Dimitri Markov

Obstructive Sleep Apnea Syndrome and Postoperative Complications: Clinical Use of the STOP-BANG Questionnaire

OBJECTIVE To determine whether high risk scores on preoperative STOP-BANG (Snoring, Tiredness during daytime, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference, Gender) questionnaires during preoperative evaluation correlated with a higher rate of complications of obstructive sleep apnea syndrome (OSAS). DESIGN Historical cohort study. SETTING Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. PATIENTS Adult patients undergoing elective surgery at a tertiary care center who were administered the STOP-BANG questionnaire for 3 consecutive days in May 2008. MAIN OUTCOME MEASURES Number and types of complications. RESULTS A total of 135 patients were included in the study, of whom 56 (41.5%) had high risk scores for OSAS. The mean (SD) age of patients was 57.9 (14.4) years; 60 (44.4%) were men. Patients at high risk of OSAS had a higher rate of postoperative complications compared with patients at low risk (19.6% vs 1.3%; P < .001). Age, American Society of Anesthesiologists class of 3 or higher, and obesity were associated with an increased risk of postoperative complications. On multivariate analysis, high risk of OSAS and American Society of Anesthesiologists class 3 or higher were associated with higher odds of complications. CONCLUSION The STOP-BANG questionnaire is useful for preoperative identification of patients at higher than normal risk for surgical complications, probably because it identifies patients with occult OSAS.

Parasomnias, violence and the law

In this review, we trace the parallel development of scientific understanding of parasomnias and the jurisprudence of violent behavior during sleep. Before sleep physiology was studied, it was generally self-evident that sleeping persons would not be criminally responsible. Though the problem of malingering was acknowledged in early American forensic psychiatry, the defendant with sleepwalking or sleep drunkenness was treated leniently. Over the past half century, sleep physiology has been examined and there is a developing nomenclature for sleep disorders. Though there is no clear-cut correlation between violence and sleep, several parasomnias have been implicated. We discuss contemporary concepts of parasomnias and suggest how expert witnesses might apply this knowledge to the difficult matter of assessing criminal intent and responsibility.

Low-Dose Doxepin for Insomnia

A tricyclic antidepressant first approved in 1969, doxepin has long been available in larger doses (10-, 25-, 50-, 75-, 100-, and 150-mg capsules) to treat depression and anxiety and as a topical preparation (5 % cream) for pruritus, but not in dosages <10 mg. Low-dose doxepin—3 and 6 mg—has demonstrated efficacy for insomnia characterized by frequent or early morning awakenings and an inability to return to sleep. FDA-approved in March 2010, doxepin (3 and 6 mg) is only the second insomnia medication not designated as a controlled substance and thus may be of special value in patients with sleep maintenance insomnia with a history of substance use disorders.