Laparoscopic mesh repair of an epigastric hernia

The repair of a large epigastric (ventral) hernia using a laproscopic or keyhole surgery technique.

Facts about Insomnia

Primary insomnia is usually associated with

• A) sleep apnea
• B) restless legs syndrome
• C) periodic limb movements
• D) circadian rhythm sleep disorders
• E) none of the above

Answer and Discussion
Insomnia is defined as inadequate or poor-quality sleep characterized by one or more of the following: difficulty falling asleep, difficulty maintaining sleep, waking up too early in the morning, or sleep that is not refreshing. Insomnia also involves daytime consequences such as fatigue, difficulty concentrating, and irritability.

Periods of insomnia lasting between 1 night and a few weeks are defined as acute insomnia. Chronic insomnia refers to sleep difficulty occurring at least 3 nights per week for 1 month or more.

Insomnia may be associated with specific sleep disorders, including restless legs syndrome, periodic limb movement disorder, sleep apnea, and circadian rhythm sleep disorders. Restless legs syndrome is characterized by unpleasant sensations in the legs or feet that are temporarily relieved by movement. Symptoms are worse in the evening, especially when a person is lying down and remaining still. The sensations cause difficulty falling asleep and are often accompanied by periodic limb movements. Periodic limb movement disorder is characterized by bilateral repeated and rhythmic, small-amplitude jerking or twitching movements in the lower extremities and, less frequently, in the arms. These movements occur every 20 to 90 seconds and can lead to awakenings, which are usually not noticed by the patient. Often the patient reports that sleep is not refreshing. In many cases, the bed partner is more likely to report the movement problem. Obstructive sleep apnea is most commonly associated with snoring, daytime sleepiness and obesity but occasionally presents with insomnia. Circadian rhythm sleep disorders including sleep-work insomnia are characterized by an inability to sleep because of a disturbance between the circadian sleep rhythm and the desired or required sleep schedule.

Primary insomnia occurs in the absence of the previously mentioned conditions . When the insomnia persists beyond 1 or 2 nights or becomes predictable, treatment should be considered. Pharmacologic treatment is usually effective, especially short-acting hypnotics.
Sleep hygiene measures may also be useful. Chronic insomnia may be more difficult to treat. Because chronic insomnia is often multifactorial in etiology, a patient may need multiple treatment modalities, including medication (antidepressants, antihistamines, melatonin) and behavioral therapy. If an underlying medical or psychiatric condition is identified, this condition should be treated first. The answer is E.