Karl Doghramji

Self-reported sleep quality and quality of life for individuals with chronic pain conditions.

OBJECTIVE To determine the sleep quality and quality of life for individuals with degenerative spinal disease or failed back surgery syndrome. DESIGN Cross-sectional survey design utilizing standardized instruments. Data were analyzed with use of hierarchical stepwise multiple regression analyses. PATIENTS One hundred sixty-seven individuals with degenerative spinal disease or postlaminectomy syndrome who presented to a tertiary care outpatient patient pain center. OUTCOME MEASURES The Center for Epidemiological Studies Depression Index measured depressive symptomatology. A modified Pittsburgh Sleep Quality Index (PSQI) measured sleep quality. The arithmetic average of least and usual VAS ratings of pain measured everyday pain. A visual analog scale rating of highest pain during the past 2 weeks measured highest pain. The Epworth Sleepiness Scale measured daytime sleepiness. The Medical Outcome Study-Short Form-Health Survey (SF-36) measured the mental health and general health components of quality of life. RESULTS Higher overall sleep quality and lower sleep latency primarily were related to higher ratings of physical functioning and shorter duration of pain. Ratings of the highest pain, but not everyday pain, were independent predictors of overall sleep quality and sleep latency. Daytime sleepiness was associated with younger age and depressed mood. Pain was not associated independently with daytime sleepiness. The quality of life related to mental functioning was associated positively with depressed mood and with the interaction of pain and depressed mood. None of the variables in the model (i.e., pain intensity, sleep quality, depression, and demographic variables) predicted quality of life related to overall general health. CONCLUSIONS These data suggest that physical functioning, duration of pain, and age may be more important than pain intensity and depressed mood in contributing to decreased overall sleep quality and sleep latency. The contribution of physical functioning was particularly strong and should be included in subsequent studies of sleep, pain, and mood. The SF-36 should be compared to pain-specific quality-of-life measures to further evaluate the usefulness of this instrument with outpatients with chronic nonmalignant pain conditions.

A new questionnaire to detect sleep disorders

OBJECTIVES Sleep disorders remain largely undiagnosed in the general population. The current study assessed whether the Global Sleep Assessment Questionnaire (GSAQ) could: (1), distinguish between sleep disorders (including no sleep disorder); (2), be a reliable and valid sleep disorder screener; and (3), serve as a practical, user-friendly screening tool for primary care and sleep centers. METHODS Two hundred and twelve adults from five sleep centers and two primary care clinics completed the GSAQ and received confirmed diagnoses from a sleep specialist. Of the 212 patients, 139 (65.6%) had at least one sleep disorder, 60 (28.3%) had two or more sleep disorders, and 13 (6.1%) had no confirmed sleep disorder. Ninety-one (43%) individuals completed the GSAQ a second time for reliability testing. Scores for each sleep disorder including, but not limited to, primary insomnia (I), insomnia associated with a mental disorder (IME), obstructive sleep apnea (OSA), periodic limb movement (PLM), and parasomnia (P) were computed. The sensitivity and specificity were estimated using comprehensive clinical diagnosis as the gold standard and mean domain scores as a cutpoint. RESULTS The mean participant age was 45 years, 52% were female. Observed frequencies were: 36 (I), 14 (IME), 31 (OSA), 7 (PLM) and 4% (P). Test-retest reliability ranged from 0.51 to 0.92. Pearson correlation coefficients suggested that the GSAQ discriminated between diagnoses. The sensitivities and specificities were 79/57, 83/51, 93/58, 93/52, and 100/49 for I, IME, OSA, PLM, and P, respectively. CONCLUSIONS Our findings suggest that the GSAQ can aid in recognizing sleep disorders. Future studies should focus on characterizing its predictive values in primary care settings.

Predictors of outcome for uvulopalatopharyngoplasty

The objective of this study was to assess the value of preoperative fiberoptic nasopharyngoscopy with the Müller maneuver (FNMM) and cephalometric radiography in predicting response to uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnea syndrome. Fifty‐three such patients having significant obstruction at the soft palatal level and variable degrees of obstruction at the base‐of‐tongue level underwent both diagnostic procedures before UPPP. Outcome was assessed by the apneaplus‐hypopnea index (AHI) as determined by polysomnography, which was performed before and after surgery. As a group, patients exhibited a significant 10‐point reduction in AHI (46.5 to 36.7). However, 17 (32.1%) were judged to be responders as defined by a reduction of the AHI by an increment of 50% or greater with respect to baseline. Of all the cephalometric variables assessed, soft palate length was the only one that differed between responders and non‐responders (45.5 mm versus 42.6 mm, respectively). However, this difference only approached significance (P=.067). Similarly, FNMM results did not discriminate between responders and nonresponders. These results indicate that preoperative cephalometric radiography and FNMM cannot be reliably used to enhance surgical success.

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.

Obstructive sleep apnea syndrome and perioperative complications: a systematic review of the literature.

Obstructive sleep apnea syndrome (OSAS) is a common sleep related breathing disorder. Its prevalence is estimated to be between 2% and 25% in the general population. However, the prevalence of sleep apnea is much higher in patients undergoing elective surgery. Sedation and anesthesia have been shown to increase the upper airway collapsibility and therefore increasing the risk of having postoperative complications in these patients. Furthermore, the majority of patients with sleep apnea are undiagnosed and therefore are at risk during the perioperative period. It is important to identify these patients so that appropriate actions can be taken in a timely fashion. In this review article, we will discuss the epidemiology of sleep apnea in the surgical population. We will also discuss why these patients are at a higher risk of having postoperative complications, with the special emphasis on the role of anesthesia, opioids, sedation, and the phenomenon of REM sleep rebound. We will also review how to identify these patients preoperatively and the steps that can be taken for their perioperative management.

Sleep disturbance in post‐traumatic stress disorder: A comparison with non‐PTSD insomnia

Sleep disturbances, including repetitive nightmares and insomnia, are central and long-lasting aspects of Post-Traumatic Stress Disorder (PTSD). This study utilized a questionnaire to compare sleep disturbance in Vietnam War combat veterans having PTSD with non-PTSD patients having insomnia without other PTSD symptoms. The PTSD group reported symptoms of anxiety, agitation and concurrent body movement which were associated with insomnia. Nightmares of this group were more repetitive and more disruptive of a return to sleep than the non-PTSD insomnia group. The PTSD group also reported more fatigue during daytime functioning and more anxiety during waking hours than the non-PTSD insomnia group.

Modafinil Augmentation of Selective Serotonin Reuptake Inhibitor Therapy in MDD Partial Responders with Persistent Fatigue and Sleepiness

BACKGROUND Partial response, no response, or residual symptoms following antidepressant therapy is common in clinical psychiatry. This study evaluated modafinil in patients with major depressive disorder (MDD) who were partial responders to adequate selective serotonin reuptake inhibitor (SSRI) therapy and excessive sleepiness and fatigue. METHODS This retrospective analysis pooled the data of patients (18-65 yrs) who participated in two randomized, double-blind, placebo-controlled studies of modafinil (6-week, flexible-dose study of 100-400 mg/day or 8-week, fixed-dose study of 200 mg/day) plus SSRI therapy. Patients (n=348) met criteria for several residual symptoms (Epworth Sleepiness Scale [ESS] score>or=10; 17-item Hamilton Depression Scale [HAM-D] score between 4 and 25; and Fatigue Severity Scale [FSS] score>or=4). RESULTS Compared to placebo, modafinil augmentation rapidly (within 1 week) and significantly improved overall clinical condition (Clinical Global Impression-Improvement), wakefulness (ESS), depressive symptoms (17-item HAM-D), and fatigue (FSS) (p<.01 for all). At final visit, patients receiving modafinil augmentation experienced statistically significant improvements in overall clinical condition, wakefulness, and depressive symptoms. Modafinil was well tolerated in combination with SSRI. CONCLUSIONS Results of this pooled analysis provide further evidence suggesting that modafinil is an effective and well-tolerated augmentation therapy for partial responders to SSRI therapy, particularly when patients continue to experience fatigue and excessive sleepiness.

Sleep in chronic pain: problems and treatments

Chronic pain of any etiology often represents a difficult problem for the clinician and patient. Pain will usually be impossible to eliminate, and adequate pain reduction usually requires multiple therapeutic trials and careful polypharmacy. Identifying and treating comorbid sleep disturbances can improve the treatment of patients with chronic pain. Both pain medicine and sleep medicine are areas in which physician training has been inadequate. The literature on sleep disturbances in selected pain conditions, pathophysiology of sleep disturbance in the pain context, a case study, and basic clinical strategies for managing sleep problems in this population will be summarized. The overall treatment approach is based on optimizing pain control, identifying and treating psychiatric comorbidity, carefully investigating sleep patterns, and use of sleep-specific pharmacotherapeutic and psychotherapeutic interventions for improving sleep.

The effect of gastro‐oesophageal reflux and omeprazole on key sleep parameters

Background:  The effect of gastro‐oesophageal reflux on sleep and sleep quality is highly controversial.

Effect of Zolpidem on the Sleep Arousal Response to Nocturnal Esophageal Acid Exposure

BACKGROUND & AIMS Nocturnal acid reflux is associated with complicated gastroesophageal reflux (GER) disease. Nocturnal GER initiates a protective arousal reflex, which induces a swallow to clear esophageal acid. The purpose of this study was to determine the effect of zolpidem on the sleep arousal mechanism and acid clearance in patients with documented GER, compared with control subjects with normal acid exposure. METHODS Eight controls and 16 GER patients were enrolled in a randomized, double-blind, placebo-controlled study. Zolpidem or placebo was given on separate nights. Reflux events and reflux-associated arousals or awakenings were recorded using simultaneous esophageal pH recording and standard polysomnography. RESULTS Nocturnal acid exposure resulted in a sleep arousal 89% of the time in participants (with and without GER) given placebo but only 40% in those given zolpidem (P < .01). In controls given placebo, acid reflux events lasted 1.15 +/- 0.28 seconds; in controls given zolpidem, they lasted 15.67 +/- 12.42 seconds (P < .01). In GER patients given placebo, the acid reflux events lasted 37.8 +/- 17.2 seconds compared with 363.3 +/- 139.3 seconds with zolpidem (P < .01). With zolpidem reflux events lasted 630.6 +/- 236.5 seconds when no arousal occurred and 49.2 +/- 19.11 seconds when an arousal was recorded (P < .001). CONCLUSIONS Zolpidem reduced the arousal response to nocturnal acid exposure and increased the duration of each esophageal acid reflux event in healthy individuals and patients with GER. Because nocturnal acid exposure was prolonged, hypnotic use by patients with GER could lead to increased risk for complicated disease.