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“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Wednesday, April 22, 2020

    "I'm having trouble sleeping" is one of the most common complaints I hear from patients. This is understandable, as up to 25% percent of the American population reports occasionally not getting enough sleep (though it seems like more to me). However the percentage suffering from the true definition of insomnia is smaller, about 6 percent. Per the DSM-5 definition, insomnia patients feel impaired from lack of sleep during the daytime; symptoms last at least a month; and are not associated with other medical conditions, substance use or other sleep disorders (restless legs syndrome would be a good example of this).

    Certainly sleep issues are seen most often in the elderly but insomnia can hit at any age. Recently while sorting through a bunch of stored papers I found a literary quarterly published by my university which I had saved for some reason. The theme was "All Night Long" and at least two of the pieces dealt with insomnia... it could have been more, possibly three or four. (These were written by people in their late teens and early twenties, mind you, and they were complaining of insomnia!) There are plenty of factors other than age, however. Sleep problems are often connected to lack of physical activity, especially these days when so many people work sedentary jobs. Daytime naps are also not a good idea as they relieve physical fatigue just enough to make it difficult to fall asleep. And irregular sleep patterns, such as working nights or sleeping late, can also ruin a good night's sleep.

    I empathize with patients as a fellow sufferer. I have had insomnia most of my life, to the point that if I sleep through the night I almost feel cheated. My nighttime awakenings are my "me time," when I ponder my work schedule, to-do lists and various deep thoughts. Certainly I need sufficient sleep to function, at least six hours. Back when I was a medical resident I realized that I was usually very depressed the day after being on call. It took a surprisingly long time for me to figure out the connection between my mood and lack of sleep.

    The basic recommendations:

    • Regulating your sleep pattern is a big one. Yes, you have to become one of those boring people who goes to sleep at the same time every night. 
    • Don't go to bed too early. If you go to bed at eight-thirty, you won't sleep through the night unless you have to get up at four-thirty every morning - or even earlier than that. 
    • Limit alcohol and caffeine. Alcohol can really screw with your sleep. No caffeine after noon. 
    • Don't go to bed until you are ready to go to sleep. I once had a friend, a fellow MD, who stated that if he had his way every bedroom in the US would be deprived of its television. Likewise, no reading or crossword puzzles in bed. You should do these fully dressed and in a separate room until you are ready to go to bed. 
    • Keep the bedroom cool, dark and quiet. 
    • And now that we have computers and smartphones, the same applies. Don't grab for your phone if you awaken in the middle of the night. You don't want to be looking at a glowing screen. 
    • Do try to get some physical activity in, it will tire your body and you will sleep better. 
    • Don't use sleep medications if you can possibly avoid it. 
    And now we come to the crux of the matter... the request for sleep medication. Many insomniacs resort to the antihistamine diphenhydramine (AKA Benadryl in the US) as it is sedating and readily available. Not to mention that if you have allergy-related postnasal drip at night, it will solve that problem as well. Pretty much every nonprescription sleep medication is a combination of diphenhydramine and either acetaminophen or aspirin. Does it work? Yes, as I can vouch from firsthand experience; I have used it myself. However it can interact with other medications and has side effects, most often associated with the elderly population, who of course are the ones most often requesting sleep medication. 

    Then there are the natural options: Camomile tea, valerian and melatonin. Also meditation. I recommend all of these options, but you can always identify a hardcore insomniac by the death glare they give you when you suggest melatonin. Also melatonin is not recommended for pregnant women, and the jury is out on valerian and pregnancy (I have seen articles saying both that it is OK and that it should be avoided). 

    And then there are the prescriptions. Sleep specialists recommend not using benzodiazepines (aka "nerve pills") for sleep, even though they work. They are also potentially addictive, and sudden discontinuation after years of heavy use can cause lifethreatening withdrawal. (A favorite saying of addition specialists: Narcotics withdrawal makes you wish you were dead; benzodiazepine withdrawal makes you actually dead.) It's easy to develop benzo tolerance with regular use, meaning you need to keep increasing the dose to get the same effect. 

    Non-benzo hypnotics are considered safer, and generally are. However, we still don't recommend using these on a nightly basis as development of drug tolerance is still a problem with this group. Examples of these drugs include zaleplon and eszopiclone. Keep in mind that any sedative, no matter which drug group we are dealing with, is dangerous to mix with alcohol or other sedation. In the elderly sedatives can cause confusion and they also increase the risk of falls and injuries. 

    Sleep specialists recommend not prescribing these medications; however, we live in the real world and I do prescribe sleep medication, because sometimes you just need it. When I do, I always emphasize that it should not be used nightly and I track patients' refill requests to see how often they are using it. I suggest using it not more than three times per week, to prevent the problems of relying on the drug and developing tolerance. 

    Not to mention that patients are missing out on the benefits of searching your soul and making to-do lists at three in the morning. 

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    Thursday, April 16, 2020
    Quarantined? Try a Mystery Series

    So I've been passing time locked down at home reading (mostly mysteries) thanks to the LA Public Library and their wonderful ebook collection. Check to see if your library will allow you to download ebooks onto your Kindle or other e-reading options. If you have a library card, you probably can.
    Mysteries are the most flexible genre I have come across. The detective can be a professional or a talented amateur, of any gender/sexual orientation/race/era/country/profession. Subgenres could include suspense, espionage, historical, procedurals, scifi, romance and the detective who has a cat that helps them solve crimes (I particularly loathe this group).
    For research purposes I can recommend the website Stop, You're Killing Me if you're looking for something that might sound interesting. This site lists mysteries alphabetically by author and by detective, as well as listing the many books nominated for awards for the last several years. I've found several interesting reads this way. You can also try TV Tropes for suggestions, particularly the historical mysteries page. 

    The books I've been reading recently include: 

    The Judge Dee series, historical mysteries/procedurals set in China during the Tang dynasty and based on a real-life judge. They are written by a Dutchman named Robert Van Gulik who made a lifelong study of China and Chinese culture, and lived there for many years... they're classics of the historical mystery genre. The descriptions of criminal trials are particularly interesting. Highly recommended. 

    The Midnight, Texas series by Charlaine Harris. Southern goth (her specialty, apparently; she's better known for the Sookie Stackhouse mysteries, which I have not read). These are set in the town of Midnight, Texas, literally a wide spot in the road. Populated by a vampire, a witch, a psychic, a couple of angels... you get the idea. I'm not big on the supernatural mystery genre but these are pretty good. 

    The Miss Julia series, by Ann B. Ross. Set in a small North Carolina town, Miss Julia is a recent widow who one day is confronted with her late husband's illegitimate child. As a good Presbyterian and one of the most proper ladies in town, this is a bitter pill for her to swallow but in true Southern lady fashion she deals with the issue and winds up taking the boy and his mother into her home. Julia is tough as nails and not always the kindest person, but the way she bonds with her husband's son is quite believable and I love the scenes with the two of them. The town manages to hide quite a few secrets, financial and otherwise, and Miss Julia goes about ferreting them out. 

    The Shadow Walker, by Michael Walters, is (I believe) the first of a series featuring a Mongolian detective. It's a police procedural dealing with a serial killer. As one of the victims is a British national, a Chief Inspector from Scotland Yard is sent to assist with the investigation - the story is told from his point of view. I run hot and cold on procedurals, especially when serial killers are involved. I'm not a fan of violence porn. But here the focus is on Mongolia, a country focusing on modernization and moving out of the shadow of China, and it's really interesting. 

    While we're on the subject, if you like procedurals an old but good series is the Gideon series featuring Commander George Gideon of Scotland Yard. The series is written by J.J. Marric, which I believe is a pseudonym. They were published from the 1950s to the 1970s. Each book interweaves several crimes taking place in London, either in the planning stage or in progress, from a petty crook who's knocking off stores to a man plotting to kill his wife for the insurance money. Gideon holds an administrative role, so does not investigate all the crimes himself; but you see him pulling the strings, sending out his subordinates and discussing the cases with them. The books take place in real time, over a day or a week or so. They're fairly interchangeable, so you don't have to read them in order. Definitely worth a look. 

    Cozy series can be a mixed bag. There are way too many knitting/embroidery/bake shop/etc mysteries out there and a lot of them are really bland, with semigeneric main characters, or just badly written. However a series I've really enjoyed is the Noodle Shop Mysteries by Vivien Chien. Set in Cleveland in the Chinese-American community, Lana Lee is in her twenties and the manager of her family's noodle restaurant set in a large Asian shopping plaza. Who knew the death rate at the mall could be so high? But the characters are well-drawn and likable, and I can't stop reading these books. Also, the characters evolve from book to book, which is an important part of any series for me. This way you get a story arc that extends over several books and really makes the series more believable.

    Lastly I'll recommend an urban fantasy noir series, the Nightside series by Simon R Green. They are set in the Nightside, part of modern day London. In the Nightside it is always three in the morning, the sun never shines, and anything goes. You can gamble, go to a bar that specializes in sadomasochism, run into a Greek god or two (or scarier things), get yourself a killer for hire. John Taylor is your classic trenchcoated detective with a murky background; his father is human, and no one seems to know who or what his mother is (was?). I've read the first several books in the series and she hasn't made an appearance yet. The series is leavened with humor and John's "gift" (he can find things with his mind) is well handled. He has to be careful how he uses the gift, because it can be used to track him and a lot of supernatural bad guys are after him. 

    And then there was that one series about a semiretired librarian who solves crimes in his home town... with a cat. Oh, all right. It's the Cat in the Stacks series, and it is somewhat flawed (IMHO) but readable enough. I've read three or four in the series but it is beginning to get a little tiresome for a few reasons. The narrator is a widower who moved back to Athena, Mississippi from Houston after his wife passed away. He is a pleasant fellow, but I am finding him somewhat bland; many of the secondary characters are more interesting, and that isn't good for the series. Our narrator works in tandem with the official detective of the city police, the only black woman on the police force, and it's implied that she has to take some crap from her co-workers; but, as with so much in this series, the details are never spelled out. Their initial interaction is prickly but they get along better over the course of the series. I'd like to see more of her and less of the narrator. The cat is Diesel, a Maine Coon cat which he takes everywhere with him, and of course everyone adores the cat. I wish I had a dime for every time a character says "What kind of cat is that?" or "I swear that cat understands everything you say!" It's that kind of series.

    Oh, well, it passes the time. (As has this blog post.) Mystery series are a great deal of fun, in most cases, and if you do a little research you can find one that will suit you. Happy reading, and if you have a series you would recommend be sure to let me know.  

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