosed with sleep apnea and were also reviewed after the use of CPAP.
Of the patients diagnosed with sleep apnea, 32% were found to have hypertension (mean systolic BP: 164.4 +/- 20.3 mmHg; mean diastolic BP: 96.9 +/- 5.3 mmHg). The average use of CPAP was 12.1 +/- 22.4 months. The hypertensive group showed a significant reduction in BP with CPAP use: systolic BP dropped by an average of 11.2 mmHg (P < .001) and diastolic BP dropped by an average of 5.9 mmHg (P < .001).
Our results confirm that frequency of hypertension is increased among sleep apnea patients. The long-term use of CPAP in hypertensive patients with sleep apnea is associated with a significant decrease in BP to levels that considerably decrease cardiovascular risk.
American Journal of Hypertension 06/2005; 18(5 Pt 1):594-600. · 3.67 Impact Factor
[show abstract][hide abstract] ABSTRACT: Decreases in melatonin production in human and animals are known to be caused by environmental lighting, especially short-wavelength lighting (between 470 and 525 nm). We investigated the novel hypothesis that the use of goggles with selective exclusion of all wavelengths less than 530 nm could prevent the suppression of melatonin in bright-light conditions during a simulated shift-work experiment. Salivary melatonin levels were measured under dim (<5 lux), bright (800 lux), and filtered (800 lux) light at hourly intervals between 2000 and 0800 h in 11 healthy young males and eight females (mean age, 24.7 +/- 4.6 yr). The measurements were performed during three nonconsecutive nights over a 2-wk period. Subjective sleepiness was measured by self-report scales, whereas objective performance was assessed with the Continuous Performance Test. All subjects demonstrated preserved melatonin levels in filtered light similar to their dim-light secretion profile. Unfiltered bright light drastically suppressed melatonin production. Normalization of endogenous melatonin production while wearing goggles did not impair measures of performance, subjective sleepiness, or alertness.
[show abstract][hide abstract] ABSTRACT: Extended hours of shift work has the potential for adverse consequences for workers, particularly during the nightshift, such as poorer sleep quality during the day, increased worker fatigue, and fatigue-related accidents and decreased work performance. This study examined subjective and objective measurements of sleep and performance in a group of underground miners before and after the change from a backward-rotating 8-hour to a forward-rotating 10-hour shift schedule. The purpose of this study was to evaluate the short- and long-term impact of a shift schedule change on sleep and performance. The results demonstrated improved subjective and objective measures of sleep and performance on the new 10-hour nightshift schedule. The 10-hour nightshift workers subjectively reported more refreshing sleep, fewer performance impairments and driving difficulties than 8-hour nightshift workers. The results of the objective measures of sleep and performance on the 10-hour nightshifts were overall similar or possibly better than those measured on the 10-hour dayshifts. These are some of the first data to suggest that a nightshift that does not encompass the entire night period could have significant benefits to shift-workers. We suggest that these benefits are mostly the result of the timing of the new nightshift start and end times rather than other shift-schedule factors.
Journal of Occupational and Environmental Medicine 04/2004; 46(3):212-26. · 1.85 Impact Factor
[show abstract][hide abstract] ABSTRACT: To review the need for primary care physicians to screen for patients with obstructive sleep apnea (OSA).
Literature was reviewed via MEDLINE from 1993 to 2000, inclusive, using the search term "sleep apnea" combined with "epidemiology," "outcome," and "diagnosis and treatment." Citations in this review favour more recent, well controlled and randomized studies, but findings of pilot studies are included where other research is unavailable.
Obstructive sleep apnea is a disorder with serious medical, socioeconomic, and psychological morbidity, yet most patients with OSA remain undetected. Primary care physicians have a vital role in screening for these patients because diagnosis can be made only through overnight (polysomnographic) studies at sleep clinics. Physicians should consider symptoms of excessive or loud snoring, complaints of daytime sleepiness or fatigue, complaints of unrefreshing sleep, and an excess of weight or body fat distribution in the neck or upper chest area as possible indications of untreated OSA.
Current research findings indicate that treating OSA patients substantially lowers morbidity and mortality rates and reduces health care costs. Primary care physicians need more information about screening for patients with OSA to ensure proper diagnosis and treatment of those with the condition.
Canadian family physician Médecin de famille canadien 07/2002; 48:1073-80. · 1.81 Impact Factor