If you are reading this because you have insomnia, you are not alone. Insomnia affects 80% of people at some time in their lives. Persistent insomnia, however, is a more challenging and frustrating problem and I am going to try to leave you with a few tips to help improve your symptoms.
There are a few caveats to get out of the way: If sleep seemed to get worse abruptly and then stayed poor, it is probably important to find out why. See your doctor. In some people poor sleep is a sign of a medical or other health condition.
Most people with persistent insomnia should consider getting psychological therapy. Even if a psychological problem was not the main cause of the sleep problem, prolonged insomnia often can affect the overall psychological state over time affecting not only the overall health but the recovery from the insomnia. Ironically, the more patients tend to resist psychological care the more likely they are to benefit from their services.
Treating ongoing insomnia can be very challenging because of the highly resistant nature of this condition. Often patients describe poor responses to sleeping medication, relaxation techniques, and other behavioral techniques. In fact, it is not unusual for some patients to claim that they have tried "everything" without success. It is under these circumstances a sleep professional needs to carefully go through the history and identify each and every intervention and assess the effectiveness of how each technique has been tried. For example, a relaxation technique is less likely to be very effective if the patient finishes 3 hours of work, brings the computer to bed to check e-mail for 45 minutes, sets the computer down, and then tries to relax for 10 minutes. When someone keeps their brain highly active and perhaps under emotional distress and then expects a sudden shift to total relaxation, it is as if that person expects slamming on the brakes, shifting into reverse, pulling the wheel to do a 180 in the middle of the highway will be relaxing for the passenger. Nearly all human brains require wind down time after stress and high level mental activity. In fact there is evidence that a very small percentage can immediately transition from high stress to relaxed brain state with very low levels of stress hormones. But I would be willing to bet that you are not James Bond so the rest of this advice does apply to you.
An evening routine requires putting away any work followed by declining intensity activities. Declining intensity means decreased speed, decreased physical demands, decreased psychological stress, etc. Paying bills definitely needs to stop at least an hour before bed. Cleaning out closets and shelves also needs to stop at least an hour before bed. Any work becomes the work that winds down the day. Folding laundry and leaving it in baskets for the next day, putting the last dishes in the dishwasher so it can be started, are reasonable tasks. Housecleaning will have to wait. Then brushing teeth and pajamas. Plan for 20-30 minutes of reading or watching television without any other activity. Avoid television in the bedroom. Then go to bed at a consistent bedtime. This bedtime may vary because of your work schedule. Roughly 10-11:30 p.m. works for most people if they don't have trouble going to sleep. If you have trouble going to sleep, go to bed an hour later.
In your room it should be dark, cool, comfortable, and quiet. If it isn't, fix whatever is disturbing you so it doesn't bother you. As I said, no T.V. We could debate the T.V. in the bedroom thing forever, but I would still say no. No computer. No smartphone. No iPad. No Playstation. Nothing with a screen. You can have your phone in your room, just don't touch it. If you were my kids I would tell you that the phone builds up a fatal electric charge during the hours of 10 p.m. and 6 a.m. and if they touch it they will die a grisly electrocution death. But they wouldn't believe me, because they grew up with me telling them ridiculous things like that. Just don't use electronics at night.
Give yourself some time to relax and fall asleep. You might be surprised by actually falling asleep. Sleep "how-to" books give specific amounts of time. I think that if you are watching the clock at night, it is counterproductive and promotes wakefulness.
Do not have a visible clock in the room. Your alarm clock can be in the room, but turn it away from you. Reminding yourself that it is 2 a.m. and you are not asleep is not useful at all. If you open your eyes and it is dark and your alarm has not rung yet, you still have time to sleep. That's all you need to know. The mental math of thinking how many hours you have been awake, how few hours you have left to sleep, how many hours you should be sleeping, how many nights it has been since you have slept well, and wondering when it will all crash down on you is not relaxing. Those thoughts are stressful.
So far:
General health exam by doctor and possibly psychologist
No alcohol or caffeine during the time we are intervening on your sleep
No tech
Wind down time for at least an hour
Regular bedtime
No visible clock
Next: if you wake up in the middle of the night and you can easily fall back to sleep, that's wonderful! However, if you are awake and can't sleep again, get out of bed and go to the living room or some other suitable, quiet room where you can be alone. Read something relaxing like a magazine or some fiction. If you read non-fiction make sure it is something that does not activate your brain excessively. Read about whales (unless you are a marine biologist) or something else pleasant. Read about the Dynasties of China. If you don't have a Kindle, consider getting one. But it's the middle of the night and Amazon (http://www.amazon.com/) delivers fast but not that fast. If you have a smart phone you can download the Kindle app and start reading books on your phone. The is the only exception I give to the No Tech rule. Now you can download thousands of books, many of them for free. Consider watching television. Watch something that pleases you. DO NOT WATCH THE NEWS! News channels have changed their formats over recent years and they are highly visually triggering and the flow of the information is jarring. Replace all of the interior windows of my standard transmission car with television screens that change channel every 3-5 seconds, configure the stereo so it plays 11 stations at once and then invite my 10 year old to drive at 90 miles per hour down I-90, grinding and clunking the gears all the way, and put Wolf Blitzer in the back seat interrupting everything all the time and we would have television news.
No TV news for you. It will not relax you. Watch Dirty Jobs or Mythbusters. Watch a movie. Get Netflix http://www.netflix.com/ and you can stream a ton of movies and TV series to your TV instantly for pennies per day. Relax. You are going to be up for a while. When you feel ready to go back to bed, go to bed and see if you can go to sleep.
How does this help? This sounds like what you were already doing, right? You were already staying up at bedime and staying up during the night. Then you would crash and sleep late some mornings when you were exhausted. Okay, now we are going to apply a schedule to your sleep. It works on the principle that your body, more specifically your brain needs sleep. If you deprive your brain of sleep it will build up sleep pressure and eventually it will fall asleep.
Let's take insomnia treatment X: Patient 1 comes in with complaints of not being able to sleep. The doctor straightens his collar, sticks out his chest and says, I can make sure you get a good long night of sleep. Patient 1 is brought into the sleep testing laboratory, is connected to testing electrodes and the technologist is instructed to keep the patient awake for 72 hours. At first it is no problem. The patient reads, watches T.V., talks on the phone, etc. By the end of 48 hours the patient is occasionally dozing off and needs to be watched. By 60 hours the patient needs constant supervision and stimulation like talking, lifting the hand, etc. The doctor indicates that it is time to let the patient sleep and they put her to bed. She sleeps for 16 hours straight and wakes up feeling very rested, but stiff and groggy. She has trouble sleeping the next night because of having just slept 16 hours, but for the next few days she sleeps with only mild difficulties. However, the problems slowly return and in a few weeks she is back to the way she was.
Insomnia treatment Y: Patient 2 comes in with similar complaints of trouble falling and staying asleep. The doctor advises relaxation, good sleep hygiene (behaviors) and schedules a 3 month follow-up appoinment. The patient expresses frustration because "I've done all of that". In fact, the patient has read a book and has tried a few of the recommendations for a night or two and got frustrated. The fact is that the patient is too frustrated to try anything that does not have tangible and clear results.
Insomnia treatment Z: Patient 3 will be treated with relaxation, sleep hygiene (appropriate sleep/bedtime behavioral therapy) and sleep scheduling also known as sleep restriction.
Sleep Restriction is one of the most effective and widely used treatments for insomnia. It works quickly, it has a sustained beneficial effect. It is often more powerful than medication but it can be used in conjunction with medication, if needed.
When Sleep Restriction is first explained to patients, they almost universally do not like it. The most favorable response is something akin to suggesting a colonoscopy. Other responses are vehement arguments against it. This is probably because Sleep Restriction seeks to take the already limited sleep in an exhausted patient and to substantially cut it down. It seems like the logic of: "Oh you are dying of thirst. Okay, I'll dump some of your last water on the ground." It is my job to explain why this protocol works.
Let's take an example:
Gretel gets home after a long day in the woods each day and makes dinner for her brother and her aunt. Then she has to clean up the kitchen, do some housework before she gets to relax. She likes to play "Pigs and Wolf" on XBox 360 and usually plays until after her witchy aunt goes to bed, typically after 11. Then she brushes her teeth and gets into bed. She thinks about how guilty she feels fattening up her brother, but her emotions are mixed because she doesn't want to get eaten. They could try to get away but the place is rent-free and meals included and that kind of deal doesn't come along every day. Plus, the old woman has serious diabetes. If she kicks the bucket, the candy house would be theirs. They could use the candy house to attract paying tenants and they would be set for life. With all of these thoughts on her mind she spends hours in bend tossing and turning and unable to fall asleep. When finally sleep comes to her the hacking cough of the warty nosed aunt wakes her and once again racing thoughts keep her from sleeping for quite a while. When she awakens she poorly rested once again, yet having to start her busy day.
For the sake of sleep math, let's say Gretel goes to bed at 11:30 p. m. and gets up at 6:30 a.m.
From 11:30 - 1 a.m. she is unable to sleep.
From 1 a.m. - 3 a.m. she sleeps.
From 3 a.m. - 4:30 a.m. she is awake again
From 4:30 a.m. - 6:30 a.m. she is asleep
Doing the sleep math: She sleeps 4 hours and she is awake 3 hours. She is in bed 7 hours. She is asleep 4/7 of the time she is in bed which is just a little more than half.
Patients would like us to be able to force them to sleep the other 3 hours. There isn't a wand in the Hansel and Gretel story or in my clinic. I can't make anyone sleep. We can teach relaxation, sleep hygiene, and occasionally give medicine. None of them will fix this by themselves. Sleep Restriction works well. Sleep Restriction is math.
If we have a fraction of 4/7 and what we want is that fraction to be closer to equaling one, but we can't change the numerator, then we have to change the denomenator. In other words, we have to decrease the amount of time in bed.
The solution is to tell Gretel to get earplugs to block out Aunt Witchy's noise. Then she needs to stop playing XBox so late. Third, her sleep schedule has to change to midnight to 5 a.m. This will eliminate both the insomnia at the beginning of the night as well as during the night.
At first she will still have the same insomnia, she will just have less sleep. However, after 2-4 days the pressure to fall asleep and stay asleep will overcome her insomnia disorder and she will fall asleep more easily and even if she wakes up she will return to sleep more easily. She needs to limit her sleep duration however to maintain an ongoing amount of sleep pressure over the next several weeks, thus the early morning awakening. When she is consistently falling asleep at midnight, not waking during the night and waking at 5 a.m. she will be getting 5 hours of consolidated sleep per night. This is much better than her 4 hours of fragmented sleep she was getting before. At this point she can start adding 30 min in the morning every 3-5 days alternating with 30 min in the night every 3-5 days until she is in bed 7 hours/night.
She can always repeat this protocol if she needs to do so. Typically, if a person has had do this protocol once there is a probability they will have to do it again. The good news is it is easier subsequent times.
Staying on a consistent sleep schedule it very important for people with insomnia.
An example would be:
Wednesday, December 29, 2010
Monday, December 27, 2010
Hypnotics: Sleeping Pills, Part 2
In this section we will review some of the common and a few of the less common hypnotics (sleeping medications) and distinguishing characteristics. I am going to break the medications down by pharmacologic class to make it easier and clearer, at least easier and clearer for me if not for the reader.
First, we should start with alcohol (ethyl alcohol). This drug has been widely available for millenia and since the invention of doctors, there have been doctors using alcohol as a medicine for their patients for sleep. And for worms. And for cankers. And for scalp lice. And for fever. And for pustules. And for rat bites. Alcohol is sedating. It can promote sleep if given in large enough quantities. However, there is initially has reduced REM sleep followed by REM rebound and vivid dreams. Sleep becomes fragmented by awakenings and is poorly restful. Often people complain of insomnia. Interestingly, the effects of alcohol on sleep can last hours after ingestion so that several drinks in the afternoon can cause insomnia for some people that night. Furthermore, heavy alcohol users can have sleep disruption months after discontinuing alcohol. Although alcohol is a fundamental component of social interaction and culinary preferences for many, it is best if it is not used pharmacologically and like most products, it should be avoided when side effects occur.
Melatonin: Take the hormone of the pineal gland and you have melatonin. If you don't know where your pineal gland is, please stop guessing! Some of you were just wrong. Some of you were guessing in places I would rather not think about. The pineal gland is in the brain. It secretes melatonin. It seems to do this to tell our brains that it is dark and we should go to sleep. The eyes tell the hypothalamus which tells the pineal gland. It is a mild but very useful effect to coax us to sleepy-land. I suspect that when we were living in smaller hunter-gatherer groups it was much more useful to have a hormone that made hunter-gatherer me drowsy at night so I would tend to want to lay down and sleep rather than run around willy-nilly in the dark where I could trip and break something (no E.R. with orthopedic surgeon on call) or get eaten by something nocturnal. Taking exogenous (pill) melatonin can be quite useful in three circumstances: a) Jet Lag: take 1 hour before bedtime at your new time throughout your trip and for 1-2 weeks when you return. b) Shift Work: take 1 hour before bedtime during day sleep. c) Chronic Insomnia: take 60-90 min before bedtime nightly. Melatonin is generally considered to have relatively few side effects. However, one major side effect is vivid dreams or nightmares. If this side effect occurs and continues, you can try to cut down on the dose or stop and restart the medicine. However, is is very likely that the side effect will return every time you take it.
Barbiturates: This class of medications is highly sedating and is very potent to induce sleep. However, these medications are hardly ever used as sleeping medications due to the abuse potential and safety issues they carry. Instead, they are now used primarily as anti-seizure medicines and anesthesia medications. Examples include: Secobarbital (Seconal), Pentobarbital (Nembutal - used for animal euthanasia, treatment of seizures, capital punishment, physician-assisted suicide), Butalbital (Fiorinal - migraine treatment), Phenobarbital (seizure treatment), among several others. Getting good sleep is important, but it will never be so important that patients should take a couple of the capital punishment pills to get to sleep.
Benzodiazepines: This is a large class of medicines some of which are used for sleep, others are used for other purposes. It ranges from the very short acting intravenous Midazolam which you are likely to receive when you have a procedure like a colonoscopy. It is sedating and it affects the memory so that you stay comfortably resting and you wake up not remembering anything about the procedure, which is the best way to have a colonoscopy. When the colonoscopy is done, the medicine is wearing off. On the other end of the spectrum is a medicine like valium. It is a mildly sedating medicine which primarily works to blunt anxiety. It works for many hours and it has active metabolic products that last more than 24 hours. The purpose is a long, low level effect to blunt revved up anxiety. In the middle of the spectrum are many medicines. Some with more sedation effects and some with more anxiety reduction, each with their varying durations of effect. The following are a list of medicines sometimes used to promote sleep. Some are used to promote sleep when other conditions are present. If these medications have been used regularly at higher doses, a taper should be used to come down off of the medicine.
Triazolam (Halcion) 0.125 - 0.25 mg
Clonazepam (Klonopin) 0.25 - 1 mg
Lorazepam (Ativan) 0.25 - 1 mg
Alprazolam (Xanax) 0.25 -1 mg
BZRA's (Benzodiazepine Receptor Agonists) Think of this group as Ambien and its cousins. You have got to give the pharmaceutical companies credit. They came up with a great one. Barbiturates are addictive and dangerous. Benzodiazepines have long half-lives and other effects on the brain besides just sleep like affecting anxiety, mood, etc. These scientists made a much more pure sleeping-only pill. Unlike its predecessors it starts to work in 20 minutes, not 45 to an hour. It wears off reliably in 6 hours. They had a brilliant pill. And they sold millions. If it's so great why haven't we cured insomnia? The answer, as you might have guessed, is that pills do not solve complicated problems like insomnia. Sleep hygiene (see subsequent blog post) is critical for good sleep. Other health issues can get in the way. Feeling sick while undergoing chemotherapy, worrying about one's business but feeling too sick to go to work, realizing that everything that was worked for is dissolving like that soggy cake in the annoying seventies song all can prevent sleep, ambien or not. Then medical professionals need to step in. Sleep professionals have specific training in these matters.
Side effects and precautions: There are many, but they occur infrequently.
Side effects of these medicines: temporary memory loss, sleep walking, sleep eating, there have been reports of sleep driving,
Precautions: Notify living partners (adults) that you are taking a sleeping pill tonight. If you seem to be walking in your sleep, they should verbally encourage you to return to bed. If you seem to be doing something that you shouldn't, such as going outside in your pajamas in the rain at 3 a.m., they should direct you back to bed. After taking your sleeping pill, do not use the internet. Ambien works quickly and you may not be thinking clearly when you make a purchase or send an email. To your boss. Calling him a name that describes the posterior portion of a donkey.
Currently available BZRA's are:
Zolpidem (Ambien) 2.5 - 10 mg
Escitalopram (Lunesta) 1-3 mg
Zolpidem (Ambien CR) 6.25 - 12.5 mg
Zaleplon (Sonata) 5-10 mg
Meltatonin receptor agonist: Ramelteon (Rozerem) is the only currently available medication in its class. It can be effective in some patients with insomnia. It is most beneficial after the patient has been using the medication for at least 1-2 weeks. Side effects are limited. There are some drug interactions that need to be checked with each prescription of Ramelteon.
First, we should start with alcohol (ethyl alcohol). This drug has been widely available for millenia and since the invention of doctors, there have been doctors using alcohol as a medicine for their patients for sleep. And for worms. And for cankers. And for scalp lice. And for fever. And for pustules. And for rat bites. Alcohol is sedating. It can promote sleep if given in large enough quantities. However, there is initially has reduced REM sleep followed by REM rebound and vivid dreams. Sleep becomes fragmented by awakenings and is poorly restful. Often people complain of insomnia. Interestingly, the effects of alcohol on sleep can last hours after ingestion so that several drinks in the afternoon can cause insomnia for some people that night. Furthermore, heavy alcohol users can have sleep disruption months after discontinuing alcohol. Although alcohol is a fundamental component of social interaction and culinary preferences for many, it is best if it is not used pharmacologically and like most products, it should be avoided when side effects occur.
Melatonin: Take the hormone of the pineal gland and you have melatonin. If you don't know where your pineal gland is, please stop guessing! Some of you were just wrong. Some of you were guessing in places I would rather not think about. The pineal gland is in the brain. It secretes melatonin. It seems to do this to tell our brains that it is dark and we should go to sleep. The eyes tell the hypothalamus which tells the pineal gland. It is a mild but very useful effect to coax us to sleepy-land. I suspect that when we were living in smaller hunter-gatherer groups it was much more useful to have a hormone that made hunter-gatherer me drowsy at night so I would tend to want to lay down and sleep rather than run around willy-nilly in the dark where I could trip and break something (no E.R. with orthopedic surgeon on call) or get eaten by something nocturnal. Taking exogenous (pill) melatonin can be quite useful in three circumstances: a) Jet Lag: take 1 hour before bedtime at your new time throughout your trip and for 1-2 weeks when you return. b) Shift Work: take 1 hour before bedtime during day sleep. c) Chronic Insomnia: take 60-90 min before bedtime nightly. Melatonin is generally considered to have relatively few side effects. However, one major side effect is vivid dreams or nightmares. If this side effect occurs and continues, you can try to cut down on the dose or stop and restart the medicine. However, is is very likely that the side effect will return every time you take it.
Barbiturates: This class of medications is highly sedating and is very potent to induce sleep. However, these medications are hardly ever used as sleeping medications due to the abuse potential and safety issues they carry. Instead, they are now used primarily as anti-seizure medicines and anesthesia medications. Examples include: Secobarbital (Seconal), Pentobarbital (Nembutal - used for animal euthanasia, treatment of seizures, capital punishment, physician-assisted suicide), Butalbital (Fiorinal - migraine treatment), Phenobarbital (seizure treatment), among several others. Getting good sleep is important, but it will never be so important that patients should take a couple of the capital punishment pills to get to sleep.
Benzodiazepines: This is a large class of medicines some of which are used for sleep, others are used for other purposes. It ranges from the very short acting intravenous Midazolam which you are likely to receive when you have a procedure like a colonoscopy. It is sedating and it affects the memory so that you stay comfortably resting and you wake up not remembering anything about the procedure, which is the best way to have a colonoscopy. When the colonoscopy is done, the medicine is wearing off. On the other end of the spectrum is a medicine like valium. It is a mildly sedating medicine which primarily works to blunt anxiety. It works for many hours and it has active metabolic products that last more than 24 hours. The purpose is a long, low level effect to blunt revved up anxiety. In the middle of the spectrum are many medicines. Some with more sedation effects and some with more anxiety reduction, each with their varying durations of effect. The following are a list of medicines sometimes used to promote sleep. Some are used to promote sleep when other conditions are present. If these medications have been used regularly at higher doses, a taper should be used to come down off of the medicine.
Triazolam (Halcion) 0.125 - 0.25 mg
Clonazepam (Klonopin) 0.25 - 1 mg
Lorazepam (Ativan) 0.25 - 1 mg
Alprazolam (Xanax) 0.25 -1 mg
BZRA's (Benzodiazepine Receptor Agonists) Think of this group as Ambien and its cousins. You have got to give the pharmaceutical companies credit. They came up with a great one. Barbiturates are addictive and dangerous. Benzodiazepines have long half-lives and other effects on the brain besides just sleep like affecting anxiety, mood, etc. These scientists made a much more pure sleeping-only pill. Unlike its predecessors it starts to work in 20 minutes, not 45 to an hour. It wears off reliably in 6 hours. They had a brilliant pill. And they sold millions. If it's so great why haven't we cured insomnia? The answer, as you might have guessed, is that pills do not solve complicated problems like insomnia. Sleep hygiene (see subsequent blog post) is critical for good sleep. Other health issues can get in the way. Feeling sick while undergoing chemotherapy, worrying about one's business but feeling too sick to go to work, realizing that everything that was worked for is dissolving like that soggy cake in the annoying seventies song all can prevent sleep, ambien or not. Then medical professionals need to step in. Sleep professionals have specific training in these matters.
Side effects and precautions: There are many, but they occur infrequently.
Side effects of these medicines: temporary memory loss, sleep walking, sleep eating, there have been reports of sleep driving,
Precautions: Notify living partners (adults) that you are taking a sleeping pill tonight. If you seem to be walking in your sleep, they should verbally encourage you to return to bed. If you seem to be doing something that you shouldn't, such as going outside in your pajamas in the rain at 3 a.m., they should direct you back to bed. After taking your sleeping pill, do not use the internet. Ambien works quickly and you may not be thinking clearly when you make a purchase or send an email. To your boss. Calling him a name that describes the posterior portion of a donkey.
Currently available BZRA's are:
Zolpidem (Ambien) 2.5 - 10 mg
Escitalopram (Lunesta) 1-3 mg
Zolpidem (Ambien CR) 6.25 - 12.5 mg
Zaleplon (Sonata) 5-10 mg
Meltatonin receptor agonist: Ramelteon (Rozerem) is the only currently available medication in its class. It can be effective in some patients with insomnia. It is most beneficial after the patient has been using the medication for at least 1-2 weeks. Side effects are limited. There are some drug interactions that need to be checked with each prescription of Ramelteon.
Friday, December 17, 2010
Hypnotics: Sleeping Pills, Part 1
Hypnotics – Sleeping Pills.
Part 1
From the Greek word hypnotikos meaning “inclined to sleep, putting to sleep, sleepy” [Wordbook.com].
From the late Latin word hypnoticus also referring to the inclination to sleep.
From the 17th century word hypnotic meaning the induction of sleep usually with drugs.
From the mid-twentieth century United States, Las Vegas term “Amazing Hypnosis Phenomenon”, referring to cheesy shows in which members of the audience are fooled into clucking like a chicken for the entertainment of the crowd.
Hypnotics are a class of medications that are intended to sedate and induce sleep. There are several presumptions regarding hypnotics that are worth stating.
1. Sleep is best done without others getting involved in the process, no matter how well intentioned. It is much like golf in this way. Once sleep… or a golf swing… has been directed to relax and progress smoothly, nothing is going to make it work better. Anything else, like sleeping pills, will only get in the way.
2. Nearly everything that prevents people from sleeping needs to be solved by changing their habits and behavior. A sleeping pill will not solve unmanaged stress, poor sleep habits, turmoil in the household, psychological issues, or using tech (computers, phones, TV, etc) late at night. Arguing that it works well for you even though it is devastating to the sleep of everyone else is not going to get you to sleep any faster.
3. Alcohol does not improve sleep. It makes people drowsy. Enough will make a person pass out. It worsens sleep quality. People with poor sleep need to stop alcohol.
4. Caffeine keeps some people awake. Avoid late day caffeine.
5. If you are using a drug that shows up on a drug screen, stop it. For about a hundred reasons. But they will mess up your sleep, too.
6. Unlike the beliefs of many patients, there are no pills which are completely safe and guaranteed to induce sleep. I am often asked for something “strong” but “safe” and I wonder if that was what Michael Jackson was after.
7. Everything that causes a physiologic effect on the brain could potentially be habit forming. When patients ask for a sleeping pill that isn’t habit forming, I want to suggest Skittles. Just don’t go to bed with them in your mouth, you might choke. Actual pharmaceuticals have a habit forming potential. So does cough syrup. So does coffee. So do pain killers. Yet most people with coughs, breakfast beverages, and pain do not end up as junkies. The same is true with sleep medications. Most people use the medication correctly. Even the people who use it incorrectly do not tend to develop substance abuse problems. Sometimes their prescriptions run out early, but it is often because of the “if one is good, two must be better” philosophy. In my career I have very rarely seen anyone abuse or sell their prescription for their sleeping medication. I have never seen anyone suffer serious consequences from sleeping pill abuse. I know it happens, but I believe other drugs are abused more frequently. Patients should use their sleeping medications correctly and worry less about ending up in rehab.
8. It is normal to wake in the night. It may take a while to return to sleep. No medication will prevent the normal phenomenon of occasional nighttime awakenings.
9. ALL sleeping medications have side effects. Don’t ask for one without side effects. They made a seedless orange. They made a seedless watermelon. They made seedless grapes. Now you can enjoy them without pesky seeds. However, you are never going to have medicine without side effects. The reason there will always be the potential for side effects is that if a medication is active in your body, it means it is changing the way your body’s physiology functions. It is more accurate to say desired and undesired medication effects. When taking any medication, some of the medication physiologic effects you were hoping to get (less prominent wrinkles following a botox injection). Some medication physiologic effects you do not want (frozen face and loss of the ability to smile). The medication is having the effects on the physiology, some are desired, some are not. Some people call them side effects, but they are actually still the same physiologically active drug effects as the principal effect you were trying to get. For example, when a sleeping pill makes you sleepy, you are happy about that. It is doing its job. When it makes you lose your memory for the details of a conversation you have while you are lying in bed and just about to go to sleep, you call it a side effect. In fact, it is the same sedating physiologic effect. Both consciousness and memory are affected. Be alerted for all of the physiologic effects (side effects, if you will) of sleeping medications. Typically, they are mild and tolerable, but one should be aware of them before taking the medication.
10. Do not Michael Jackson me. What I mean is: do take sleeping medication and then complain it doesn’t work and ask for more or stronger medication. When a patient tells me that a very effective sleep aid taken in double or triple the usual dose “doesn’t work” I am 99% certain at that moment that the problem is not that there is too little medicine, the problem is that there is too little therapy dealing with the cause if the insomnia. (For those of you with short memories or little interest in the King of Pop, Michael Jackson died due to a massive overdose of sedatives and the injectable anesthetic propofol administered by his doctor. Mr. Jackson apparently suffered from insomnia for a long time and had a history of insisting on high doses of sedatives from his doctors.)
Saturday, December 4, 2010
Weight Loss for Sleep Apnea- A Possible Treatment for Sleep Apnea
When we treat patients with obstructive sleep apnea we offer multiple treatments options to improve their symptoms such as snoring, disrupted sleep, tiredness, difficulty staying alert on the job as well as alleviate the cardiovascualar risks of sleep apnea. Typically people receive treatment with positive airway pressure (CPAP) because of its high rates of success in treatment, safety, and easy tolerability. However, other treatment methods are used as well. These include surgery by an ear, nose and throat surgeon to open the airway. Also the patients may do well with an oral device which is an acrylic piece like a mouth guard that is built and fitted by a specialist dentist to keep the jaw from sinking back and the tongue from collapsing the airway.
One treatment we mention but usually does not get immediately implemented is weight loss. Obstructive sleep apnea is often caused by obstruction worsened with excessive weight in and around then neck tissues. Losing weight can have a dramatic responses on the severity of sleep apnea. Many have been able to reduce their CPAP pressures. Others have been retested and their tests no longer detect sleep apnea and they no longer need treatment.
As exciting as a complete cure from sleep apnea would be, a significant weight loss is a long and difficult challenge. We do not tell patients with sleep apnea that they should lose weight and expect their efforts will suddenly get easier. They will still need another treatment for sleep apnea while they tackle the weight problem. However, if someone is serious about losing weight, there are several approaches that can be helpful and have data to support their greater level of success.
Organized approaches work better than general approaches. Programs requiring meetings, appointments with a trainer, etc. are better than trying to follow good intentions.
Record-keeping is highly effective. Now there are very easy online record keeping software systems that not only have huge food catalogs already in them but they remember what you eat so you just have to click on coffee, cereal, grapefruit and you have entered your usual breakfast. To make this even better, some of these are even available on iPhone/iPod Touch and other handheld platforms. You enter your exercise in the same way. By using software you know when you have done well and when you did... less well. It helps you realize which decisions make a significant impact.
I recommend "FitDay" and "My Fitness Pal"
Exercise is critical. Daily exercise. It is okay to have a few days per week of hard work at the gym with a trainer or whatever your choice of harder exercise. On the other days there needs to be some sort of activity to keep up your metabolism. A shorter walk, a shorter time on the exercise machine, an easier yoga session. Whatever you chose it needs to be something.
Dietician: I strongly encourage people to see a dietician. Almost every morbidly obese patient looks at me and says, "I know how to eat. I don't need to be taught." The irony of their statement is completely lost on them. When we need to learn something, it is time to go to the person who can teach us.
Bariatric Medicine and Surgery: Bariatric medicine is a specialty in medicine in which there is more than a dietician needed. The person needs a doctor who specializes in the body's metabolism. They work on directing the metabolic processes and the patient to work more effectively and when they do, the weight goes down. People who follow the program have excellent results.
Bariatric Surgery is a field of medicine which changes the gastrointestinal system by surgical means to promote weight loss. It is highly effective and has become a standard in the care and management of obese patients who have failed other approaches.
In our clinic when we see patients who have lost a significant amount of weight we often find they no longer need CPAP. They also often tell us they have stopped other medicines, as they no longer need diabetes pills, cholesterol medicines, etc.
One treatment we mention but usually does not get immediately implemented is weight loss. Obstructive sleep apnea is often caused by obstruction worsened with excessive weight in and around then neck tissues. Losing weight can have a dramatic responses on the severity of sleep apnea. Many have been able to reduce their CPAP pressures. Others have been retested and their tests no longer detect sleep apnea and they no longer need treatment.
As exciting as a complete cure from sleep apnea would be, a significant weight loss is a long and difficult challenge. We do not tell patients with sleep apnea that they should lose weight and expect their efforts will suddenly get easier. They will still need another treatment for sleep apnea while they tackle the weight problem. However, if someone is serious about losing weight, there are several approaches that can be helpful and have data to support their greater level of success.
Organized approaches work better than general approaches. Programs requiring meetings, appointments with a trainer, etc. are better than trying to follow good intentions.
Record-keeping is highly effective. Now there are very easy online record keeping software systems that not only have huge food catalogs already in them but they remember what you eat so you just have to click on coffee, cereal, grapefruit and you have entered your usual breakfast. To make this even better, some of these are even available on iPhone/iPod Touch and other handheld platforms. You enter your exercise in the same way. By using software you know when you have done well and when you did... less well. It helps you realize which decisions make a significant impact.
I recommend "FitDay" and "My Fitness Pal"
Exercise is critical. Daily exercise. It is okay to have a few days per week of hard work at the gym with a trainer or whatever your choice of harder exercise. On the other days there needs to be some sort of activity to keep up your metabolism. A shorter walk, a shorter time on the exercise machine, an easier yoga session. Whatever you chose it needs to be something.
Dietician: I strongly encourage people to see a dietician. Almost every morbidly obese patient looks at me and says, "I know how to eat. I don't need to be taught." The irony of their statement is completely lost on them. When we need to learn something, it is time to go to the person who can teach us.
Bariatric Medicine and Surgery: Bariatric medicine is a specialty in medicine in which there is more than a dietician needed. The person needs a doctor who specializes in the body's metabolism. They work on directing the metabolic processes and the patient to work more effectively and when they do, the weight goes down. People who follow the program have excellent results.
Bariatric Surgery is a field of medicine which changes the gastrointestinal system by surgical means to promote weight loss. It is highly effective and has become a standard in the care and management of obese patients who have failed other approaches.
In our clinic when we see patients who have lost a significant amount of weight we often find they no longer need CPAP. They also often tell us they have stopped other medicines, as they no longer need diabetes pills, cholesterol medicines, etc.
Wednesday, November 17, 2010
Liquid Lightning Bolts: Energy Beverages, The Promises, Hype and Truth
If your car were making noises or running slowly you could go to a trusted mechanic and have it repaired properly so it would run well for a long time. However, you could also go to the auto-parts store and spend $19.99 on a product with a name like "Octane-Insane Booster", pour it into your gas tank and see if it solves your problem. You would probably find that you had wasted 20 bucks and decide to get and oil change and a tune up.
If your body feels tired and is moving slowly, you can rest, eat well, take care of yourself properly, or there are cans and bottles of products that promise to rev you up and keep you fully functional even though your body is clearly telling you that you need rest and care.
Let's review some of these products.
Sport drinks like Gatorade and Powerade are marketed primarily as products that rehydrate. They suggest that they replace carbohydrates, electrolytes, as well as missing water. They do not suggest that the user will not need to sleep or will have more energy other than feeling better for being hydrated.
True energy drinks like "Red Bull", "Rockstar", "Monster", "Full Throttle", and "5 Hour Energy" all derive their energy delivery from caffeine. With the exception of "5 Hour Energy" there is also a significant amount of carbohydrate. That means the "energy" is a sugar rush and a "sugar rush" tends to have a quick onset, last a short time and then end with a dull, slow feeling.
Each of the energy drinks add 10 - 20 dietary supplements in form of vitamins and herbs with unproven effects. Some of the ingredients could cause dehydration which could be detrimental to someone participating in athletic or heavy physical activity. There is no clearly stated advantage to most of these ingredients other than a vague "energy" claim without any data to support the claims.
Energy drinks are probably not significantly dangerous, but it is probably better to work toward getting adequate rest, addressing sleep problems and then forcing alerness won't be necessary.
Darius Zoroufy, M.D.
Reference:
Higgins, John P, et al, "Energy Beverages: Content and Safety", Mayo Clin Proc, Nov 2010; 85(11)1033-1041.
If your body feels tired and is moving slowly, you can rest, eat well, take care of yourself properly, or there are cans and bottles of products that promise to rev you up and keep you fully functional even though your body is clearly telling you that you need rest and care.
Let's review some of these products.
Sport drinks like Gatorade and Powerade are marketed primarily as products that rehydrate. They suggest that they replace carbohydrates, electrolytes, as well as missing water. They do not suggest that the user will not need to sleep or will have more energy other than feeling better for being hydrated.
True energy drinks like "Red Bull", "Rockstar", "Monster", "Full Throttle", and "5 Hour Energy" all derive their energy delivery from caffeine. With the exception of "5 Hour Energy" there is also a significant amount of carbohydrate. That means the "energy" is a sugar rush and a "sugar rush" tends to have a quick onset, last a short time and then end with a dull, slow feeling.
Each of the energy drinks add 10 - 20 dietary supplements in form of vitamins and herbs with unproven effects. Some of the ingredients could cause dehydration which could be detrimental to someone participating in athletic or heavy physical activity. There is no clearly stated advantage to most of these ingredients other than a vague "energy" claim without any data to support the claims.
Energy drinks are probably not significantly dangerous, but it is probably better to work toward getting adequate rest, addressing sleep problems and then forcing alerness won't be necessary.
Darius Zoroufy, M.D.
Reference:
Higgins, John P, et al, "Energy Beverages: Content and Safety", Mayo Clin Proc, Nov 2010; 85(11)1033-1041.
Saturday, November 6, 2010
Sleep Apnea is Associated with Heart Disease in Large University of Wisconsin Study
When a study follows a particular demographic or statistical group, that study can be considered a cohort study. One carefully followed group is the Wisconsin Sleep Cohort. The Department of Medicine, and the University of Wisconsin has been following this cohort for over 20 years. I was fortunate to attend my residency at the University of Wisconsin and to meet some of the researchers who are still actively involved in this project.
[“Sleep Disordered Breathing and Mortality: Eighteen-Year Follow-up of the Wisconsin Sleep Cohort”, Young, Terry PhD, et al., Department of Population Health Sciences and Department of Medicine, University of Wisconsin-Madison, Madison, WI. SLEEP, Vol 31, No. 8, 2008.]
When the researchers wrote their 18th year report and released it to SLEEP Journal it was released for expedited publication. The cohort sample includes 1522 adults assessed at baseline for sleep disordered breathing/sleep apnea and stratified as mild, moderate, and severe sleep apnea. All-cause mortality risk was adjusted for confounding factors such as age, gender, weight (body mass index), other disease states, etc that could have affected the results.
The researchers found startling results. People with severe untreated sleep apnea had a 3.8 times greater chance of dying than the baseline population without sleep apnea. They also had a 5.2 times greater chance of dying of cardiovascular disease. These people did not necessarily have current cardiovascular disease or other cardiovascular risk factors.
Moderate sleep apnea conveyed an overall 1.7 times greater risk. Mild sleep apnea conveyed a 1.4 times greater risk.
These findings were significant and were consistent with other important studies like the Sleep Heart Health Study.
Patients at the Swedish Sleep Medicine Associates Clinics get a thorough evaluation. If they are found to have sleep apnea they are advised to get treatment and to consistently adhere to their treatment plan in order to eliminate symptoms of sleep apnea such as daytime sleepiness, snoring, loss of mental acuity. They are also told that treating sleep apnea also has the critically important role of reducing cardiovascular risk.
Darius Zoroufy
Children with Sleep Apnea have Higher Blood Pressures
Many of you have already learned about increased cardiovascular disease risk markers in patients with uncontrolled sleep apnea. When I speak with patients, they often seem to take on an opinion that the cardiovascular risk issues are have more to do with older adults and people who already have significant heart disease. Patients in their 20’s, 30’s, 40’s and even 50’s sometimes seem disinterested in the cardiac effects of sleep disordered breathing, as if they are too young to be affected by sleep related breathing affects on the heart.
In the article by Marilisa Montesano, M.D. and her colleagues at The Pediatric Department “La Sapienza” University, Il Faculty, Medicine, Rome, Italy in SLEEP (Vol 33, No. 10, Oct. 1, 2010, pp. 1349-1355.) In the study children ages 7 – 14 underwent overnight sleep studies. 18 had obstructive sleep apnea and 25 were in the control group.
The investigative group did many sophisticated analyses leading to many surprising results. One of the most significant was that children have markedly greater blood pressure if they have sleep apnea compared to those who do not.
Obstructive Sleep Apnea Group | Control Group | |
Systolic Blood Pressure | 111.7 mm Hg | 100.5 mmHg |
Diastolic Blood Pressure | 64.7 mm Hg | 57.7 mmHg |
Heart Rate | 77.0/min | 67.5/min |
Apnea/Hypopnea Index | 5.3/hour | 0.3/hour |
Statistical analysis showed a clear and direct relationship between the AHI (Apnea-Hypopnea Index: the number of apneas and hypopneas per hour) and cardiovascular parameters in these children.
It is evident that there are already cardiovascular changes in children who are suffering from obstructive sleep apnea. We must take the cardiovascular effects of sleep apnea very seriously in every sleep apnea patient and make sure we are fully managing sleep apnea in every single patient to the best of our ability.
Darius Zoroufy, M.D.
Late Night is Better for Rest and Less Effective for Work
Many studies have demonstrated that sleep quality has a close relationship with memory and mental performance. In fact, many of us have recognized in our own lives that our memory and recall are not as sharp when we are sleep deprived compared to times when we are well rested. In this month’s journal SLEEP (Vol 33, No. 10, Oct. 1, 2010) another study and associated editorial were published on this very subject. (“A Time for Learning and a Time for Sleep: The Effect of Sleep Deprivation on Contextual Fear Conditioning at Different times of the Day” Roeline Hagewoud, et al, pp 1315-1322)
This study showed that rats demonstrated reduced learning when allowed to sleep less following a learning stimulus when compared with rats which had the opportunity to sleep amounts consistent with the normal rat sleep cycle. The researchers concluded that not only was the amount of sleep deprivation a significant factor, but the timing of sleep deprivation (deprived during normal sleep hours) that affected learning and the consolidation of memories. It appears that each stage of sleep may have a layering effect in the production of long term, integrated memories.
A corollary of the study is that late night work is not nearly as productive as we tend to think it is. It is far better to put work away at bedtime, get adequate, restorative sleep and start fresh in the morning.
The age-old question “How much sleep do I need may be a much more complicated question that it initially seems but the answer definitely requires getting a full night of sleep on a consistent schedule. Adults should be getting to bed by 10-11 p.m. and sleeping 8 hours. Children have varying sleep schedule requirements depending on their ages. However, essentially all children should be in bed going to sleep at least by 9 p.m. and most school aged children should be getting 9-10 hours of sleep/night. If you or the children are too tired to wake up easily, you are probably not getting enough sleep.
Sleep well and have a good day.
Darius Zoroufy, M.D.
Sunday, October 31, 2010
Sleep Apnea Screening is Necessary Before Surgery
For patients undergoing surgery, unidentified Obstructive Sleep Apnea is associated with increased risk of complications. Untreated sleep apnea patients are at greater risk of cardiovascular disease, type II diabetes, and premature death. During October 16-20, 2010 the annual meeting of the American Society of Anesthesiologists two similar studies were presented regarding screening presurgical patients for sleep apnea. The patients who screened positive for sleep apnea could be definitively diagnosed and treated and/or monitored more carefully during their time in surgical care.
One study used a comprehensive home sleep study or a full in-laboratory study. 819 patients were enrolled and a stunning 536 patients, 2/3 of the total (65.4%) tested positive for sleep apnea. Of these 85.5% of the patients with severe sleep apnea were not identified by the surgeons and 47% of the severe sleep apnea patients were not identified by the anesthesiologists based on clinical assessment alone.
In a second study a questionnaire followed by an overnight oxygen recorder screened for possible sleep apnea. Although this protocol did not diagnose sleep apnea, it identified patients at greater risk for sleep apnea and therefore at greater risk for surgical complications. 367 patients patients completed the study. It was concluded that simply performing the questionnaire followed by the overnight oxygen overnight screening test identified greater than 90% of the cases of sleep apnea.
The doctors could send the patients for full diagnostic sleep testing to reduce the surgical risks.
In our practice we routinely evaluate and treat patients before surgery. Since surgery often requires a specific time frame, we work closely with the surgical team, cardiology team, or other procedural team to integrate with their surgical schedules. As a result our services are often requested to assist patients in pre-operative evaluation. We use comprehensive questionnaires, home screening tests when appropriate, and state of the art full diagnostic sleep testing to assess patients
When speaking with your surgeon, cardiologist, or other physician prior to a surgery or significant procedure, ask for a referral to Sleep Medicine for a pre-operative assessment for Obstructive sleep apnea.
Darius Zoroufy
One study used a comprehensive home sleep study or a full in-laboratory study. 819 patients were enrolled and a stunning 536 patients, 2/3 of the total (65.4%) tested positive for sleep apnea. Of these 85.5% of the patients with severe sleep apnea were not identified by the surgeons and 47% of the severe sleep apnea patients were not identified by the anesthesiologists based on clinical assessment alone.
In a second study a questionnaire followed by an overnight oxygen recorder screened for possible sleep apnea. Although this protocol did not diagnose sleep apnea, it identified patients at greater risk for sleep apnea and therefore at greater risk for surgical complications. 367 patients patients completed the study. It was concluded that simply performing the questionnaire followed by the overnight oxygen overnight screening test identified greater than 90% of the cases of sleep apnea.
The doctors could send the patients for full diagnostic sleep testing to reduce the surgical risks.
In our practice we routinely evaluate and treat patients before surgery. Since surgery often requires a specific time frame, we work closely with the surgical team, cardiology team, or other procedural team to integrate with their surgical schedules. As a result our services are often requested to assist patients in pre-operative evaluation. We use comprehensive questionnaires, home screening tests when appropriate, and state of the art full diagnostic sleep testing to assess patients
When speaking with your surgeon, cardiologist, or other physician prior to a surgery or significant procedure, ask for a referral to Sleep Medicine for a pre-operative assessment for Obstructive sleep apnea.
Darius Zoroufy
Saturday, October 30, 2010
Aerobic Exercise Relieves Insomnia
Insomnia is a common problem of sleep leaving millions awake for hours at night. Many interventions are tried, some successfully, some without success. Often the most effective techniques over the long term are behavioral techniques such as consistent bedtime, relaxing nighttime routine without work and stimulating media, etc.
Regular aerobic exercise during the day improves nighttime sleep quality as well. A study from Northwestern Medicine reported in Sleep Review in the October 27, 2010 issue included 23 sedentary insomniac women who were enrolled in a 30-40 min/day stationary bicycle or treadmill program 4 days per week for 16 weeks. A control group had 45 minuted meetings instead of exercise.
Both groups had exercise about good sleep behaviors.
Exercise improved self-reported sleep quality in the exercise group with participants no longer describing themselves as poor sleepers. They described fewer depressive symptoms and less daytime sleepiness as well. These improvements were not seen in the control group.
For those suffering from insomnia, regular aerobic exercise is an effective intervention. Consistently applying an exercise regime may be one of the most helpful tools for treating insomnia.
Darius Zoroufy, M.D.
Regular aerobic exercise during the day improves nighttime sleep quality as well. A study from Northwestern Medicine reported in Sleep Review in the October 27, 2010 issue included 23 sedentary insomniac women who were enrolled in a 30-40 min/day stationary bicycle or treadmill program 4 days per week for 16 weeks. A control group had 45 minuted meetings instead of exercise.
Both groups had exercise about good sleep behaviors.
Exercise improved self-reported sleep quality in the exercise group with participants no longer describing themselves as poor sleepers. They described fewer depressive symptoms and less daytime sleepiness as well. These improvements were not seen in the control group.
For those suffering from insomnia, regular aerobic exercise is an effective intervention. Consistently applying an exercise regime may be one of the most helpful tools for treating insomnia.
Darius Zoroufy, M.D.
Sunday, October 24, 2010
A clean mask every day makes CPAP a much better experience
Mask Care Advice From Dr. Zoroufy
Every day I hear complaints about how the mask does not seal correctly, slides to one side in the night, needs to be put on so tightly it is painful and a long list of other complaints.
I ask, quite innocently, "How often do you wash your mask?"
I get answers like, "I try to do it once a week." If they try to do it once a week that means they are probably not succeeding to do it that often. I will even get answers like, "I was supposed to wash that thing? It looks fine to me."
Keeping mask or nasal pillows and headgear is not only hygienic and will help prolong the life of your mask, it will also help your mask seal better against your skin. The problem is that adding another long procedure to your daily routine is not likely to be welcome. Some of the official instructions recommend filling the sink and using dish soap and soaking in an undertaking lasting 15 precious minutes as you are trying to get yourself and possibly your children out the door on time on a busy morning.
Here is a much easier technique that works well and leaves your mask smelling nice at the end of the day.
When your morning alarm rings and you remove your mask, disconnect it from the tubing and shuffle to the bathroom where you hang the mask in the shower. Do not take the mask apart.
When you take your shower the steps of washing the mask are as follows:
Darius Zoroufy, M.D.
Every day I hear complaints about how the mask does not seal correctly, slides to one side in the night, needs to be put on so tightly it is painful and a long list of other complaints.
I ask, quite innocently, "How often do you wash your mask?"
I get answers like, "I try to do it once a week." If they try to do it once a week that means they are probably not succeeding to do it that often. I will even get answers like, "I was supposed to wash that thing? It looks fine to me."
Keeping mask or nasal pillows and headgear is not only hygienic and will help prolong the life of your mask, it will also help your mask seal better against your skin. The problem is that adding another long procedure to your daily routine is not likely to be welcome. Some of the official instructions recommend filling the sink and using dish soap and soaking in an undertaking lasting 15 precious minutes as you are trying to get yourself and possibly your children out the door on time on a busy morning.
Here is a much easier technique that works well and leaves your mask smelling nice at the end of the day.
When your morning alarm rings and you remove your mask, disconnect it from the tubing and shuffle to the bathroom where you hang the mask in the shower. Do not take the mask apart.
When you take your shower the steps of washing the mask are as follows:
- Hold the mask and headgear in the water until it is all wet.
- Use a small amount of liquid soap or shampoo to wash all surfaces and headgear. Key word: "small" amount. If you use too much you will be rinsing soap out for a long time. Remember, you will be doing this every day, so it will not be that dirty. Avoid expecially greasy, slimy soaps or they will build up on your mask. The whole process should take only a few minutes. If you spend more than 5 minutes, you are taking too long.
- Rinse your mask.
- Shake it out and hang it up
- Get your mask the next night. It should be dry or nearly dry.
- *** As a courtesy, tell others in the household you will be leaving your mask in the shower.
- Once a week take the tube into the shower, wash it and hang it with a similar procedure.
- The CPAP machine itself does NOT get washed in the shower.
Darius Zoroufy, M.D.
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