Asendin

Andrew Y. Hwang, PharmD

• Postdoctoral Fellow, Departments of Pharmacotherapy & Translational Research and Community Health & Family Medicine, Colleges of Pharmacy and Medicine, University of Florida, Gainesville, Florida

http://www.highpoint.edu/pharmacy/files/2019/03/Andrew-Hwang-CV.pdf

The follow-ups of selected papers for that meta-analysis were mainly short (12 months) and sometimes medium-term (36 months) anxiety 35 weeks pregnant buy asendin overnight delivery. Adverse events fi Mesh exposure Mesh exposure is the condition whereby synthetic mesh is displayed/exposed (usually visualised through separated vaginal epithelium) (Haylen et al depression hole definition purchase 50 mg asendin with amex. These exposures can cause pain during sexual intercourse depression definition movement purchase asendin 50mg online, cause blood loss or foul vaginal discharge depression definition ppt order asendin 50mg fast delivery, but can also be asymp to matic depression from work purchase cheap asendin online. In a systematic review of 54 studies on 4566 patients depression youtube video purchase asendin cheap online, the dyspareunia rate after a vaginal mesh procedure was reported to be 8. Randomised trials comparing vaginal mesh versus native tissue repair surgery however did not demonstrate a difference in de novo dyspareunia, nor in post-operative dyspareunia (Milani et al. The most important risk fac to r for post-operative dyspareunia was pre-operative dyspareunia. Pain caused by shrinkage of vaginal tissue caused by an excessive inflamma to ry reaction against the polypropylene mesh, which acts as a foreign body, is of a different nature and can be serious and difficult to treat. Pain in the lower abdomen or pubic region 12 months after a mesh augmented prolapse repair is reported by between 3-10% of patients. Infracoccygeal sacropexy is an operation that involves the insertion of a piece of material (mesh) with the aim of holding the womb in place. The advisers said that problems may include mesh extrusion, infections, damage to the bladder, bowel or rectum and painful sexual intercourse. The advisers also said that there may be fewer complications with newer types of mesh. Concerning the effect of a learning curve on the success rates (objective and/or subjective cure rates), the published data remain controversial. However, complication rates remained unchanged throughout this learning curve series. The complication rates were also low throughout this series and were not affected by the learning curve. However, this study analysed the learning curve of a senior urogynecologic surgeon who commenced this technique, and not the learning curve of a trainee. Prior training in laparoscopic suturing coincided with a short learning process for the phases requiring suturing (Claerhout et al. The most time-consuming step is the dissection of the vault, for which it to ok the trainee 31 procedures to achieve an operation time comparable to that of the teacher (Claerhout et al. However, following multivariate analysis, the only independent risk fac to rs of exposure were the kind of prosthesis, age less than 60 years and concomitant hysterec to my (Guillibert et al. Ideally the increasing literature on complications (and by deduction, on successful outcomes for patients) will in the future support a meta-analysis of patient selection for avoiding poor outcomes. A useful consensus statement published in the International Urogynaecology Journal (Davila et al. This highlights the following patient groups for which caution should be exercised regarding transvaginal mesh implants: fi Primary prolapse cases. The decision to operate should be based upon 2 symp to matic problems from the prolapse defined by the patient. However, other fac to rs may also increase the likelihood of complications associated with urogynaecological mesh implantation. Patient counselling the informed consent process should be a wide-ranging discussion with the patient regarding her specific situation. It depends on the ana to mic and functional indications and has its own risk/benefit ratio, which in some instances can be more serious and needs to be discussed in the shared decision process with the patient. Manufacturers of urogynaecological mesh devices have also been required to undertake manda to ry post-market studies to provide comparative data between mesh kits and conventional surgery. The Advisory notes the increased Canadian and international reports of surgical complications associated with urogynaecological mesh use and requests the reporting of any adverse event associated with this type of device. These recommendations included statements regarding the potential for higher rates of complications in transvaginal placement of mesh compared to abdominally placed mesh or native tissue repair. Health Canada is reviewing labelling related to these products to determine if it provides appropriate safety information. Following this review, a detailed analysis was undertaken in 2013 of the available published literature, the information supplied with each device and associated training materials provided by sponsors and manufacturers. As a consequence, there was an absence of evidence to support the overall effectiveness of these surgical meshes as a class of products. However, the literature did identify the already known adverse outcomes associated with their use. Certain patients, including those who smoked or were obese, were found to be at higher risk of adverse events and repeated procedures. Risks associated with the use of mesh in urogenital surgery Are specific meshes, in terms of designs and/or materials, considered to be of a higher riskfi Current evidence suggests: fi Type 1 (macroporous, monofilament) polypropylene is considered to be the most appropriate synthetic mesh for insertion via the vaginal route. In general terms, vaginal surgery is associated with a higher risk of mesh-related morbidity than abdominal insertion of mesh. Furthermore, the abdominal route requires general anaesthesia, whereas the vaginal route is feasible also under spinal anaesthesia. Most complications associated with mesh insertion are related to the route of insertion. Its use should be restricted to patients selected according to established evidence based clinical guidelines. With vaginal insertion of non-absorbable synthetic mesh a large surface area is associated with a higher complication rate compared with transabdominal insertion. However, there are generic differences and potential complications distinguishing the two surgical approaches, and this fact should also be taken in to account in a risk assessment. The use of synthetic non-absorbable mesh is associated with a risk of mesh exposure. However, other surgical procedures, such as colposuspension, are associated with an increased risk of long-term rec to cele/enterocele. Moreover, there are generic differences and different potential complications for these two surgical approaches. In the light of the above, identify risks associated with use(s) of meshes other than for urogynecological surgery and advise if further assessment in this field(s) is needed. This needs to be quantified by further research before any conclusion can be made. Information about the public consultation was broadly communicated to national authorities, international organisations and other stakeholders. Where appropriate, the text of the relevant sections of the opinion has been modified or explanations have been added to take account of relevant comments. Biomechanical Author Sample Host Response Properties Moderate and uniform infiltration of host fibroblasts and Au to logous rectus fascia neovascularisation after 5 and 8 implanted in 5 patients weeks implantation. Samples obtained, respectively, from After 4 years implantation, no transvaginal revision after 3, 5, (Fitzgerald et evidence of inflamma to ry cell infiltrate 8 and 17 weeks and from al. Au to logous lata fascia implanted in 16 rabbits randomised in to 4 survival Low inflamma to ry cell infiltration. Au to logous rectus fascia implanted in 15 rabbits No significant decrease randomised in to 3 survival of biomechanical (Dora et al. Au to logous rectus fascia Collagen remodeling by moderate implanted in 20 rabbits collagen infiltration but encapsulation randomised in to 2 survival as well. Half of biomechanical implanted on the rectus fascia Minimal inflamma to ry response. Au to logous fascia grafts explanted after sling revision Collagen remodeling by new from 5 women, due to different collagen fibres organised complications, between 2-65 (Woodruff et longitudinally. Au to logous fascia lata implanted in 14 rabbits randomised in to 2 survival No significant inflamma to ry (Pinna et al. No significant decrease of Human cadaveric fascia implanted the fracture to ughness in 20 rats randomised in to 2 (Kim et al. Freeze-dried and gamma Significant decrease of irradiated human cadaveric lata biomechanical properties fascia implanted in 18 rabbits and (Walter et al. Human cadaveric fascia lata implanted subcutaneously on the abdominal wall of 20 rats (Spiess et al. Cadaveric fascia lata implanted subcutaneously on the anterior Minimal to moderate degree of rectus fascia of 10 rabbits scar. Human cadaveric dermis slings explanted after revision from 2 High levels of degradation. Human cadaveric dermis and fascia lata implanted in 16 rats, Thin fibrous capsule formation. Human cadaveric dermis Increase of tensile strength (AlloDerm ) implanted in 18 rats Moderate amounts of collagen after 30 days and, again, randomised in to 2 survival groups deposition well organised. Porcine dermis implanted in Very significant decrease of 2 missing or fragmented materials 12 20 rabbits randomised in to 2 biomechanical properties weeks after being implanted on the survival groups (6 and 12 after 12 weeks implantation. Half implanted on the (Hilger et rectus fascia and half on the Moderate to strong inflamma to ry al. They just were degraded grafts which may be expedited thicker and to lerated less in vaginal environment. Cross-linked porcine dermis Mild inflamma to ry response decreased (Permacol ) implanted to minimal from day 7 to day 180 after (Kolb et al. Abdominal wall defect Cell infiltrate in to entire grafts by day repaired with porcine dermis 35. Biomechanical Author Sample Host Response Properties 16 women were implanted Mersilene induces higher inflamma to ry (Falconer et al. Cadaveric fascia lata group: the implant Implantation of Surgipro was incorporated in a plate of fibrous (Rabah et al. Polypropylene type I mesh and Macroporous silk Polypropylene meshes induce a moderate (Spelzini et al. Grafts implanted on the vaginal wall are stiffer than the ones implanted 79 the safety of surgical meshes used in urogynecological surgery Biomechanical Author Sample Host Response Properties on the abdominal wall, after retrieval. Gore membrane Membrane substitute 81 the safety of surgical meshes used in urogynecological surgery 10. Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, Van Kerrebroeck P, Vic to r A, Wein A. The standardisation of terminology of lower urinary tract function: Report from the International Standardisation Sub-Committee Continence Society. Surgical Treatment of Recurrent Stress Urinary Incontinence in Women: A Systematic Review and Meta-analysis of Randomised Controlled Trials. Laparoscopic sacrocolpopexy for female genital organ prolapse: establishment of a learning curve. Additional surgical risk fac to rs and patient characteristics for mesh extrusion after abdominal sacrocolpopexy. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Araco F, Gravante G, Sorge R, Over to n J, De Vita D, Primicerio M, Dati S, Araco P, Piccione E. Strength over time of a resorbable bioscaffold for body wall repair in a dog model. Transvaginal repair of genital prolapse with Prolift: evaluation of safety and learning curve. Risk fac to rs associated with failure 1 year after retropubic or transobtura to r midurethral slings, American Journal of Obstetrics and Gynecology. Polypropylene midurethral tapes do not have similar biologic and biomechanical performance in the rat. Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and paras to mal hernia repair! The role of synthetic and biological prostheses in reconstructive pelvic floor surgery. Pelvic floor muscle training in treatment of female stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. Bogusiewicz M, Wrobel A, Jankiewicz K, Adamiak A, Skorupski P, Tomaszewski J, Rechberger T. Collagen deposition around polypropylene tapes implanted in the rectus fascia of female rats. European Journal of Obstetrics Gynecology and Reproductive Biology 2006; 124, 106-109. European Journal of Obstetrics Gynecology And Reproductive Biology 2007; 134, 262-267. Tissue integration and to lerance to meshes used in gynecologic surgery: An experimental study. European Journal of Obstetrics Gynecology and Reproductive Biology 2006; 125, 103-108.

Syndromes

• Three or more drinks of alcohol per day on most days
• Urinary tract infection
• Grimacing
• A high-calorie diet that supplies essential vitamins and minerals, as well as certain types of carbohydrates, proteins, and fats
• Melanoma
• Pale skin and bluish color around the eyes
• Fluids by IV
• Serum insulin-like growth factor 1 (IGF-1)
• Reducing distractions during nursing, performing a gentle massage, and applying heat to the breast
• Have pain in, or between, your shoulder blades with nausea

According to the included surveys bipolar depression and christianity best buy asendin, high proportions of children with otitis media have hearing impairment mood disorder related to general medical condition order discount asendin online. The data were obtained from the series of surveys among children in Africa (13) bipolar depression 3rd purchase asendin 50mg free shipping, India (83) anxiety bc discount asendin 50mg fast delivery, and Sierra Leone (151) depression during pms buy generic asendin on line, and among the general population in Thailand (7) depression quest steam buy genuine asendin on-line. Otitis media accounted for 91% of Vellore children (in India) and 66% of Saudi Arabian children with hearing loss. Minja (117) reported that, in 354 Tanzanian schoolchildren, otitis media accounted for 8. Cholestea to ma was found in over 60% of ears that had persistent o to rrhoea for five years or more in Zaire (107), in 40% of children and 26% of adult cases in South Korea (128), in 0% among Navajo children (127), in 0. Non-randomized clinical trials in the 1940s and 1950s have also demonstrated reductions in clinical mas to iditis from 32% to 6% in sulfonamide-treated patients and from 8% to 1% in penicillin-treated patients (18). In Zaire, most deaths attributed to otitis media were due to serious complications arising from neglected draining ears (107). The most common extracranial complications were subperiosteal abscess and labyrinthine fistula; facial weakness, post-auricular swelling and otalgia were the most frequent symp to ms and signs. Meningitis was the most common intracranial com plication, usually presenting with fever, headache, and meningeal signs. Some 14% of deaths from otitis media come from Middle Eastern countries; no deaths are found in the Americas. Reliable his to ry-taking depends on good recall on the part of the patient or carer, an infrequent trait since neither parents nor teachers of children with otitis media have been shown to reliably estimate the number of otitis media episodes, the degree of hearing loss, or the possible impact of the condition (6). This is only possible by removing any obstructing wax, ear discharge, debris or masses in the external audi to ry canal and visualizing the whole expanse of the ear drum and, if possible, the middle ear through the perforation. Such an examination requires adequate illumination through a head mirror, head light, o to scope or o to microscope, suction apparatus and small instruments. It also requires considerable skill and patience particularly when examining the ears of struggling children. In Kenya, the physician could visualize both tympa nic membranes in only 84% of the children examined (138). Acute otitis externa and acute otitis media can produce both ear pain and ear discharge. The discharge in otitis externa is less profuse and foul-smelling and there is no mucus, as can be tested with a cot to n mop by the ten dency to form mucus threads. In Kenya, the sensitivity and specificity of health workers in detecting o to rrhoea was 97% and 95%, respectively, compared with the physician (138). In Gondar, Ethiopia, the sensitivity and specificity of health workers in detecting o to r rhoea was 66% and 95%, respectively (154). A more sensitive way of determining o to rrhoea, such as swabbing the ear canal with a cot to n pledget or using a penlight to illuminate the ear canal better, is needed in the primary health care setting. Still it is possible to misdiagnose a patient with o to rrhoea as a case of acute oti this externa or otitis media, but what would be its impactfi The consequence would be decreased efficiency (because of increased cost of medication and lower effectiveness) and exposure to systemic adverse reactions. In the presence of co-morbidity like a protracted respira to ry infection or malnutri tion, the likelihood of non-resolution is higher. The observation that antibiotic therapy decreased the incidence of acute mas to i ditis complicating acute otitis media (19,148), similar to the decrease in suppu rative complications among antibiotic-treated patients with strep to coccal pharyngitis; and 2. A meta-analysis that showed the short-term benefits of prolonged antibiotics on patients with recurrent otitis media. Again the availability of cost-effective antibiotics with relatively low like lihood of adverse reactions would justify such an empiric policy. In prac tice, however, patients with draining ears do expect some treatment regardless of culture results. Since to pical treatment is often effective and seldom harmful, most experts would start with a wide-spectrum antibiotic on an empiric basis and make a request for cultures if drug resistance is suspected (150,152). This will avoid delay in operating on those patients whose infections are medically intractable from the outset. Generally, infection that involves the hidden upper recesses (attic) of the mid dle ear and the mas to id antrum (attico-antral disease) is usually to o deep within the ear to be reached by antibiotics. A cholestea to ma, a nest of squamous keratini zing epithelium within the middle ear cleft that destroys bone and permits spread of infection is a surgical disease. These conditions are often associated with a purulent foul-smelling discharge that fails to resolve with the usual course of antibiotics. In addition, recognition of the suppurative complications within and/or outside the cranial cavity should also immediately exclude such patients from medical management and should call for immediate mas to idec to my. Such complications include subperiosteal abscesses, facial nerve paralysis, lateral sinus thrombophlebi tis, suppurative labyrinthitis, brain abscess, meningitis and otitic hydrocephalus. Among such patients, medical treatment can be aimed at control of infection and elimination of ear discharge as short-term goals and eventual healing of the tympanic perforation and improve ment of hearing as ultimate goals. The most commonly measured outcome was disappearance of discharge after treatment, but post-treat ment observations were to o short to demonstrate lasting benefits and the studies that attempted to do this did not find significant differences in hearing status or closure of perforation between treatments. This was based on two field trials among children in the Solomon Islands (50) and Kenya (155). Further studies are therefore needed to demonstrate the benefit of aural to ilet alone. As discussed in the next section on Antimicrobial Treatment, aural to ilet must be combined with anti biotics or antiseptics to be effective. Practical implications Aural to ilet is best performed in the clinics by means of small suction tips, forceps and curettes (95) to remove small mucosal granulations from the middle ear. This would ordinarily require skilled o to logists working with good illumination and magnification. In addition, aural to ilet could be continued outside the clinic by means of irriga ting the ear with cleaning solutions and/or dry mopping the ear with cot to n wool wisps on orange sticks four times per day. The patients themselves, their parents, schoolmates or teachers could perform this. Brobby did not recommend syringing the ear as it might cause irritation of the vestibular apparatus or infection of the labyrinth. Nonetheless, most authors agree on the benefits of mechanically swishing cleansing solutions inside the ear (135,152). Irrigating solutions must be warmed to near body temperature so as not to induce vertigo. They can be instilled in to the middle ear by means of medicine droppers or bulb syringes. Alternately compressing and releasing the rubber bulbs to instil and suck back the solution could mechanically dislodge mucus and debris from the middle ear. The patient may perform a 31 Chronic Suppurative Otitis media: Burden of illness and Management options Valsalva manoeuvre to further express mucus from the Eustachian tube in to the middle ear for removal. The tips of tightly wound pieces of cloth or nap kins may also be inserted inside ear canals to wipe off discharge. The entire procedure is done two to three times daily until discharge disappears (150). The entry of water or soap in to the ear, particularly during bathing, is avoi ded by plugging the ear with rubber or cot to n wool covered with vaseline (97). This also prevents soiling and irritating the skin surrounding the ear canal with infected discharge (159). However, the choice of antimicrobial treatment to be combined with aural to ilet is a highly contentious issue. A consensus of management formed by 141 physicians with expertise and interest in middle ear infections yielded the follo wing recommended treatment: suction out and culture the discharge, prescribe oral antibiotics, and adjust according to sensitivity results. Ludman (105) and Nelson (127) advocated similar approaches and cited potential o to to xic effects as a major disadvantage of to pical antibiotics. On the other hand, most o to laryn gologists recommend to pical antibiotic therapy and point out the poor penetra tion by most antibiotics in to a devascularized middle ear mucosa marked with subepithelial scarring and thickening (85). An initial trial of to pical antibiotics is recommended and oral antibiotics may be added if a susceptible organism is cultured. Another trial comparing oral clindamycin with aural to ilet alone found o to rrhoea resolution rates of 93% and 29%, respectively (37). Some oral antibiotics are as good as others Similar rates of o to rrhoea resolution were found between cefotiam and amoxycillin clavulanic acid (61% and 65%, respectively) by Cannoni et al. In the Cannoni trial, adverse effects were more common among the amoxycillin clavulanic acid-treated group (36%) than in the cefotiam-treated group (14%). The to pical antibiotics used were framycetin, gra micidin, ciprofloxacin, to bramycin, gentamicin and chloramphenicol. Six studies (27,54,55,136,145,189) used gentamicin, chlo ramphenicol, ofloxacin, and ciprofloxacin as to pical antibiotics; hydrogen peroxide, and boric acid with iodine powder as to pical antiseptics; and cephalexin, flucloxaci llin, cloxacillin, amoxycillin, coamoxiclav, erythromycin, metronidazole, piperacillin, ciprofloxacin, azactam, trimethoprim-sulfa, ofloxacin, and intramuscular gentami cin as systemic antibiotics. Topical quinolones are better than to pical non-quinolones the Cochrane review showed that among to pical antibiotics, to pical fluoroquinolo nes are more effective than other types of to pical antibiotics. Miro (118) found that to pical ciprofloxacin was more effective than to pical polymyxin-neomycin-hydrocortisone in terms of clinical response (87% and 76%, respectively), but the bacterial eradication rates were the same (79% and 76%, respectively). Combined to pical and systemic antibiotics are no better than to pical antibiotics alone Should oral antibiotics be added to to pical antibioticsfi The Cochrane review showed that combined oral- to pical antibiotics were no more effective than to pical antibio tics alone; the rates of resolution of o to rrhoea were 50% and 53%, respectively. In terms of eradication of middle ear bacteria, oral and to pical ciprofloxacin were slightly more effective than to pical ciprofloxacin alone (15% vs 5%), but this was not statistically significant (54). Thus, although combination antibiotics are effective in resolving o to rrhoea, adding oral antibiotics to to pical antibiotics and aural to ilet increases the cost with out increasing the success rate. This confirms the difficulty of systemic drug pene tration through the devascularized, fibrotic mucosa of the middle ear and mas to id. Powdered antibiotics and antiseptics are routinely recom mended when there is good access to the middle ear cavity, such as in cases of sub to tal tympanic perforations or draining mas to id cavities (85). Ophthalmic antibiotic drops containing buffered neutral solutions of gentamicin, to bramycin, sulfisoxazole, chloramphenicol, sulfacetamide, tetracycline, polymyxin B, trimethoprim, nor floxacin, ofloxacin, ciprofloxacin and erythromycin (85,97) 2. The risk of o to to xicity is one stumbling block in the widespread use of to pical antibio tics. But much of the evidence on o to to xicity consists of experimental introduction of putative agents in to intact, normal middle ears or painted on the round window mem branes of animals such as chinchillas, rats and baboons (56,121,122). Unlike that of animals, however, the round window membrane (the structure which drugs penetrate 35 Chronic Suppurative Otitis media: Burden of illness and Management options to gain access to the inner ear) of humans is more deeply set within bone. There have been several case reports of sensorineural hearing loss in humans following administration of ear drops (109,121,146,188); however, these case reports have not changed the clinical practice of most clinicians (109,121). Clinicians rarely see them and a recent survey showed that 80% were more concerned with the very real danger of sensorineural hearing loss from otitis media than with the theoretical possibility of o to to xicity from to pical antibiotics (146). In two separate clinical trials, patients treated with to pical gentamicin did not show significant post-treatment threshold shifts (26,69). The safety and effectiveness of to pical quinolones in children have been well documented (48). Adverse reactions have been minor and as frequent as with other to pical antibiotics. The concentrations of these drugs are highest in o to rrhoea, the main route of exit from the ear, and lowest in the serum (130). Parenteral antibiotics Parenteral antibiotics are better than aural to ilet alone One trial (58) found that intravenous mezlocillin and ceftazidime were more effecti ve than aural to ilet alone in resolving o to rrhoea and eradicating middle ear bacteria (100% and 8%, respectively). Penicillins: Carbenicillin, piperacillin, ticarcillin, mezlocillin, azlocillin, methicillin, nafcillin, oxacillin, ampicillin, penicillin G 2. Rotimi combined oral clindamycin, metronidazole and lincomycin with intra muscular gentamicin. Topical antiseptics Topical antiseptics may be as effective as to pical antibiotics Topical antiseptics tended to be more effective than aural to ilet alone in resolving o to rrhoea in the trial by Eason et al. This pro mising result is corroborated by three trials that were included in the Cochrane review (27,35,50). Topical antiseptics were found to be just as effective as to pical antibiotics; however, olfoxacin/ciprofloxacin produced high cure rates. The combined sample size was still small and, judging from the width of the 95% confidence interval, had little power to detect small differences in effectiveness.

Generic 50 mg asendin with visa. Mood Disorders.

Other labora to ry measures show evidence mood disorder in children symptoms buy cheap asendin 50mg, although not consistently anxiety joint pain asendin 50 mg visa, of increased arousal and a generalized activation of the hypothalamic-pituitary-adrenal axis depression symptoms loss of balance purchase genuine asendin on-line. In general depression symptoms nz buy asendin 50 mg on line, findings are consistent with the hypothesis that increased physiological and cognitive arousal plays a significant role in insomnia disorder mood disorder journal discount 50mg asendin. There may be an increased incidence of stress related psychophysiological symp to ms mood disorder due to general medical condition purchase asendin with paypal. Functional Consequences of Insomnia Disorder Interpersonal, social, and occupational problems may develop as a result of insomnia or excessive concern with sleep, increased daytime irritability, and poor concentration. Persistent insomnia is also associated with long-term consequences, including increased risks of major depressive disorder, hypertension, and myocardial infarction; increased absenteeism and reduced productivity at work; reduced quality of life; and increased economic burden. Some individuals who require little sleep ("short sleepers") may be concerned about their sleep duration. Short sleepers differ from individuals with insomnia disorder by the lack of difficulty falling or staying asleep and by the absence of characteristic daytime symp to ms. However, some short sleepers may desire or attempt to sleep for a longer period of time and, by prolonging time in bed, may create an insomnia-like sleep pattern. Clinical insomnia also should be distinguished from normal, age-related sleep changes. Situational/acute insomnia is a condition lasting a few days to a few weeks, often associated with life events or with changes in sleep schedules. Shift work type differs from insomnia disorder by the his to ry of recent shift work. Restless legs syndrome often produces difficulties initiating and maintaining sleep. Nonetheless, as many as 50% of individuals with sleep apnea may also report insomnia symp to ms, a feature that is more common among females and older adults. Parasomnias are characterized by a complaint of unusual behavior or events during sleep that may lead to intermittent awakenings and difficulty resuming sleep. However, it is these behavioral events, rather than the insomnia per se, that dominate the clinical picture. Substance/medication induced sleep disorder, insomnia type, is distinguished from insomnia disorder by the fact that a substance. For example, insomnia occurring only in the context of heavy coffee consumption would be diagnosed as caffeine-induced sleep disorder, insomnia type, with onset during in to xication. Persistent insomnia represents a risk fac to r or an early symp to m of subsequent bipolar, depressive, anxiety, and substance use disorders. Individuals with insomnia may misuse medications or alcohol to help with nighttime sleep, anxiolytics to combat tension or anxiety, and caffeine or other stimulants to combat excessive fatigue. In addition to worsening the insomnia, this type of substance use may in some cases progress to a substance use disorder. Despite their clinical appeal and heuristic value, there is limited evidence to support these distinct phenotypes. Self-reported excessive sleepiness (hypersomnolence) despite a main sleep period lasting at least 7 hours, with at least one of the following symp to ms: 1. A prolonged main sleep episode of more than 9 hours per day that is nonres to rative. The hypersomnolence is not better explained by and does not occur exclusively during the course of another sleep disorder. The hypersomnolence is not attributable to the physiological effects of a substance. Coexisting mental and medical disorders do not adequately explain the predominant complaint of t^ypersomnolence. Specify if: With mental disorder, including substance use disorders With medicai condition With another sleep disorder Coding note: the code 780. Diagnostic Features Hypersomnolence is a broad diagnostic term and includes symp to ms of excessive quantity of sleep. Individuals with this disorder fall asleep quickly and have a good sleep efficiency (>90%). They may have difficulty waking up in the morning, sometimes appearing confused, combative, or ataxic. The persistent need for sleep can lead to au to matic behavior (usually of a very routine, low-complexity type) that the individual carries out with little or no subsequent recall. For example, individuals may find themselves having driven several miles from where they thought they were, unaware of the "au to matic" driving they did in the preceding minutes. For some individuals with hypersomnolence disorder, the major sleep episode (for most individuals, nocturnal sleep) has a duration of 9 hours or more. However, the sleep is often nonres to rative and is followed by difficulty awakening in the morning. These daytime naps tend to be relatively long (often lasting 1 hour or more), are experienced as nonres to rative. Individuals typically feel sleepiness developing over a period of time, rather than experiencing a sudden sleep "attack. Associated Features Supporting Diagnosis Nonres to rative sleep, au to matic behavior, difficulties awakening in the morning, and sleep inertia, although common in hypersomnolence disorder, may also be seen in a variety of conditions, including narcolepsy. While many individuals with hypersomnolence are able to reduce their sleep time during working days, weekend and holiday sleep is greatly increased (by up to 3 hours). Awakenings are very difficult and accompanied by sleep inertia episodes in nearly 40% of cases. Hypersomnolence fully manifests in most cases in late adolescence or early adulthood, with a mean age at onset of 17-24 years. Individuals with hypersomnolence disorder are diagnosed, on average, 10-15 years after the appearance of the first symp to ms. Hypersomnolence has a progressive onset, with symp to ms beginning between ages 15 and 25 years, with a gradual progression over weeks to months. For most individuals, the course is then persistent and stable, unless treatment is initiated. Although hyperactivity may be one of the presenting signs of daytime sleepiness in children, voluntary napping increases with age. Hypersomnolence can be increased temporarily by psychological stress and alcohol use, but they have not been documented as environmental precipitating fac to rs. Diagnostic iVlarlcers Nocturnal polysomnography demonstrates a normal to prolonged sleep duration, short sleep latency, and normal to increased sleep continuity. Some individuals with hypersomnolence disorder have increased amounts of slow-wave sleep. The multiple sleep latency test documents sleep tendency, typically indicated by mean sleep latency values of less than 8minutes. In hypersomnolence disorder, the mean sleep latency is typically less than 10 minutes and frequently 8minutes or less. Hypersomnoience can lead to significant distress and dysfunction in work and social relationships. Prolonged nocturnal sleep and difficulty awakening can result in difficulty in meeting morning obligations, such as arriving at work on time. Unintentional daytime sleep episodes can be embarrassing and even dangerous, if, for instance, the individual is driving or operating machinery when the episode occurs. If social or occupational demands lead to shorter nocturnal sleep, daytime symp to ms may appear. An inadequate amount of nocturnal sleep, or behaviorally induced insufficient sleep syndrome, can produce symp to ms of daytime sleepiness very similar to those of hypersomnoience. An average sleep duration of fewer than 7 hours per night strongly suggests inadequate nocturnal sleep, and an average of more than 9-10 hours of sleep per 24-hour period suggests hypersomnoience. Unlike hypersomnoience, insufficient nocturnal sleep is unlikely to persist unabated for decades. A diagnostic and therapeutic trial of sleep extension for 10-14 days can often clarify the diagnosis. Hypersomnoience disorder should be distinguished from excessive sleepiness related to insufficient sleep quantity or quality and fatigue. Excessive sleepiness and fatigue are difficult to differentiate and may overlap considerably. Individuals with hypersomnoience and breathing related sleep disorders may have similar patterns of excessive sleepiness. Polysomnographie studies can confirm the presence of apneic events in breathing related sleep disorder (and their absence in hypersomnolence disorder). Circadian rhythm sleep-wake disorders are often characterized by daytime sleepiness. A his to ry of an abnormal sleep-wake schedule (with shifted or irregular hours) is present in individuals with a circadian rhythm sleep wake disorder. Parasomnias rarely produce the prolonged, undisturbed nocturnal sleep or daytime sleepiness characteristic of hypersomnolence disorder. Hypersomnolence disorder must be distinguished from mental disorders that include hypersomnolence as an essential or associated feature. Assessment for other mental disorders is essential before a diagnosis of hypersomnolence disorder is considered. Comorbidity H)fiersomnolence can be associated with depressive disorders, bipolar disorders (during a depressive episode), and major depressive disorder, with seasonal pattern.

Diseases

• Onychogryphosis
• Marfan-like syndrome
• Usher syndrome, type 1C
• Thrombocytopathy
• Epstein syndrome
• Lipodystrophy Rieger anomaly diabetes
• Cerebellar hypoplasia endosteal sclerosis
• Anemia, hypoplastic, congenital