Clarifying the role of sleep in depression: A narrative review.

It has been established that 4.4 to 20% of the general population suffers from a major depressive disorder (MDD), which is frequently associated with a dysregulation of normal sleep-wake mechanisms. Disturbances of circadian rhythms are a cardinal feature of psychiatric dysfunctions, including MDD, which tends to indicate that biological clocks may play a role in their pathophysiology. Thus, episodes of depression and mania or hypomania can arise as a consequence of the disruption of zeitgebers (time cues). In addition, the habit of sleeping at a time that is out of phase with the body's other biological rhythms is a common finding in depressed patients. In this review, we have covered a vast area, emerging from human and animal studies, which supports the link between sleep and depression. In doing so, this paper covers a broad range of distinct mechanisms that may underlie the link between sleep and depression. This review further highlights the mechanisms that may underlie such link (e.g. circadian rhythm alterations, melatonin, and neuroinflammatory dysregulation), as well as evidence for a link between sleep and depression (e.g. objective findings of sleep during depressive episodes, effects of pharmacotherapy, chronotherapy, comorbidity of obstructive sleep apnea and depression), are presented.

Do Disparities in Sleep Duration Among Racial and Ethnic Minorities Contribute to Differences in Disease Prevalence?

Sleep duration in the USA has declined continually during the second half of the twentieth century, before reaching a plateau in the early twenty-first century. However, not everyone has been equally affected by this continuous decline. Epidemiological studies indicate that ethnic minorities are sleeping even less than those in the general population. Today, Americans are sleeping, on average, for 6 h. This is significantly below the minimum recommended sleep duration of at least 7 h a day. This insufficiency of sleep duration, however, is not evenly distributed in the population, and different racial and ethnic minority groups are known to have an increased risk of experiencing shorter sleep duration and poorer sleep quality than their White peers. In tandem with this disproportionate decline in sleep duration are similar racial and ethnic disparities in overall health. This paper explores the differences in sleep duration and quality which exist for different ethnic groups, the probable causes behind such inequities, and their relationship to the growth of specific disease conditions. This review also considers sleep disorders in various racial and ethnic groups, and how these disorders are related to health outcomes. Finally, we discuss some of the implications of these differences, and particularly their clinical relevance, and recommend ways in which they might be addressed.

The Interlinked Rising Epidemic of Insufficient Sleep and Diabetes Mellitus.

For healthy existence, humans need to spend one-third of their time sleeping. Any qualitative or quantitative disturbances in sleep would result in an increased prevalence of obesity, metabolic disorders, diabetes, cardiovascular diseases, and hypertension. The paper aims to highlight the growing global problem of insufficient sleep and its significant impact on the rising incidence of diabetes mellitus. An extensive literature search was done in all major databases for "insufficient sleep" and "Diabetes Mellitus" for this review. Shorter (<6 h) and longer (>9 h) durations of sleep have been adversely related to insulin resistance. Though the relation between insufficient sleep and diabetes mellitus is more or less understood, little is known about how oversleeping or hypersomnia (10⁻12 h) increases the risk of diabetes. The relationship between sleep disturbances and diabetes is dual-sided, as chronic sleep disturbances would elevate the risk of developing insulin resistance, while diabetes would worsen the quality of sleep. Both the qualitative and quantitative disturbances in sleep significantly increase the risk of developing diabetes, which is supported by numerous community-based and hospital-based epidemiological studies discussed in this review. Obstructive sleep apnea is one of the most common sleep disorders and is characterized by chronic intermittent hypoxia and increased sympathetic activity, thus leading to a higher prevalence of diabetes. Sleep therapy may serve as a low-cost method for fighting against the rising epidemic of diabetes.

Impact of health education based intervention on community's awareness of dengue and its prevention in Delhi, India.

Dengue is endemic in India. The capital, Delhi, continues to witness a higher number of cases due to urbanization-related factors. This study is intended to implement health education towards prevention of dengue, and to assess its impact on people's knowledge and practices related to causes and prevention of dengue among urban poor in Delhi. Pre- ( n = 484) and post- ( n = 496) intervention surveys from 15 sub-clusters from five slums/slum-like settlements in Delhi were carried out. Health education based intervention was carried out through partnership with the municipal bodies and non-governmental organizations. Socio-demographic characteristics of participants were similar in both surveys. Intervention resulted in significant increase in knowledge on cause, symptom perception and mosquito behaviour in terms of breeding and biting habits. Practice of personal protection measures increased significantly. The participation of people increased during intervention compared to the routine programme. Health education based interventions are instrumental in improving people's knowledge and behaviour. Hence, routine health educational activities as a supportive strategy in the health system need to be strengthened. New integrated approaches such as eco-bio-social approaches with community participation are to be developed and tested in endemic settings like Delhi.

The Global Problem of Insufficient Sleep and Its Serious Public Health Implications.

Good sleep is necessary for good physical and mental health and a good quality of life. Insufficient sleep is a pervasive and prominent problem in the modern 24-h society. A considerable body of evidence suggests that insufficient sleep causes hosts of adverse medical and mental dysfunctions. An extensive literature search was done in all the major databases for "insufficient sleep" and "public health implications" in this review. Globally, insufficient sleep is prevalent across various age groups, considered to be a public health epidemic that is often unrecognized, under-reported, and that has rather high economic costs. This paper addresses a brief overview on insufficient sleep, causes, and consequences, and how it adds to the existing burden of diseases. Insufficient sleep leads to the derailment of body systems, leading to increased incidences of cardiovascular morbidity, increased chances of diabetes mellitus, obesity, derailment of cognitive functions, vehicular accidents, and increased accidents at workplaces. The increased usage of smart phones and electronic devices is worsening the epidemic. Adolescents with insufficient sleep are likely to be overweight and may suffer from depressive symptoms. The paper concludes by emphasizing sleep quality assessments as an important early risk indicator, thereby reducing the incidence of a wide spectrum of morbidities.

Mite and Bed Bug Infections.

Patients with suspected bites or skin rashes regularly present to their primary care physician. Common mite infections encountered in the primary care office include scabies, chiggers, grain itch, and allergic responses from dust mites. In fact, scabies is one of the 50 most prevalent diseases worldwide. Bed bugs are also becoming increasingly common, living in dark crevices, such as mattresses, feeding at night, and causing a maculopapular immune mediated allergic skin response in humans. Proper identification of the mite or bed bug is essential to guide treatment and eradication.

Sleep Disorders: Sleep-Related Breathing Disorders.

Sleep-related breathing disorders or sleep-disordered breathing are characterized by abnormal respiration during sleep. They are grouped into obstructive sleep apnea (OSA), central sleep apnea, sleep-related hypoventilation, and sleep-related hypoxemia disorder. OSA is a common disorder encountered in the family medicine setting that is increasingly being recognized because of the obesity epidemic and greater public and physician awareness. OSA is characterized by recurrent episodes of partial or complete closure of the upper airway resulting in disturbed breathing during sleep. It is associated with decreased quality of life and significant medical comorbidities. Untreated OSA can lead to a host of cardiovascular diseases including coronary artery disease, stroke, and atrial fibrillation. Patients who report symptoms of snoring, witnessed apneas, or daytime sleepiness should be screened for sleep apnea. In-laboratory attended diagnostic polysomnography or portable home sleep testing can be used to diagnose sleep apnea. Continuous positive airway pressure (CPAP) therapy is the first-line treatment for OSA in adults. Other modalities include mandibular advancement devices, surgery, or upper airway stimulation therapy. Adjunctive therapy should include weight loss in overweight patients, avoidance of sedatives and alcohol before sleep, and possibly positional therapy.

Sleep Disorders: Insomnia.

Insomnia is the most common type of sleep disorder in the family medicine population. It is defined as a persistent difficulty initiating or maintaining sleep, or a report of nonrestorative sleep, accompanied by related daytime impairment. Insomnia is a significant public health problem because of its high prevalence and management challenges. There is increasing evidence of a strong association between insomnia and various medical and psychiatric comorbidities. Diagnosis of insomnia and treatment planning rely on a thorough sleep history to address contributing and precipitating factors as well as maladaptive behaviors resulting in poor sleep. Using a sleep diary or sleep log is more accurate than patient recall to determine sleep patterns. A sleep study is not routinely indicated for evaluation of insomnia. Cognitive behavioral therapy for insomnia (CBT-I) is the mainstay of treatment and is a safe and effective approach. The key challenge of CBT-I is the lack of clinicians to implement it. The newer generation nonbenzodiazepines (eg, zolpidem, zaleplon) are used as first-line pharmacotherapy for chronic insomnia. Newer drugs active on targets other than the gamma-aminobutyric acid receptor are now available, but clear treatment guidelines are needed.

Sleep Disorders: Circadian Rhythm Sleep-Wake Disorders.

Shift work sleep disorder is a common problem in industrialized countries because of the need for occupations and services to continue to function 24 hours/day. Approximately 20% of employed adults in the United States are engaged in shift work. Shift work sleep disorder is diagnosed if there is a report of insomnia or excessive sleepiness for at least 3 months associated with a recurring work schedule that overlaps the usual time for sleep. Shift work is associated with an increased occurrence of metabolic disorders, such as insulin resistance, diabetes, dyslipidemia, and metabolic syndrome, and it has been implicated in weight gain and cognitive impairment. There is evidence of increased absenteeism in night workers compared with day workers. A planned sleep schedule, timed bright light exposure, timed melatonin administration, and stimulants or drugs promoting alertness can be used to manage shift work sleep disorder. Jet lag is characterized by a misalignment between internal circadian rhythms and local time caused by rapid travel across at least two time zones. Not all travelers experience jet lag; risk factors include age, number of time zones crossed, and circadian preference. Management includes timed melatonin along with optional timed and dosed bright light exposure.

Sleep Disorders: Restless Legs Syndrome.

Restless legs syndrome (RLS) is a common disorder that often is underdiagnosed and undertreated. Patients with RLS describe an urge to move their legs, especially in the evenings and during periods of inactivity. The prevalence of clinically significant RLS is approximately 2% to 3% in adults in Europe and North America. RLS can be an independent disorder or may occur in conjunction with other conditions (eg, iron deficiency, pregnancy, chronic renal failure). Diagnosis is based on clinical history. Routine polysomnography typically is not recommended unless there is suspicion of other sleep disorders (eg, obstructive sleep apnea). Management includes a combination of supportive measures, dopaminergic drugs, gabapentinoids, opioids, or benzodiazepines. Good sleep hygiene can help prevent development of insomnia related to RLS. Avoiding alcohol and reducing caffeine intake is recommended. If iron stores are low, iron supplementation may improve symptoms. The main pharmacologic options for RLS management are dopaminergic agonists (eg, pramipexole and ropinirole); gabapentinoids also are good options. Patients may experience augmentation, an increase in RLS symptom severity with increasing drug dosage, which is the main complication of dopaminergic drugs. There is no evidence to support use of vibratory devices that provide stimulation to the lower extremities.

Allergy Testing.

Allergic diseases are common in outpatient primary care. Allergy testing can guide management to determine allergy as a cause of symptoms and target therapeutic interventions. This article provides a review of common methods of allergy testing available so that physicians may counsel and refer patients appropriately. Immediate-type hypersensitivity skin tests can be used for airborne allergens, foods, insect stings, and penicillin. Radioallergosorbent testing can be used to evaluate immediate-type hypersensitivity. Delayed-type hypersensitivity or patch-type skin tests are used in patients with suspected contact dermatitis.

Minilaparoscopic versus laparoscopic cholecystectomy: a randomised controlled trial.

Since its introduction in 1987, the technique of cholecystectomy has continued to undergo evolution. Surgeons have reduced the port size and number or both to achieve improvement in postoperative pain control, rapid return to activity and better cosmetic results. Therefore, this study was done to compare the standard 4 port laparoscopic cholecystectomy (LC) with the 3 port laparoscopic cholecystectomy using a 5 mm telescope instead of 10 mm telescope (mini laparoscopic cholecystectomy - MLC). Forty patients were randomised to each group. Mean operating time, intraoperative and postoperative complications, mean period to resume walking, eating and return to normal activities and mean hospital stay were similar in the two groups. The level of postoperative pain was significantly lower in the MLC group. Patients who underwent MLC required a significantly lower dose of analgesics. In conclusion mini laparoscopic cholecystectomy is a feasible and safe procedure with less postoperative pain and better cosmesis and without increased complications.