Insomnia during pregnancy: diagnosis and rational interventions

Sleep disturbances are common in pregnancy. Insomnia is a frequent sleep disturbance experienced by pregnant women which can be primary or due to co-morbid conditions

The differential diagnosis of insomnia in pregnancy includes anxiety disorders, mood disorders, breathing related sleep disorders and restless legs syndrome. Early interventions to treat the sleep disturbance are recommended to avoid adverse pregnancy outcomes. Management strategies include improving sleep hygiene, behavioral therapies, and pharmacotherapy. The risks of pharmacotherapy must be weighed against their benefits due to the possible risk of teratogenicity associated with some medications

Methods: We searched PubMed and Google Scholar employing a combination of key words: pregnancy, sleep disturbances, Obstructive Sleep Apnea, Sleep disorders and insomnia

We included original studies, review articles, meta-analysis and systematic reviews in our search prioritizing articles from the last 10-15 years. Articles older than 15 years were only included if their findings had not been superseded by more recent data. Further selection of articles was done from bibliographies and references of selected articles

Conclusion: Sleep disturbances in pregnancy are common and cause considerable morbidity. Management includes a combination of non-pharmacological and pharmacological treatments carefully weighing the risks and benefits of each for the expectant mother and fetus

Urdu translation of the Hamilton rating scale for depression: results of a validation study

Objective: To develop a standardized validated version of the Hamilton Rating Scale for Depression [HAM-D] in Urdu

Methods: After translation of the HAM-D into the Urdu language following standard guidelines, the final Urdu version [HAM-D-U] was administered to 160 depressed outpatients. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation between HAM-D-U scores at baseline and after a 2-week interval was evaluated for test-retest reliability. Moreover, scores of two clinicians on HAM-D-U were compared for inter-rater reliability. For establishing concurrent validity, scores of HAM-D-U and BDI-U were compared by using Spearman correlation coefficient. The study was conducted at Mayo Hospital, Lahore, from May to December 2014

Results: The Cronbach alpha for HAM-D-U was 0.71. Composite scores for HAM-D-U at baseline and after a 2-week interval were also highly correlated with each other [Spearman correlation coefficient 0.83, p-value < 0.01] indicating good test-retest reliability. Composite scores for HAM-D-U and BDI-U were positively correlated with each other [Spearman correlation coefficient 0.85, p < 0.01] indicating good concurrent validity. Scores of two clinicians for HAM-D-U were also positively correlated [Spearman correlation coefficient 0.82, p-value < 0.01] indicated good inter-rater reliability

Conclusion: The HAM-D-U is a valid and reliable instrument for the assessment of Depression. It shows good inter-rater and test-retest reliability. The HAM-D-U can be a tool either for clinical management or research

Actigraphy in post traumatic stress disorder

Patients with posttraumatic stress disorder [PTSD] frequently complain of sleep disturbances such as insomnia and nightmares. Evaluation of sleep disturbances is often difficult due to the subjective nature of the complaints. Polysomnography [PSG] and other sleep studies are generally not indicated in the evaluation of insomnia or nightmares associated with PTSD. Actigraphy, [electronic activity monitoring] has been used in research to evaluate sleep disturbances in patients with PTSD. We reviewed the literature on the use of actigraphy in evaluation of sleep problems in patients with PTSD. A literature search for articles on the topic was conducted on PubMed using the search algorithm [actigraphy [Title/Abstract] OR actigraphic [Title/Abstract]] AND PTSD [Title/Abstract]. Out of 11 search results, 9 studies in which application of actigraphy had relevance to the primary objective and outcome in PTSD patients with sleep problems were selected for review. We also handpicked one additional article from personal communication with our colleagues who have done some of these studies. Actigraphy has been used to evaluate circadian rhythm sleep disorders. Use of actigraphy in psychiatry clinics is uncommon. There is no data to support that there are specific actigraphic sleep related findings in PTSD patients. However, it can be a useful tool to complement the use of sleep diaries when assessing sleep and wake patterns in patients with PTSD

Nocturnal awakening and sleep duration in veterans with PTSD: an actigraphic study

To assess whether awakenings from sleep and sleep duration in Post Traumatic Stress Disorder [PTSD] were related to demography, posttraumatic or depressive symptoms, subjective sleep quality, and daytime sleepiness. Sample consisted of 23 veterans with lifetime PTSD and current sleep disturbance not due to apnea or other diagnosable conditions. Data collection included demography, two weeks of actigraphy, Beck Depression Inventory, Posttraumatic Checklist, Clinical Assessment of Posttraumatic Symptoms, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. The study revealed that awakenings increased with younger age. Variability in awakenings also increased with younger age [p = 0.002]. More awakenings were associated with shorter sleep duration. These paradoxical observations regarding younger age and more awakening may be related to increased sleep symptoms early in the course and then gradual waning of posttraumatic symptoms over time, since awakenings tend to increase with age in normals [rather than decrease, as we observed]

Association of smoking [pack years] with Agnor count in buccal mucosal cytology

Background: Tobacco smoking is a self-inflicted major health hazard worldwide. Cigarette smoking influences proliferative activity in normal oral mucosa. This proliferative activity can be detected by AgNOR count. This study was conducted in an attempt to find any association between smoking [Pack Years] and AgNOR count

Methods: Silver stained cytologic smears of buccal mucosa in 75 smokers and 75 nonsmokers were viewed for AgNOR count and a comparison between pack years of smoking and increased AgNOR number was assessed using SPSS analysis

Results: A positive correlation [r = .604] significant at the 0.01 level was found, between pack years and AgNOR count. This explains significant replicative activity under the influence of cigarette smoking

Conclusion: The effect of cigarette smoking in buccal mucosa is related to dose exposure [Pack Years of smoking] and a positive correlation exists between proliferative activity [AgNOR Count] and smoking [Pack Years]. An association between pack years of smoking and increased AgNOR count explains cigarette smoke`s effect on buccal mucosa