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Background: Acute myocardial infarction (AMI) can result in severe left ventricular dysfunction (LVD) and cardiac failure, increasing risk of complications like stroke, thrombo-embolism, and recurrent AMI. Appropriate anticoagulation strategies are crucial for mitigating adverse events. The risk stratification of these patients involves evaluating their propensity for thrombotic and hemorrhagic events. Objectives: The study determined risk stratification and anticoagulation strategies for AMI patients with severe LVD post-PCI. Methods: At a tertiary hospital in Peshawar Pakistan, an investigation was conducted on 300 patients who presented with anterior AMI and 40% LVEF upon admission. Group A received anticoagulant therapy as part of their post-PCI management, whereas Group B received standard post-PCI management without anticoagulant therapy. Various risk scores, including CHA2DS2-VASc and HAS-BLED score, and major adverse cardiovascular events, were used in assessing patient's risk of thrombosis events of bleeding through risk stratification. Results: Mean age of patients was 63.47+8.19 years, mean BMI was 28.76+3.0 and 193/300 (64.33%) were females. Hypertension, hyperlipidemia and diabetes were the prevailing comorbidities (p

Background and aim: Teaching is an important part of the medical curriculum. Different teaching methods include small group discussions, demonstrations, inquiry approaches, lectures, problem solving methods, and tutorials. Group discussions are at the core of medical education because they help students learn more effectively. As a result, the current study sought to analyze the efficacy of small group discussions in teaching biochemistry to undergraduate medical students. Place and Duration: Gomal Medical College MTI, Dera Ismail Khan and Department of Biochemistry of Amna Inayat Medical College Lahore for the duration from March 2022 to August 2022. Method: This study included 50 undergraduate medical students of first year registered in international medical program. Prior to study conduction, ethical approval and informed written consent was taken. Student’s perception regarding small group discussion sessions were elicited based on unknown questionnaires provided to them. Likert scale was used to show their level of agreement with the questionnaire's claims. Results: Of the 50 undergraduate medical students, 28 (56%) were male and 22 (44%) were females students. About 64.6% (n=32) students believed that their grasp over the study material improved with small group discussion and 52.4% (n=26) agreed to the facilitation of active learning in small group discussion. Communication skills and clinical reasoning improved by small group discussion were claimed by 36% (n=18) medical students. Majority of undergraduate medical students 68% (n=34) strongly agreed to the claims that small group discussion helped them to correlate medical problems with biochemical concepts. Conclusion: The present study concluded that small group discussion in combination with lectures appears to provide the best instruction for the learner or medical students. Mostly students emphasized on importance of small group discussion in terms of topic better comprehension, promoting knowledge, correlation of biochemical ideas with medical issues, and interest. Similarly, they discussed the need of developing effective communication skills, as well as leadership and teamwork abilities. Keywords: Medical students, Undergraduate, Small group discussion, Biochemistry, Effectiveness

Background Psychogenic non-epileptic seizures (PNES) are often seen as indicators of poor motor and sensory function caused by psychological responses to stressful experiences. A seizure might trigger these reactions. The aim of our study was to assess the structural changes in brain MRI associated with psychogenic non-epileptic seizures. Methodology A retrospective analytical cross-sectional study at the Department of Medicine and Neurology, Ayub Teaching Hospital, Abbottabad, was conducted from October 2020 to September 2021. The medical records of patients with confirmed PNES were collected and retrospectively evaluated. Results Medical records and MRI scans were accessible for 52 patients with PNES; 10 patients were excluded from the study. The average age of the patients (standard deviation) was 34 (±9) years, and the average age at onset was 31.6 (±5.8) years. Based on the video-EEG recordings, 57.1% of patients (n=24) were classified as having broadly generalized motor seizures, 40% of patients (n=17) were classified as having predominantly akinetic seizures defined primarily by blank spells, and only one patient was classified as having focal motor seizures. Only three patients (7%) had a positive epilepsy family history. Twenty-four (47.6%) patients with brain MRI scans reported abnormal findings, while 22 (52.4%) had normal MRI findings. The majority of patients with abnormal MRIs had nonspecific white matter changes (50%), mesial temporal sclerosis (15%), and cysts (15%). In a statistical analysis, age at the beginning of PNES (p = 0.04), duration of PNES (p=0.01), concomitant epilepsy (p = 0.05), generalized motor seizures (p= 0.03), and focal motor seizures (p= 0.02) were strongly associated with abnormal brain MRI findings. Conclusion Research reveals that persons with PNES have a higher-than-average prevalence of anatomical brain abnormalities. The main takeaway is that these findings lend credence to the growing body of data suggesting that PNES may not be a medical mystery but rather a disorder with physical foundations in the brain. Important implications for diagnosing and treating PNES patients are discussed, as are the outcomes of earlier neuroimaging investigations of PNES. Studying the involvement of structural brain anomalies in the etiology of psychogenic non-epileptic seizures requires further well-designed multicenter studies with larger sample sizes and a consistent imaging approach (PNES). It is crucial to consider any confounding variables, such as co-occurring mental diseases, while designing this study.

Background Epilepsy is considered when a patient has at least two unprovoked seizures that occurred more than a day apart. Seizure control depends upon several factors, including adequate treatment and its dosage, patients' daily activities, and adherence to antiepileptic medications. The study aimed to assess the rate of adherence to antiepileptic drugs (AED) in patients with epilepsy. Methodology A cross-sectional study was conducted at the Department of Neurology, Ayub Teaching Hospital, Abbottabad, Pakistan, between November 2019 and October 2020. All participants who presented to the emergency room with complaints of seizures, had a known diagnosis of epilepsy, aged above 18 years, with no cognitive dysfunction or severe psychiatric disorders were included in the study. Patients with other neurological disabilities (brain tumors, cerebral palsy, neuromuscular disorder) or severe psychotic episodes and those with undiagnosed cases of epilepsy were excluded from the study. A predefined proforma was used to assess the level of adherence and non-adherence among patients and they were then divided into their respective groups. Results A total of 150 participants were included in the study. Of patients, 110 were adherent to AED treatment while 40 were non-compliant. It was found that the most frequent cause of non-adherence was that patients forgot their pills (72.5%). Of patients, 7.5% stopped taking the medication when symptoms were relieved. About 12.5% reported affordability to be the reason for non-adherence. The rate of poor seizure control was significantly higher in non-adherent patients as compared to adherent patients (77.5% vs. 49.1%, p = 0.001). It was also found that a greater number of non-adherent patients experienced convulsive seizures in the past year as compared to those who were adherent to their medications (p = 0.006). Conclusion To enhance treatment adherence, the practice of prescribing more simpler treatment regimens among physicians can result in better seizure control, as the complexity of the regimen is found to be a major challenge for adjustment of AED regimens in this regard.

Background and Aim: Migraine is a spiking prime headache disorder that has a significant impact on both patients and society. Migraine and other headache disorders are major causes of misery and frailty on a global scale. The aim of the present study was to determine the prevalence of migraine in young male patients presented with severe headache. Methodology: This cross-sectional study was carried out on 276 young male patients who presented with severe headache Medicine outpatient department (OPD) at Ayub Teaching Hospital, Abbottabad from August 2019 to July 2020. Criteria of International Classification of Headache Disorders were followed for headache diagnosis. All the patients of age range 15-40 years with severe headaches were enrolled whereas patients of previous chronic medical conditions were excluded. Ethical approval was taken from the institutional ethical committee. All the demographic details were gathered in a pre-designed proforma. SPSS version 24 was used for data analysis. Results: A total of 276 young adult patients who presented with severe headaches were investigated during the study period. The mean age was 29.38±8.65 years with an age varies from 15 years to 40 years. Most of the patients were in the age range of 31-40 years 132 (47.8%) followed by 21 to 30 years 97 (35.1%). Patients of age 15-20 years were less frequent with a prevalence of 47 (17.1%). The overall prevalence of migraine headache was in 137 (49.6%) patients out of which migraine with and without aura was 5.7% and 43.9% respectively. Tension-type headache being the second common headache was found in 23.7% followed by Cluster headache at 2.8%. Conclusion: Migraine without aura was the most prominent headache among young male outpatients with severe headache. The findings highlight the socioeconomic factors impact on headache epidemiology and show that excessive use of NSAIDs may have an effect the primary headaches distribution. More multicenter studies are needed to assess headache epidemiology across the country. Keywords: Severe Headache, Migraine, Prevalence, Tension Type Headache (TTH)

Protease Inhibitors belong to class of drug which are used to cure or prevent infection by viruses like HIV and HCV. Protease Inhibitors from Bacillus subtilis-M15 prevent viral multiplication by inhibiting the activity of Trypsin and Pepsin. Pharmaceutically designed ion-exchange resins are proved as promising candidates to enhance the Inhibitory activities of Protease. The novel Biological anti-viral drugs are characterized by Hydrogen Peroxide, Dimethyl Sulfur, HCl, and Acidic-Alkaline Proteinase. When Protease Inhibitory activity of chemically formulated drug already available in market i.e. Lopinavir/Ritonavir are compared with novel anti-viral drug from Bacillus subtilis-M15 then Lopinavir/Ritonavir are proved as less effective than Biological drug due to their lower Inhibitory activity in terms of units per milliliter. Lopinavir/Ritonavir has 2446U/ml and 241U/ml Protease Inhibitory activities against trypsin and pepsin respectively whereas Biological drug from Bacillus subtilis-M15 has 2581U/ml and 3360U/ml Protease Inhibitory activities against Trypsin and Pepsin respectively. In this context Biological drug developing treatment has attracted much attention than chemically designed drug due to their high efficacy, least side effect, cost efficient and environment friendly nature. Hence we conclude the current application of novel anti-viral drug as a Protease Inhibitors from Bacillus subtilis-M15 and its future clinical prospects against targeted Protease based HIV and HCV therapy.

Association of Varicella Zoster Virus (VZV) with a considerable variety of complications has been well documented throughout literature. Primary infection, most often seen in children, is generally characterized by mild symptoms, as opposed to the more severe presentations in adult and immunocompromised populations. Manifestations of disseminated VZV include dermatologic, pulmonary, neurologic, and ocular involvement. Vascular and hematologic complications are also reported and sometimes pose serious health threat. We present an interesting case of disseminated VZV infection, complicated by meningitis, encephalitis, and bilateral pulmonary embolism in an otherwise immunocompetent 52-year-old man with no prior chicken pox exposure.

Insomnia is defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment. A comprehensive history and physical examination differentiate the subtypes of insomnia: acute, chronic, and associated with comorbid disorders. Evaluation of insomnia entails understanding the predisposing, precipitating, and perpetuating factors of insomnia unique to each person. Effective treatment is incomplete without implementing cognitive-behavioral therapy for behaviors nonconducive to sleep as monotherapy or in combination with pharmacotherapy. Setting realistic goals and expectations of quality and quantity of sleep required to feel rested determine treatment success and outcomes. This article reviews the prevalence, symptoms, subtypes, and diagnosis and management of insomnia, particularly in women with emotional and hormonal changes of symptomatic premenstrual syndrome, pregnancy, and menopause. [ Psychiatr Ann. 2019;49(12):518–523.]

Iron deficiency is a well-known cause of anemia. However, it is an under-recognized cause of venous thromboembolism (VTE). Iron deficiency predisposes to VTE mainly by inducing thrombocytosis, which can lead to a hypercoagulable state. Identifying iron deficiency as a possible cause of thromboembolic phenomena has clinical significance since this is a potentially avoidable risk factor. This case report serves as a reminder that iron deficiency is an important risk factor for VTE that should be considered in the evaluation of patients. This is particularly true in patients like ours who have recurrent venous thromboembolic disease.

COVID-19 infection causes considerable morbidity and mortality, especially to those who are aged, have impaired renal function and are obese. We propose to examine the potential utility of oral activated charcoal with the hypothesis that such treatment would lower absorption of microbiome derived toxins and ameliorate systemic oxidant stress and inflammation.

Sleep medicine is a multidisciplinary field with growth potential. Sleep and psychiatric disorders are comorbid. Many psychiatrists were at the forefront during the earlier years of the field and played significant roles during critical developments of the field. Today there is a shortage of psychiatrists trained in sleep medicine in the United States, with many psychiatry residents not knowing that subspecialty training in sleep medicine is an option. Psychiatrists trained in sleep medicine can bridge the gap between nonpsychiatric and mental health providers to increase awareness of the impact sleep disorders have on mental health and improve care of the patients. [ Psychiatr Ann . 2018;48(11):520–523.]

Breathing-related sleep disorders (BRSD) include obstructive sleep apnea (OSA), central sleep apnea, and sleep-related hypoventilation. The prevalence of BRSD increases with age and contributes to morbidity in the elderly. OSA, the most common BRSD, is characterized by an intermittent decrease in or cessation of airflow during sleep due to a collapsed airway. Clinical features of OSA include loud snoring, daytime sleepiness, choking spells, and documented episodes of hypopnea/apnea on polysomnography. OSA is a risk factor for cardiovascular disease, hypertension, atrial fibrillation, and cognitive problems. This review provides an overview of OSA in the elderly and its relationship with other medical disorders. [ Psychiatr Ann. 2018;48(6):287–291.]

Although often underdiagnosed, sleep disorders can significantly add to morbidity in neurodegenerative illnesses. Early detection and management can not only improve sleep, but also alleviate caregiver burden and assist with future prognosis. In this article, we discuss various sleep disturbances noted in neurodegenerative disorders in the aging population. Characteristics and changes in sleep architecture with normal aging are described. Various types of sleep disturbances including insomnia, hypersomnia, sleep-related movement disorders, and parasomnias associated with major neuropathological categories of synucleinopathies and tauopathies are discussed. [ Psychiatr Ann. 2018;48(6):296–302.]

Insomnia disorder in older adults is associated with dissatisfaction with quality or quantity of sleep and is also associated with difficulty falling asleep, maintaining sleep, or early morning awakening. It is frequently associated with an age-related decrease in restorative stage 3 of nonrapid eye movement sleep as well as advance phase shift leading to early morning awakening. Sleep disturbances in older adults, as in younger patients, have a bidirectional relationship with many medical and psychiatric disorders as well as polypharmacy. The health consequences of insomnia in the elderly may also include manifestation or magnification of cognitive deficits. Diagnosis of insomnia is based on history from the patient, the bed partner, self-administered questionnaire or sleep diary, comprehensive evaluation for comorbid medical/psychiatric disorders, and comprehensive medication history. Both nonpharmacological and pharmacological strategies are effective in the management of insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) should be considered as an initial intervention for chronic insomnia. Pharmacological treatment with short-acting hypnotics is a valuable adjunct to CBT-I for acute insomnia for a brief period followed by a slow taper. Any treatment intervention should be in collaboration with the patient and/or family and include a discussion of the risks, benefits, and costs. [ Psychiatr Ann. 2018;48(6):279–286.]

The United States population continues to become more geographically, linguistically, and culturally diverse. Health care professionals, including psychiatrists, have to manage an increasing number of patients from a variety of cultural backgrounds. In addition to language barriers, cultural issues are becoming increasingly important in assessing and treating patients from different cultures including those suffering from trauma-related illnesses. With the persistence of domestic and international conflicts and terroristic incidents all over the world, posttraumatic stress disorder and trauma-related illness rates may continue to rise. Psychiatrists and mental health professionals need to be familiar with how the effects of trauma and trauma-related illness present across different cultures and how assessment and treatment will need to differ in these different populations. The American Psychiatric Association has responded to these challenges by including a section on “Cultural Formulation” in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition ( DSM-5 ). This article focuses on examining various aspects of the presentation of trauma-related illness in different cultures with specific emphasis on culturally sensitive assessment and treatment along the lines advised in DSM-5 . The article also includes guidelines for clinicians on how to incorporate culture-specific approaches and tools in their day-to-day practice to achieve optimal outcomes for patients and their families. [ Psychiatr Ann . 2017;47(3):128–133.]

Excessive daytime sleepiness (EDS) is one of the leading reasons that patients present to sleep clinics. Approximately 10% to 14% of the adults report that excessive sleepiness interferes with their daily lives. Common causes of EDS include obstructive sleep apnea, sleep deprivation, circadian rhythm disorders, medication effects, psychiatric conditions especially depression, and primary hypersomnia such as narcolepsy or central idiopathic hypersomnia. Vitamin B(12) deficiency is a rare cause of EDS. We are presenting a case of severe vitamin B(12) deficiency as an unusual and rare cause of hypersomnia. CITATION: Khawaja I, Yingling K, Bukamur H, Abusnina W. Vitamin B(12) deficiency: a rare cause of excessive daytime sleepiness. J Clin Sleep Med. 2019;15(9):1365–1367.

Chronic obstructive pulmonary disease or COPD is one of the conditions that physicians frequently see in both the hospital and outpatient setting. In order to improve diagnostic and treatment outcomes, the Global Strategy for the Diagnosis, Management and Prevention of COPD, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was created in 2001. Every year, a new report is generated based on an analysis of published studies which attempts to improve the way physicians handle COPD. GOLD reports are considered to be essential evidence-based reference tools for the implementation of effective management plans, and represent the current best practices for the care of patients with COPD. The 2017 report greatly revised the guidelines and added a few components that changed the system of COPD diagnosis and treatment. This review article addresses those changes, explains the current guidelines, and draws attention to areas that still require improvement.

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

Objective: The purpose of the research was to conclude the results of balance training with the ocular response using inert and dynamic biodex balance system for the hazard of fall as well as mobility in elderly individuals. Material and Methods: The mode of the research was pilot RCT (Randomized control trial) carried out at Jinnah Hospital, Lahore from August 2017 to February 2018. The research contains society habitants aged personals having batter health state. The mode of selecting the individual was non-verisimilitude purposive sampling. Individuals irregularly distributed into two balanced categories. The controlled category does not get any training whereas the intervention category passes through training of eight weeks on biodex balance system. Berg balance scale, biodex fall risk score, Go & timed up test prior and after the therapy was used for composition of facts and the data were further analyzed on SPSS software. Results: The researcher made two groups comprising of nine (50%) individuals in each group. Evaluation of the groups presented substantial betterment in intervention category with P-value ˂ 0.001 whereas no substantial improvement noticed in control group with P-value ˃ 0.05. Post-intervention, the findings remain constant while comparison of both the categories (P-value ˂ 0.05). Conclusion: Dynamic postural training through inert as well as dynamic biodex balance system had categorical consequences on mobility as well as equilibrium in aged individuals. Key Words: Mobility, Biodex Balance System (BDEX), Static & Dynamic (SD), Biodex Fall Risk Score (BFRS), Berg Balance Score (BBS), Timed Up and Go Test (TUG).

Objective: Raised intracranial pressure (ICP) stays very known appearance of Spartan brain damage. Quick judgement also appropriate involvement remains essential to avert minor brain injury also decease. Extent of optic nerve sheath diameter (ONSD) through ultrasound remains progressively practiced by way of the indicator to perceive elevated Raised intracranial pressure. Information of standard optic nerve sheath diameter inside the fit populace remains important to understand the current dimension. The researchers intended to assess standard optic nerve covering length in well unpaid worker inside the Pakistan. Methodology: Our current research remained very potential, observational research in which 110 fit unpaid worker of our country nationals, aged extra than 19 years remained employed in our research. Our examination was driven at Jinnah Hospital Lahore from April 2017 to March 2018. The ultrasound investigation remained positioned on greater also adjacent characteristic of trajectory in contradiction of higher eyelid through eye bolted. For apiece respondent, main detective achieved 3 dimensions on every eye. The dimensions of every eye remained then normal to harvest the average optic nerve covering length. Results: The average optic nerve covering measurement of rightward eye remained 5.85 mm also 96% of persons had normal ONSD in variety 5.85–5.98 mm whereas regular ONSD of left-hand eye remained 5.87 mm also 96% of persons got average OPSD in assortment 5.86–5.97 mm. Here remained not any variance amongst three recurrent procedures of OPSD in apiece eye. Here remained not any association among optic nerve sheath diameter through age, sex also dimension taken amongst leftward also rightward eyes. Conclusion: 96% of our research participants got OPSD not as much of as compared 5.83 mm. OPSD additional than 5.83 mm in our research populace would remain measured irregular also might reproduce elevated intracranial heaviness. Key Words: Optic Nerve; Intracranial Heaviness; Visual Tightness; Optical Tonometry; Optical ultrasound; Ultrasonography.

Transthoracic echocardiography (TTE) is an incredibly valuable tool in today's emergency rooms and intensive care units (ICUs). It has the ability to provide a complete evaluation of the structure and function of the heart, the valves, stroke volume, ejection fraction, and much more. Previous academic studies have also determined that point-of-care TTE done by non-cardiologist physicians can also provide higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. The aim of this review article is to examine further these point-of-care evaluations, what they entail, their benefits, and where further research would better our own understanding.

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Obstructive sleep apnea (OSA) is caused by intermittent episodes of partial or complete closure of the upper airway, leading to apneic episodes while the patient is asleep. Atrial fibrillation (AF) leads to more than 750,000 hospitalizations per year and accounts for an estimated 130,000 deaths each year. The death rate from AF as the primary or a contributing cause of death has been rising for more than two decades. The material reviewed in this paper focuses on the association between OSA and arrhythmias. It goes into the details of the epidemiology, pathophysiology, and types of arrhythmias and the therapies seen in association with OSA.

Lung ultrasonography has a tailored diagnostic and therapeutic approach in the critical care setting. Lung ultrasonography in critically ill (LUCI) is a helpful modality for the early detection and assessment of various lung pathologies and guides the management protocol for the same. The aim of this review was to highlight the basics of an ultrasound machine, the fundamentals of a lung ultrasound and the importance of lung artifacts in detecting the anatomy and pathology of the lung disease. In addition, we have also discussed regarding the effective approach to lung ultrasonography through the two protocols: the Bedside Lung Ultrasound in Emergency (BLUE) protocol and the Fluid Administration Limited by Lung Sonography (FALLS) protocol.

Post-traumatic stress disorder (PTSD) and nightmares are major psychiatric problems among veterans with combat experience. Veterans who have obstructive sleep apnea (OSA) have increased nightmares while sleeping on their back. Treatment of sleep apnea with a continuous positive airway pressure (CPAP) device lessens the arousals from sleep, and patients do not remember their nightmares as they sleep through their dreams. The case report describes a veteran who had severe nightmares especially when sleeping on his back. He was diagnosed with sleep apnea and treated with auto CPAP. During the follow-up visit, the patient reported a dramatic improvement in his PTSD symptoms, nightmares frequency, and intensity. He also reported feeling better, less sleepy, and more energetic during the day. Besides, he reported experiencing no nightmares when using CPAP and improvement in his quality of sleep. He also reported an improvement in daytime functioning and quality of life.

Narcolepsy is a chronic neurological disease with five domains of symptoms including excessive daytime sleepiness (EDS), cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis, and sleep fragmentation. Several overlapping symptoms of schizophrenia and narcolepsy often make it challenging to differentiate between the two conditions. A 23-year-old African American female was diagnosed with schizophrenia based on a two-year history of auditory and visual hallucinations. The patient was referred to a sleep physician for excessive daytime sleepiness. She has been sleepy since her teenage years taking 1–2 naps daily (Epworth sleepiness scale (ESS) was 14). She also complained of occasional sudden loss of muscle tone, which was triggered by strong emotions. In addition, she had episodes of inability to move her body in the morning, feeling as if someone was sitting on her chest. A full “hypersomnia workup” was scheduled including a nocturnal polysomnography (PSG) followed by a multiple sleep latency test (MSLT). The MSLT was positive for narcolepsy with cataplexy, or type 1 narcolepsy. She was prescribed modafinil 200 mg daily for EDS and venlafaxine 75 mg was added for cataplexy. In two weeks her ESS improved from 14 to 8. This case illustrates the potential of narcolepsy being misdiagnosed as schizophrenia in patients who have excessive daytime sleepiness and symptoms mimicing psychosis.

Schizophrenia is a chronic, disabling condition that significantly impacts social and occupational functioning. Sleep problems are common to the illness, but are often overlooked. Patients with schizophrenia often have a combination of subjective sleep complaints and objective findings on polysomnographic testing. As a group, people with schizophrenia have a higher prevalence of common sleep disorders. This article reviews sleep abnormalities and disorders in schizophrenia and provides an overview of treatment options. [ Psychiatr Ann . 2016;46(3):192–196.]

Sleep disturbances are common in adults with posttraumatic stress disorder (PTSD) and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together, these findings suggest profound disturbances in rapid eye movement (REM) and non-REM sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiologic mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma-exposed populations. A number of psychologic and pharmacologic treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD-focused clinical care. [ Psychiatr Ann . 2016;46(3):173–176.]

Obstructive sleep apnea (OSA) is a common sleep disorder associated with several medical conditions, increased rates of motor vehicle accidents, and higher overall health care expenditure. There is a higher prevalence of depression in people with sleep-disordered breathing in clinical and community samples. Depression and OSA share many symptoms, which may explain the underdiagnosis of OSA in depressed patients. OSA may be responsible for treatment resistance in depression. The relationship between depression and OSA is complex and remains unclear; however, several pathophysiologic mechanisms could be involved. Increased understanding of the relationship between these two disorders will likely improve clinical outcomes. [ Psychiatr Ann . 2016;46(3):187–191.]

Autism spectrum disorder (ASD) is characterized by early-onset socialization and communication difficulties associated with restricted interests and behavioral rigidities. Recent epidemiologic studies show that 1 in 68 children has autism. This complex condition is among the least-understood developmental disorders of childhood but there is a growing body of research on ASD, making it critically important that clinicians are well informed about these conditions. Recent changes in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition, regarding ASD criteria can affect how the diagnosis is made. Various comorbidities can have a huge impact on assessment and management. There are various behavioral and pharmacologic strategies focusing on cluster symptoms of hyperactivity/inattention, irritability, aggression, self-injurious behaviors, and ritualistic behaviors. In the past few years, the US Food and Drug Administration has approved psychotropic medications for treating irritability associated with autism. Speech and language assessment and interventions, parent education, and appropriate educational programs are integral parts of management. [ Psychiatr Ann . 2016;46(1):58–62.]

Sleep problems are common among children and adolescents, with up to 50% of children experiencing sleep difficulties and as many as 4% receiving a formal sleep disorder diagnosis. Early identification of sleep problems may prevent negative consequences, such as daytime sleepiness, misdiagnosis, learning difficulties, or poor academic performance. This article provides an overview of common sleep disorders in children and adolescents, including common presenting symptoms, diagnosis, and treatment. [ Psychiatr Ann . 2016;46(1):39–44.]

Parasomnias are a group of sleep disorders characterized by abnormal, unpleasant motor verbal or behavioral events that occur during sleep or wake to sleep transitions. Parasomnias can occur during non-rapid eye movement (NREM) and rapid eye movement (REM) stages of sleep and are more commonly seen in children than the adult population. Parasomnias can be distressful for the patient and their bed partners and most of the time, these complaints are brought up by their bed partners because of the possible disruption in their quality of sleep. As clinicians, it is crucial to understand the characteristics of various parasomnias and address them with detailed sleep history and essential diagnostic approach for proper evaluation. The review aims to highlight the epidemiology, pathophysiology and clinical features of various types of parasomnias along with the appropriate diagnostic and pharmacological approach.

The overlap syndrome (OS) was first coined by David C. Flenley in 1985 to describe the coexistence of obstructive sleep apnea (OSA) in patients with chronic obstructive pulmonary disease (COPD). Patients with OS experience more profound nocturnal oxygen desaturation (NOD) than patients with OSA or COPD alone. This underlying hypoxia in OS increases the risk of cardiovascular disease including atrial fibrillation, right heart failure, and pulmonary hypertension, thereby increasing the mortality associated with the disease. Keeping in mind the risk of mortality, it is crucial for clinicians to clinically evaluate the patients with OSA or COPD for the occurrence of OS and provide effective treatment options for the same. This review aims to highlight the pathophysiology and the risks associated with the OS along with early detection and appropriate management protocols to reduce the mortality associated with it.

Objective To examine the correlations between obstructive sleep apnea (OSA) and psychiatric disorders such as major depressive disorder (MDD), posttraumatic stress disorder (PTSD), or bipolar disorder (BD) and whether comorbid psychiatric diagnosis increases the risk of OSA. Methods This retrospective chart review study included all patients (N = 413) seen within a randomly selected 4-month period (August 2014 to November 2014) in a Veterans Administration outpatient psychiatry clinic. Patients were screened for symptoms of OSA with the STOP-BANG Questionnaire. Those with a positive screen were referred to the sleep clinic for confirmation of the diagnosis by polysomnogram (PSG). Frequency of PSG-confirmed OSA was correlated with different psychiatric disorders and comorbid psychiatric diagnoses. Results The study showed a high prevalence of OSA in psychiatric patients, particularly with MDD (37.8%) and PTSD (35.5%) and less so with BD (16.7%). Among all patients with OSA (n = 155), those with comorbid BD and PTSD had a significantly higher rate of OSA than those with BD alone (χ² = 7.28, P < .05) but not with PTSD alone. We also found a statistically significant higher incidence of OSA in male veterans with either MDD comorbid with PTSD (χ² = 3.869, P < .05) or BD comorbid with PTSD (χ² = 6.631, P < .05) compared with either mood disorder or PTSD alone. Conclusions The study showed a high prevalence of OSA in psychiatric patients, particularly in those with PTSD and MDD and less so with BD. There was a statistically significant increase in the incidence of OSA in male veterans with either BD with comorbid PTSD or MDD with comorbid PTSD.​​.

Most psychotropics are currently given a US Food and Drug Adminstration (FDA) drug rating of category C, meaning there is evidence of potential risk to a fetus. Some psychotropics, however, have a higher degree of risk to the fetus than others, and this article discusses the use of those psychotropics for which caution is warranted based on currently available evidence and clinical opinion. The psychotropics that will be highlighted here include paroxetine, monoamine oxidase inhibitors, lithium, valproate, carbamazepine, and benzodiazepines. We suggest caution with regards to their routine use or as a first-line treatment in pregnancy. Five benzodiazepines are category X according to the FDA and are therefore contraindicated in pregnancy. For all these medications it is important not to overlook the benefits of psychiatric stability from continued treatment and the harms of discontinuation, which include increased risk of relapse of the illness. [ Psychiatr Ann. 2015;45(2):71–76.]

Parasomnias comprise a category of sleep disorders that includes behavioral and emotional disturbances occurring during any stage of sleep or during states of mixed sleep and wakefulness. These disorders can range from having vocalizations and minor movements to very complex and aggressive behaviors that result in serious injury and disruption of sleep for the patients and the bed partners. Parasomnias need careful clinical history-taking often followed by a sleep lab study to rule out other sleep disorders. Parasomnias can frequently be mistaken as nocturnal manifestations of psychiatric disorders, which makes it very important for psychiatrists to have a proper understanding of these sleep disorders. [ Psychiatr Ann . 2015;45(1):30–34.]

Obstructive sleep apnea (OSA) is a common breathing disorder during sleep that has many implications beyond disrupted sleep. The Diagnostic and Statistical Manual of Mental Disorders , fifth edition recognizes three sleep-related breathing disorders—OSA, central sleep apnea, and sleep-related hypoventilation. OSA has many overlapping symptoms with depression, and is increasingly recognized as an independent risk factor for hypertension and cardiovascular disease. It is crucial for mental health providers to remain vigilant in recognizing patients with signs and symptoms consistent with OSA. This review focuses on updates in terminology and testing, complications of untreated OSA, and its relationship with mental disorders. [ Psychiatr Ann . 2015;45(1):19–24.]