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BackgroundPostoperative delirium is common after extensive surgery, and is known to be associated with sleeping medications. In this study, we aimed to investigate the relationships between sleeping medications and postoperative delirium after pharyngolaryngectomy with esophagectomy.MethodsWe performed a retrospective analysis of 65 patients who underwent pharyngolaryngectomy with esophagectomy at Shizuoka Cancer Center Hospital between January 2012 and March 2016. All data were assessed by two psychiatrists, and univariate and multivariate analyses were performed.ResultsPostoperative delirium developed in 9 (13.8%) patients, with most cases (77.8%) occurring between postoperative day (POD) 1 and POD 3. Of the 24 patients taking a minor tranquilizer after surgery, 8 (33.3%) became delirious, but, of the remaining 41 patients taking ramelteon with or without suvorexant, only one (2.4%) became delirious after surgery. Moreover, of the 16 patients taking both ramelteon and suvorexant, no postoperative delirium was observed. Ramelteon with or without suvorexant was significantly associated with a decreased rate of postoperative delirium compared with minor tranquilizer use (p = 0.001). Multivariate analysis confirmed that the use of ramelteon with or without suvorexant was the only significant preventive factor of postoperative delirium (odds ratio 0.060, p = 0.013).ConclusionThe use of ramelteon with or without suvorexant was the only significant preventive factor of postoperative delirium after pharyngolaryngectomy with esophagectomy. However, using minor tranquilizers was associated with postoperative delirium. We recommend ramelteon with or without suvorexant for preventing postoperative delirium after pharyngolaryngectomy with esophagectomy.

The incidence of delirium after the commencement of fentanyl injection was significantly lower, suggesting that fentanyl is a useful opioid injection drug from the perspective of delirium risk.

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Inquiring about the weekly frequency of difficulty 'falling asleep within 30 min,' 'waking up in the middle of the night or early morning,' and 'sleep quality' may help to diagnose depression.

Signs of suicidal depression often go undetected in primary care settings. This study explored predictive factors for depression with suicidal ideation (DSI) among middle-aged primary care patients at 6 months after an initial clinic visit. New patients aged 35–64 years were recruited from internal medicine clinics in Japan. Baseline characteristics were elicited using self-administered and physician questionnaires. DSI was evaluated using the Zung Self-Rating Depression Scale and the Profile of Mood States at enrollment and 6 months later. Multiple logistic regression analysis was conducted to calculate adjusted odds ratios for DSI. Sensitivity, specificity, and likelihood ratios for associated factors were calculated. Among 387 patients, 13 (3.4%) were assessed as having DSI at 6 months. Adjusted for sex, age, and related factors, significant odds ratios for DSI were observed for “fatigue on waking ≥1/month” (7.90, 95% confidence intervals: 1.06–58.7), “fatigue on waking ≥1/week” (6.79, 1.02–45.1), “poor sleep status” (8.19, 1.05–63.8), and “relationship problems in the workplace” (4.24, 1.00–17.9). Fatigue on waking, sleep status, and workplace relationship problems may help predict DSI in primary care. Because the sample size in this investigation was small, further studies with larger samples are needed to confirm our findings.

We would like to express our appreciation to Dr. Kawada for his attention and comments.We totally agree with his comments. We also had the same concern as he expressed in his letter. However, we thought the results might interest the readers and might be of some use to those who were engaged in the management of postoperative delirium. Therefore, in spite of the incompleteness in statistical treatment, we thought it worth to report the results of this small research. We also think the results should be validated by randomized control trial procedure.We reported the results of the multivariable logistic regression analysis based on only 9 events in 65 patients, because this study was conducted as an effort of our team therapy to prevent postoperative complications of esophagectomy and the objective was to understand the preventive effect of the combination of ramelteon and suvorexant to postoperative delirium using the available data. As pointed out by the letter, there is some incompleteness in the statistical treatment. Especially, based on the one in ten rule, we should have included more than 20 events in the analysis. We think that we should have displayed some statistical information such as confidence interval, sample size, event size and so on. We also should have included some statistical limitations in the article, so that the readers could interpret the results properly without confusion.Regarding individual data, retrospective single institute researches may have some kind of biases, but all patients' charts were systematically assessed by two psychiatrists to minimize them.Regarding the recommendation to include minor tranquilizer as one of the variables, we did it as shown in Table 2. This retrospective study led to the conclusion that ramelteon with or without suvorexant was more effective than minor tranquilizer.We hope the above could be a good explanation to the comments in Dr. Kawada's letter.This reply refers to the article available at https ://doi

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