Perioperative Pharmacological Sleep‐Promotion and Pain Control: A Systematic Review

Drug-facilitated sexual assault followed by femicidal chloroform poisoning and suffocation: A case-report of criminal responsibility

INTRODUCTION

Criminal responsibility evaluation represents one of the most controversial and debated issues in forensic psychiatry. Although clear procedures have been recommended, little research exists on decision-making process by forensic psychiatrists. We present a case assessing the criminal responsibility of a murderer who committed femicide as a result of chloroform poisoning and suffocation after a drug-facilitated sexual assault.

MATERIALS AND METHODS

A.S., a 30-year-old female, was found dead in the home of S.P., a 50-year-old male. S.P. recounted killing A.S. by forced inhalation of chloroform, when the woman had experienced sensory clouding following unintentional ingestion of Zolpidem, a hypnotic agent. A multidisciplinary approach was taken to resolve the case. Autopsy, histological, genetic, and toxicological examinations were performed by a forensic pathologist, while a digital forensic examiner analysed electronic devices. A pool of three forensic psychiatrists and two psychologists was asked to assess the mental state of S.P. at the time of the crime.

RESULTS AND CONCLUSIONS

The cause of death of A.S. was identified as a lethal chloroform intoxication in altered consciousness caused by Zolpidem, while homicidal suffocation was also described. Mobile forensics demonstrated that S.P. had videotaped the crime scene, clearly revealing that A.S. had been sexually assaulted by S.P. before dying. Criminal responsibility of S.P. was evaluated through various psychological tests and seven interviews with the accused, each lasting an average of 180 min. Specialists concluded that S.P. could not be exempted from being responsible for the homicide.

Lagged effect of Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep Disturbance on subacute postsurgical PROMIS Pain Behavior

Sleep disturbance is a modifiable risk factor that, when reduced, may improve subacute postsurgical outcomes (e.g., pain-related impact). Evidence also indicates that pain and sleep may have a bidirectional longitudinal relationship before to (sub) acutely after surgery. The objective of the present study is to examine the degree to which sleep disturbances and pain behavior have uni- or bidirectional relationships in a sample of patients undergoing sports orthopedic surgery. In this observational, longitudinal cohort study, participants ( = 296) were adult (ages 18+) active duty service members who underwent open or arthroscopic shoulder or knee surgery at Walter Reed National Military Medical Center. Participants were asked to complete PROMIS Sleep Disturbance and Pain Behavior computer adaptive testing item banks before surgery, 6 weeks postsurgery, and 3 months postsurgery. Patient-level covariates were analyzed for interrelationships using nonparametric bivariate statistics. Autoregressive and cross-lagged structural equation modeling examined the bidirectional relationships of patient-level covariates and PROMIS outcomes. When controlling for patient-level covariates, sleep disturbance at presurgical and 2-week postsurgical timepoints were positively associated with both sleep disturbance and pain behavior at the subsequent timepoint. Sleep disturbance may contribute to pain-related functioning and quality of life after sports orthopedic surgery. Future studies utilizing multidimensional patient report outcomes and robust analytics are needed to better understand whether sleep-targeted interventions can improve subacute and long-term orthopedic sports surgery outcomes.

Pharmacotherapy for improving postoperative sleep quality: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Improving the quality of sleep may promote enhanced recovery in surgical patients. In addition to controversial or conflicting study conclusions, the current clinical studies on pharmacotherapy for improving postoperative sleep quality are mostly limited to evaluating the effect of a specific drug or supplement compared with placebo, and they lack comparisons between drugs or supplements. Therefore, we plan to conduct a systematic review and network meta-analysis to compare the efficacy of different drugs or supplements for improving postoperative sleep quality.

METHODS AND ANALYSIS

We will search the MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CNKI and Wanfang databases from the dates of their inception to December 2022. We will only include randomised controlled trials, irrespective of language and publication status. The primary outcome is postoperative sleep quality assessed by any validated tools or polysomnography. We will assess the quality of all included trials according to version 2 of the Cochrane risk-of-bias tool for randomised trials. We will use the GeMTC package of R software to perform direct and indirect comparisons via a Bayesian framework using a random-effects model. We will use the Confidence in Network Meta-Analysis approach to evaluate the quality of evidence.

ETHICS AND DISSEMINATION

Ethical approval is not required for this protocol because we will only be pooling published data. We plan to submit our review to academic conferences and peer-reviewed academic journals.

PROSPERO REGISTRATION NUMBER

CRD42022356508.

Benzodiazepines and Related Drugs in Orthopaedics

➤

Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants.

➤

The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic.

➤

Benzodiazepines can increase the risk of prolonged opioid use and abuse.

➤

Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications.

➤

Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.

The Effect of Improving Preoperative Sleep Quality on Perioperative Pain by Zolpidem in Patients Undergoing Laparoscopic Colorectal Surgery: A Prospective, Randomized Study

Methods

A prospective, randomized study was conducted with 88 patients undergoing laparoscopic colorectal surgery. The experimental group (S group, n = 44) was given 10 mg of zolpidem tartrate one night before the surgical procedure, while no medication was given to the control group (C group, n = 44). The primary outcome was the intraoperative remifentanil consumption. Sufentanil consumption, average patient-controlled analgesia (PCA) effective press times, the visual analog scale (VAS) scores, and incidences of postoperative nausea and vomiting (PONV) were recorded at 6 h (T1), 12 h (T2), and 24 h (T3) postoperatively.

Results

The intraoperative remifentanil consumption was significantly lower in the S group than that in the C group (p < 0.01). Sufentanil consumption at 6 h and 12 h postoperatively was significantly lower in the S group than that in the C group (p < 0.05); average PCA effective press times and VAS scores, at 6 h and 12 h postoperatively, were significantly lower in the S group than those in the C group (p < 0.01); differences between groups 24 h postoperatively were not significant. No significant between-group difference was noted in the incidence of nausea and vomiting.

Conclusion

Improving patients' sleep quality the night before surgical procedure by zolpidem can decrease the usage of intraoperative analgesics and reduce postoperative pain.

Case Report: High doses of Zolpidem and QT interval lengthening: Is there a relationship? A case series

Zolpidem is indicated in cases of severe insomnia in adults and, as for BDZs, its assumption should be limited to short periods under close medical supervision. Since several drugs cause corrected QT interval (QTc) elongation, the authors investigated whether high daily doses of Zolpidem could cause QTc elongation. The study was conducted in the Addiction Medicine Unit of the G.B. Rossi University Hospital in Verona. The data were collected from hospitalizations carried out between January 2015 and February 2020 and refer to a total of 74 patients, 38 males and 36 females, who were treated for detoxification from high doses of Zolpidem with the "Verona Detox Approach With Flumazenil." One patient out of 74 had QTc elongation (479 ms). The patient was male and took a daily dose of 50 mg of Zolpidem; he did not take concomitant therapies that could cause QTc lengthening. He had no electrolyte alterations, no contemporary or previous intake of barbiturates, heroin, cocaine, THC, alcohol, NMDA or nicotine which could cause an elongation of the QTc interval. The present study highlights the low risk of QTc elongation due to high dosages of Zolpidem; however, if, on one hand, we can affirm that Zolpidem is a safe drug, on the other, the widespread use of high dosages of this drug for prolonged periods of time is problematic and worrying.

Zolpidem improves patients' sleep quality after surgical treatment for infective endocarditis: a prospective observational study

PURPOSE

The objective of this study was to investigate the efficacy of zolpidem for improving post-operative sleep quality among patients with infective endocarditis (IE) and to identify the potential risk factors for impaired sleep quality at 6 months after surgery.

METHODS

Patients with IE who underwent surgical treatment were divided into two groups according to zolpidem usage. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) were used to evaluate patients' sleep quality and daytime sleepiness at baseline, which was the second day after transferal, and at 6 months after surgery. Logistic regression was used to identify potential risk factors.

RESULTS

There were 32 patients in the zolpidem group and 42 in the control group. The PSQI and ESS scores at 6 months after surgery were significantly lower than those at baseline in both groups (P = 0.04). Additionally, 9 patients (28%) in the zolpidem group and 22 patients (52%) in the control group suffered poor sleep quality. Multivariate analysis identified age (odds ratio [OR] = 1.26, 95% confidence interval [CI]: 1.12-1.42), baseline PSQI score (OR = 2.66, 95%CI: 1.55-4.65), and no zolpidem usage (OR = 45.48, 95%CI: 3.01-691.23) as independent factors for poor sleep quality.

CONCLUSIONS

Poor sleep quality after IE surgery was prevalent among patients even 6 months after IE surgery. Age, baseline PSQI score and no zolpidem usage were independently associated with poor sleep quality. Therefore, zolpidem has the potential to be an effective part of a treatment arsenal for poor sleep quality after surgical treatment for IE.

Differential expression of cerebrospinal fluid neuroinflammatory mediators depending on osteoarthritis pain phenotype

Supplemental Digital Content is Available in the Text.

Distinct cerebrospinal fluid neuroinflammatory profiles may be associated with different objective characteristics of persistent pain in osteoarthritis patients undergoing total hip arthroplasty.

Neuroinflammation is implicated in the development and maintenance of persistent pain states, but there are limited data linking cerebrospinal fluid (CSF) inflammatory mediators with neurophysiological pain processes in humans. In a prospective observational study, CSF inflammatory mediators were compared between patients with osteoarthritis (OA) who were undergoing total hip arthroplasty due to disabling pain symptoms (n = 52) and pain-free comparison controls (n = 30). In OA patients only, detailed clinical examination and quantitative sensory testing were completed. Cerebrospinal fluid samples were analyzed for 10 proinflammatory mediators using Meso Scale Discovery platform. Compared to controls, OA patients had higher CSF levels of interleukin 8 (IL-8) (P = 0.002), intercellular adhesion molecule 1 (P = 0.007), and vascular cell adhesion molecule 1 (P = 0.006). Osteoarthritis patients with central sensitization possibly indicated by arm pressure pain detection threshold <250 kPa showed significantly higher CSF levels of Fms-related tyrosine kinase 1 (Flt-1) (P = 0.044) and interferon gamma-induced protein 10 (IP-10) (P = 0.024), as compared to subjects with PPDT above that threshold. In patients reporting pain numerical rating scale score ≥3/10 during peripheral venous cannulation, Flt-1 was elevated (P = 0.025), and in patients with punctate stimulus wind-up ratio ≥2, CSF monocyte chemoattractant protein 1 was higher (P = 0.011). Multiple logistic regression models showed that increased Flt-1 was associated with central sensitization, assessed by remote-site PPDT and peripheral venous cannulation pain, and monocyte chemoattractant protein-1 with temporal summation in the area of maximum pain. Multiple proinflammatory mediators measured in CSF are associated with persistent hip OA-related pain. Pain phenotype may be influenced by specific CSF neuroinflammatory profiles.

Sex Differences, Sleep Disturbance and Risk of Persistent Pain Associated With Groin Hernia Surgery: A Nationwide Register-Based Cohort Study

Persistent pain after groin hernia repair is a major health problem. Sleep disturbance is associated with heightened pain sensitivity. The main objective of this study was to examine the role of sleep disturbance in the development and long-term maintenance of chronic postherniorrhaphy inguinal pain (CPIP), with exploration of sex differences. From 2012 to 2017, a national cohort of patients with prior groin hernia repair (n = 2084;45.8% females) were assessed for the development of CPIP 12 months after surgery. Patients then underwent long-term (median 5.0 years) follow-up to evaluate the contribution of sex and sleep disturbance on the maintenance of CPIP. Associations between pre- and postoperative sleep problems (assessed at long-term follow-up) and CPIP were tested using logistic regression. Females had higher rates of CPIP with negative impact on daily activities 12 months after surgery as compared to males (14.6 vs 9.2%, P < .0005), and were more likely to have moderate-severe CPIP in the long-term (3.1 vs 1.2%, P = .003). Preoperative sleep problems predicted development of CPIP 12 months after surgery (adjusted odds ratio [aOR] 1.76 [95%CI 1.26-2.46], P = .001) and CPIP in the long-term (aOR 2.20 [1.61-3.00] , P < .0001). CPIP was associated with insomnia and depression. Sleep disturbance may increase the risk for CPIP, and contribute to maintenance of postsurgical pain. PERSPECTIVE: Females are at heightened risk for CPIP as compared to males. Increased severity of pain symptoms are linked to poorer sleep and psychiatric morbidity. Given the robust associations between sleep disturbance and CPIP, interventions which consolidate and promote sleep, especially in females, may improve long-term pain control.

Preoperative sleep quality and adverse pain outcomes after total hip arthroplasty

BACKGROUND

Sleep disturbance is thought to aggravate acute postoperative pain. The influence of preoperative sleep problems on pain control in the long-term and development of chronic postsurgical pain is largely unknown.

METHODS

This prospective, observational study aimed to examine the links between preoperative sleep disturbance (Pittsburgh Sleep Quality Index, PSQI) and pain severity (Brief Pain Inventory, BPI) 6 months postoperative (primary outcome), objective measures of pain and postoperative pain control variables (secondary outcomes). Patients (n = 52) with disabling osteoarthritis (OA) pain undergoing total hip arthroplasty (THA) were included. Quantitative sensory testing (QST) was performed preoperatively on the day of surgery to evaluate pain objectively. Clinical data, as well as measures of sleep quality and pain, were obtained preoperatively and longitudinally over a 6-month period.

RESULTS

Preoperatively, sleep disturbance (i.e., PSQI score >5) occurred in 73.1% (n = 38) of THA patients, and pain severity was high (BPI pain severity 5.4 ± 1.3). Regression models, adjusting for relevant covariates, showed that preoperative PSQI score predicted pain severity 6 months postoperative (β = 0.091 (95% CI 0.001-0.181), p = .048, R²  = 0.35). Poor sleep quality was associated with increased pressure pain sensitivity and impaired endogenous pain inhibitory capacity (R² range 0.14-0.33, all p's < 0.04). Moreover, preoperative sleep disturbance predicted increased opioid treatment during the first 24 hr after surgery (unadjusted β = 0.009 (95% CI 0.002-0.015) mg/kg, p = .007, R²  = 0.15).

CONCLUSIONS

Preoperative sleep disturbance is prevalent in THA patients, is associated with objective measures of pain severity, and independently predicts immediate postoperative opioid treatment and poorer long-term pain control in patients who have undergone THA.

SIGNIFICANCE

Poor sleep quality and impaired sleep continuity are associated with heightened pain sensitivity, but previous work has not evaluated whether preoperative sleep problems impact long-term postoperative pain outcomes. Here, we show that sleep difficulties prior to total hip arthroplasty adversely predict postoperative pain control 6 months after surgery. Given sleep difficulties robustly predict pain outcomes, targeting and improving sleep may have salutary effects on postoperative pain reports and management.

Risk of Postoperative Hyperalgesia in Adult Patients with Preoperative Poor Sleep Quality Undergoing Open-heart Valve Surgery

Purpose

Studies have reported that preoperative poor sleep quality could decrease the pain threshold in patients undergoing noncardiac surgery. However, the risk of postoperative hyperalgesia (HA) in cardiac surgery patients with preoperative poor sleep quality remains unclear.

Patients and Methods

We retrospectively collected clinical data from patients undergoing open-heart valve surgery between May 1 and October 31, 2019, in Fuwai Hospital (Beijing). We assessed preoperative sleep quality and postoperative pain severity using the Pittsburgh sleep quality index (PSQI) and numerical pain rating scale (NPRS), respectively. A PSQI of six or greater was considered to indicate poor sleep quality, and a NPRS of four or greater was considered to indicate HA. Multivariable logistic regression analysis was used to study the risk of postoperative HA in patients with preoperative poor sleep quality.

Results

We divided 214 eligible patients into two groups based on postoperative HA; HA group: n=61 (28.5%) and nonHA group: n=153 (71.5%). Compared with nonHA patients, patients with postoperative HA showed a higher percentage of history of smoking, 17 (11.1%) vs 15 (24.6%) and alcohol abuse, 5 (3.3%) vs 6 (9.8%), higher intraoperative dose of sufentanil (median, 1.02 vs 1.12 μg/kg/h), and longer duration of ventilation with tracheal catheter (median, 760 vs 934 min). Preoperative poor sleep quality was associated independently with an increased risk of postoperative HA (adjusted odds ratio [AOR]: 2.66; 95%CI: 1.31–5.39, P=0.007). Stratification by history of smoking revealed a stronger risk of postoperative HA in nonsmoking patients with preoperative poor sleep quality (AOR: 3.40; 95%CI: 1.51–7.66, P=0.003). No risk was found in patients who had history of smoking (AOR: 0.83; 95%CI: 0.14–4.75, P=0.832).

Conclusion

Preoperative poor sleep quality is an independent risk factor for postoperative HA in adult patients undergoing open-heart valve surgery who had no history of smoking.

Zolpidem reduces pain intensity postoperatively: a systematic review and meta-analysis of the effect of hypnotic medicines on post-operative pain intensity

BACKGROUND

This systematic review aimed to investigate whether the administration of hypnotic medicines, z-drugs, melatonin or benzodiazepines, reduced pain intensity postoperatively.

METHODS

Medline, Embase, Cinahl, Psych info, Central and PubMed databases were searched, from inception to February 2020 to identify relevant trials. The search was extended, post hoc, to include meta-Register of Controlled Trials, the Web of Science and the conference booklets for the 14th, 15th, and 16th International Association for the Study of Pain conferences. Two independent reviewers screened titles and abstracts and cross-checked the extracted data.

RESULTS

The search retrieved 5546 articles. After full-text screening, 15 trials were included, which had randomised 1252 participants. There is moderate-quality evidence that in the short-term [WMD - 1.06, CI - 1.48 to - 0.64, p ≤ .01] and low-quality evidence that in the medium-term [WMD - 0.90, CI - 1.43 to - 0.37, p ≤ .01] postoperative period oral zolpidem 5/10 mg with other analgesic medicines reduced pain intensity compared to the same analgesic medicines alone. There is low-quality evidence that melatonin was not effective on postoperative pain intensity compared to placebo. The results of benzodiazepines on pain intensity were mixed. The authors reported no significant adverse events.

CONCLUSIONS

There is promising evidence that the hypnotic medicine zolpidem, adjuvant to other analgesics, is effective at achieving a minimally clinically important difference in pain intensity postoperatively. There is no consistent effect of melatonin or benzodiazepines on postoperative pain intensity. Readers should interpret these results with some caution due to the lack of data on safety, the small number of trials included in the pooled effects and their sample sizes.

SYSTEMATIC REVIEW REGISTRATION

The protocol for this systematic review was registered with PROSPERO ID= CRD42015025327 .

Sleep quality among orthopaedic patients in Denmark - A nationwide cross-sectional study

BACKGROUND

Hospitalised patients sleep less and have a lower quality of sleep compared to patients who recover in their own home. Low sleep quality is associated with complications such as increased pain sensation, delirium and reduced rehabilitation capacity.

PURPOSE

To investigate patients' self-reported sleep quality and factors related to sleep quality during admission to a department of Orthopaedic Surgery.

METHODS

The Richard-Campbell Sleep Questionnaire was used to assess patients' sleep quality, measured using a VAS 0-100 scale, (a higher score indicating good sleep quality). The moderated Pittsburgh Sleep Quality Index assessed the most severe and frequent barriers to high sleep quality.

RESULTS

A total of 533 patients undergoing orthopaedic surgery participated. There was an overall mean sleep quality score of 54. The most common and severe factors impacting sleep quality were; waking during the night, difficulties falling asleep, waking early, waking for toileting or pain. The intensity of the pain was found to be proportional to the quality of sleep.

CONCLUSION

Patients reported their overall quality of sleep to be moderately good due to difficulties falling asleep, waking up during the night or early morning and having pain. The results call for better pain management and non-pharmacological nursing interventions to optimise sleep quality.

Activation and Inactivation of Nicotinic Receptnors in the Dorsal Hippocampal Region Restored Negative Effects of Total (TSD) and REM Sleep Deprivation (RSD) on Memory Acquisition, Locomotor Activity and Pain Perception

Sleep deprivation (SD) is a common issue in today's society. Sleep is essential for proper cognitive functions, including learning and memory. Furthermore, sleep disorders can alter pain information processing. Meanwhile, hippocampal nicotinic receptors have a role in modulating pain and memory. The goal of this study is to investigate the effect of dorsal hippocampal (CA1) nicotinic receptors on behavioral changes induced by Total (TSD) and REM Sleep Deprivation (RSD). A modified water box and multi-platform apparatus were used to induce TSD and RSD, respectively. To investigate the interaction between nicotinic receptors and hippocampus-dependent memory, nicotinic receptor agonist (nicotine) or antagonist (mecamylamine) was injected into the CA1 region. The results showed, nicotine at the doses of 0.001 and 0.1 µg/rat and mecamylamine at the doses of 0.01 and 0.1 µg/rat decreased memory acquisition, while both at the doses of 0.01 and 0.1 µg/rat enhanced locomotor activity. Additionally, all doses used for both drugs did not alter pain perception. Also, 24 h TSD or RSD attenuated memory acquisition with no effect on locomotor activity and only TSD induced an analgesic effect. Intra-CA1 administration of subthreshold dose of nicotine (0.0001 µg/rat) and mecamylamine (0.001 µg/rat) did not alter memory acquisition, pain perception and locomotor activity in sham of TSD/RSD rats. Both drugs reversed all behavioral changes induced by TSD. Furthermore, both drugs reversed the effect of RSD on memory acquisition, while only mecamylamine reversed the effect of RSD on locomotor activity. In conclusion, CA1 nicotinic receptors play a significant role in TSD/RSD-induced behavioral changes.

Impact of Sleep Disorder as a Risk Factor for Dementia in Men and Women

Sleep is an essential physiological process, especially for proper brain function through the formation of new pathways and processing information and cognition. Therefore, when sleep is insufficient, this can result in pathophysiologic conditions. Sleep deficiency is a risk factor for various conditions, including dementia, diabetes, and obesity. Recent studies have shown that there are differences in the prevalence of sleep disorders between genders. Insomnia, the most common type of sleep disorder, has been reported to have a higher incidence in females than in males. However, sex/gender differences in other sleep disorder subtypes are not thoroughly understood. Currently, increasing evidence suggests that gender issues should be considered important when prescribing medicine. Therefore, an investigation of the gender-dependent differences in sleep disorders is required. In this review, we first describe sex/gender differences not only in the prevalence of sleep disorders by category but in the efficacy of sleep medications. In addition, we summarize sex/gender differences in the impact of sleep disorders on incident dementia. This may help understand gender-dependent pathogenesis of sleep disorders and develop therapeutic strategies in men and women.

Postoperative sleep disorders and their potential impacts on surgical outcomes

Postoperative sleep disturbance is a common occurrence with significant adverse effects on patients including delayed recovery, impairment of cognitive function, pain sensitivity and cardiovascular events. The development of postoperative sleep disturbance is multifactorial and involves the surgical inflammatory response, the severity of surgical trauma, pain, anxiety, the use of anesthetics and environmental factors such as nocturnal noise and light levels. Many of these factors can be managed perioperatively to minimize the deleterious impact on sleep. Pharmacological and non-pharmacological treatment strategies for postoperative sleep disturbance include dexmedetomidine, zolpidem, melatonin, enhanced recovery after surgery (ERAS) protocol and controlling of environmental noise and light levels. It is likely that a combination of pharmacological and non-pharmacological therapies will have the greatest impact; however, further research is required before their use can be routinely recommended.