Restless Legs Syndrome Symptoms in Primary Care

Parasomnias and sleep-related movement disorders induced by drugs in the adult population: a review about iatrogenic medication effects

Parasomnias and sleep-related movement disorders (SRMD) are major causes of sleep disorders and may be drug induced. The objective of this study was to conduct a systematic review of the literature to examine the association between drug use and the occurrence of parasomnias and SRMD. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for reporting systematic reviews, we searched PubMed databases between January 2020 and June 2023. The searches retrieved 937 records, of which 174 publications were selected for full-text screening and 73 drugs were identified. The most common drug-induced parasomnias were nightmares and rapid eye movement (REM) sleep behaviour disorders and sleepwalking. In terms of drug-induced SRMD, restless legs syndrome, periodic limb movement disorders (PLMD), and sleep-related bruxism were most frequent. Medications that inhibit noradrenergic, serotonergic, or orexin transmission could induce REM sleep (e.g., nightmares). Regarding sleepwalking, dysregulation of serotoninergic neurone activity is implicated. Antipsychotics are mentioned, as well as medications involved in the gamma-aminobutyric acid (GABA) pathway. A mechanism of desensitisation-autoregulation of GABA receptors on serotoninergic neurones is a hypothesis. SRMD and PLMD could involve medications disrupting the dopamine pathway (e.g., antipsychotics or opioids). Opioids would act on mu receptors and increase dopamine release. The role of adenosine and iron is also hypothesised. Regarding bruxism, the hypotheses raised involve dysregulation of mesocortical pathway or a downregulation of nigrostriatal pathway, related to medications involving dopamine or serotonin. Parasomnias are rarely identified in drug product labels, likely due to the recent classification of their diagnoses. An analysis of pharmacovigilance data could be valuable to supplement existing literature data.

Sleep disturbance and menopause

PURPOSE OF REVIEW

Sleep problems are among the most prevalent and bothersome symptoms of menopause. This review characterizes menopausal sleep disturbances, describes biopsychosocial predictors, and summarizes the evidence supporting pharmacological and nonpharmacological treatment options.

RECENT FINDINGS

Recent studies found that sleep changes are early indicators of perimenopause and sought to disentangle the respective impacts of menopausal status, hot flashes (HFs), and changes in reproductive hormones on peri-/postmenopausal sleep problems. Both HFs and reproductive hormones predicted sleep problems, but neither solely accounted for the myriad changes in sleep, thus highlighting the contribution of additional biopsychosocial risk factors. Inconsistencies across studies were likely due to differences in study design and methodology, participants' menopausal stage, and the presence of sleep complaints. Recent studies support the use of psychological (cognitive-behavioral therapy for insomnia) and pharmacological (e.g., neurokinin B antagonists) treatments in addition to hormone therapy.

SUMMARY

Sleep problems are common and of critical import to women during the menopausal transition, significantly influencing treatment preferences and satisfaction. Thus, sleep problems should be routinely assessed from a biopsychosocial perspective and treated with evidence-based interventions throughout menopause. Treatment selection should be based on diagnosis and careful assessment.

Restless legs syndrome among blood donors: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Restless legs syndrome (RLS), with adverse health outcomes, has been linked to blood donation, but evidence published thus far has not been rigorously analysed. This systematic review aggregates existing evidence on RLS among blood donors and identifies associated factors worthy of further investigation.

MATERIALS AND METHODS

MEDLINE and EMBASE were searched for articles published through 16 December 2023. Eleven studies from eight countries were selected from 142 publications. The pooled prevalence of RLS was calculated using a random-effects model, with heterogeneity assessed by the Cochran Q and I2 statistics. Meta-regression and sensitivity analyses explored sources of heterogeneity and the robustness of findings.

RESULTS

Eleven studies, involving 20,255 blood donors, were included. The pooled prevalence of RLS among blood donors was 10.30% (95% confidence interval [CI]: 5.54%-16.30%), which was significantly higher than in the general adult population (3.0%, 95% CI: 1.4%-3.8%). Meta-regression identified the year of study and geographical region as significant sources of heterogeneity. From the five studies that used logistic regression analyses, female sex and older age stand out as associated factors. No publication bias was detected, and sensitivity analysis confirmed the robustness of results.

CONCLUSION

Our findings suggest a high burden of RLS among blood donors, underscoring the need for further research with standardized criteria, appropriate design and analytical methodologies to better understand the impact of RLS on individual donors and the global blood supply.

Efficacy and safety of intravenous ferric carboxymaltose in the treatment of Restless Legs Syndrome: a systematic review and meta-analysis

INTRODUCTION

Restless Legs Syndrome (RLS), also known as Willis-Ekbom Disease (WED), is a sensorimotor disorder characterized by an uncontrollable urge to move the legs, typically accompanied by discomfort. Low iron levels, pregnancy, and age are some identified risk factors. RLS is treated using various pharmacological options, including dopamine agonists, benzodiazepines, anticonvulsants, opioids, and bupropion. Iron supplementation, particularly with intravenous Ferric carboxymaltose (FCM), has gained attention due to the role of iron deficiency in RLS pathophysiology. This meta-analysis evaluates the efficacy and safety of FCM in treating RLS symptoms.

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted following the PRISMA guidelines, using databases such as PubMed, Google Scholar, and Cochrane. Studies involving intravenous FCM in patients diagnosed with RLS were included. Statistical analysis was performed using Review Manager 5.4.

RESULTS

Seven studies involving 539 participants were analyzed. FCM significantly reduced IRLS scores (WMD = -5.77; 95% CI = [-8.85, -2.70]; p = 0.0002) and improved VAS and SF-36 scores compared to placebo. However, FCM did not significantly improve RLS quality of life scores. Adverse events were more common in the FCM group, particularly nausea, but no significant differences were found for severe adverse events.

CONCLUSION

In conclusion, intravenous ferric carboxymaltose significantly reduces Restless Legs Syndrome symptoms, especially in patients with confirmed iron deficiency. The treatment appears generally well-tolerated, with adverse effects being manageable. However, further long-term studies are needed to fully assess the safety profile and confirm sustained symptom improvement in a broader population.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42024585233.

Sleep disturbance in rodent models and its sex-specific implications

Sleep disturbances, encompassing altered sleep physiology or disorders like insomnia and sleep apnea, profoundly impact physiological functions and elevate disease risk. Despite extensive research, the underlying mechanisms and sex-specific differences in sleep disorders remain elusive. While polysomnography serves as a cornerstone for human sleep studies, animal models provide invaluable insights into sleep mechanisms. However, the availability of animal models of sleep disorders is limited, with each model often representing a specific sleep issue or mechanism. Therefore, selecting appropriate animal models for sleep research is critical. Given the significant sex differences in sleep patterns and disorders, incorporating both male and female subjects in studies is essential for uncovering sex-specific mechanisms with clinical relevance. This review provides a comprehensive overview of various rodent models of sleep disturbance, including sleep deprivation, sleep fragmentation, and circadian rhythm dysfunction. We evaluate the advantages and disadvantages of each model and discuss sex differences in sleep and sleep disorders, along with potential mechanisms. We aim to advance our understanding of sleep disorders and facilitate sex-specific interventions.

Frequency, risk factors, and impacts on quality of life of the restless legs syndrome and side effects among antidepressant users in a tertiary hospital: an observational cross-sectional study

Restless leg syndrome (RLS) is a common but underestimated sensorimotor disorder that significantly affects the quality of life (QoL) which can be induced by antidepressants. This study aims to investigate the frequency and potential risk factors of RLS and side effects in selective serotonin reuptake inhibitors/serotonin and noradrenaline reuptake inhibitors (SSRI/SNRI) users. This cross-sectional study included 198 outpatients who received SSRI/SNRI for 4-8 weeks. Clinical evaluation was performed using the International Restless Leg Syndrome Study Group rating scale for RLS, Udvalg for Kliniske Undersøgelser side effects rating scale, and a short form 36 (SF-36) questionnaire for QoL. The frequency of RLS was 25%. RLS significantly increased with smoking and habituality. Also, habituality increased neurologic side effects reporting. The use of antipsychotics and calcium channel blockers decreased reporting of autonomic side effects. QoL decreased with RLS, psychiatric, neurologic, autonomic, and other side effects in different domains of SF-36. These findings suggested that SSRI/SNRI use could be associated with a higher risk of RLS, especially in smokers. QoL could be influenced negatively by RLS and all side effects. However, further prospective studies are needed to confirm these associations in large samples.

Lateral Subdermic Venous Plexus Insufficiency: The Association of Varicose Veins with Restless Legs Syndrome and Nocturnal Leg Cramps

PURPOSE

To determine whether nocturnal symptoms of restless legs syndrome (RLS) and muscle cramps in the legs are associated specifically with lateral subdermic venous plexus (LSVP) insufficiency and whether treatment can provide symptomatic relief.

MATERIALS AND METHODS

A retrospective cross-sectional observational study of 506 patients at a single site analyzed whether RLS or nighttime leg cramping symptoms were associated with venous reflux in the LSVP using comprehensive venous ultrasound. The treatment outcomes of ultrasound-guided foam sclerotherapy (USGFS) were followed up for 1 year.

RESULTS

Of 209 patients who reported restless legs symptoms, 179 (85%) demonstrated an abnormal LSVP. A total of 214 patients reported nighttime muscle cramping, of whom 197 (92%) demonstrated an abnormal LSVP. Among 124 patients presenting with both the symptoms, 113 (91%) demonstrated an abnormal LSVP. Conversely, of 83 patients who presented with neither RLS nor nocturnal cramping, 2 (2%) had an abnormal LSVP. Among 242 symptomatic patients with an abnormal LSVP who underwent treatment, the technical success rate was 100%. At 90-day follow-up, 224 patients (93%) reported continued relief, which was maintained at 93% (224/242) at follow-up at 1 year. When substratified, 90 patients presented primarily with RLS or cramping and showed only LSVP reflux, and when treated, all 90 (100%) had significant or complete relief of the symptoms.

CONCLUSIONS

LSVP insufficiency demonstrates an association with symptoms of RLS and nocturnal leg cramps. LSVP treatment using USGFS demonstrated high technical and clinical success rates, with symptomatic relief up to 1 year, most pronounced when the LSVP was the only treated vein.

Prevalence and Determinants of Restless Legs Syndrome (Willis-Ekbom Disease) in an Older Greek Population

OBJECTIVES

The present study aimed to explore the descriptive and analytic epidemiology of restless legs syndrome (RLS) in the older Greek population, with a specific focus on lifestyle indicators.

METHODS

Baseline data from the randomly selected non-demented older participants of the population-based HELIAD cohort were analyzed. Multivariable binary logistic regression with RLS diagnosis as the dichotomous dependent outcome was performed. Demographic, socioeconomic, anthropometric, dietary, sleep-related and psychological parameters, physical activity, use of psychoactive substances and personal medical history were investigated for potential associations.

RESULTS

A total of 133 from the eligible sample of 1,838 participants were diagnosed with RLS. The mean age-sex standardized prevalence of RLS among the elderly was estimated at 6.1% (95%CI = 5.0-7.2), with a female (8.0%, 95%CI = 6.4-9.6) to male (3.7%, 95%CI = 2.4-5.1) ratio of 2.1. The prevalence of RLS peaked during the 8^th decade of life and diminished thereafter. The positive associations of RLS with female sex [OR = 2.06, 95%CI = (1.19-3.57)], anxiety levels [assessed by the 22-point HADS scale, OR = 1.08, 95%CI = (1.03-1.13)] and traumatic brain injury [OR = 2.22, 95%CI = (1.37-3.62)] were reproduced. Good sleep quality was related to 55% [95%CI~(24-83%)] lower odds of having RLS in comparison with both poor and moderate quality. Adherence to the Mediterranean dietary pattern [assessed by a 55-point scale, OR = 1.06, 95%CI = (1.01-1.11)], and low daily energy intake [low-moderate vs. low: OR = 0.45, 95%CI = (0.26-0.79)]; [moderate-high vs. low: OR = 0.69, 95%CI = (0.40-1.22)]; [high vs. low: OR = 0.31, 95%CI = (0.13-0.69)] were related to RLS for the first time.

CONCLUSIONS

More emphasis should be placed on the dietary-nutritional aspects of RLS.

Prevalence, risk factors and effects of restless legs syndrome in COPD patients

Restless legs syndrome (RLS), a sensory motor disorder, is commonly seen amongst chronic obstructive pulmonary disease (COPD) patients. We conducted a study to know its prevalence in COPD and analyse the possible cause and effect of RLS. It is an analytical cross-sectional study conducted between July 2016-December 2020.The prevalence of RLS was evaluated in patients of COPD using RLS diagnostic criteria. Spirometry, iron profile and arterial blood gas analysis was performed in all the patients to evaluate the cause of RLS. The effect was evaluated with diagnostic criteria for insomnia and patient health questionnaire (PHQ2) for depression. There were 205 participants with a mean age of 59±8 years, 182 (88.7%) men and 23 (11.2%) women. The mean body mass index (BMI) was 29±3.9 kg/m2. The prevalence of RLS was 31.2%. RLS was more common amongst women compared to men (60.8% vs 27.4%). RLS was more prevalent among hypoxemic (PaO2<60 mm Hg) and hypercapnic (PaCO2>45 mm Hg) patients (p<0.016; p<0.017). The ROC curve plotted between PaO2 and RLS occurrence showed that the patients having PaO2 less than 76 mm of Hg were more prone to develop RLS. RLS patients had a higher incidence of insomnia as compared to those without RLS (68.8% vs 36.8%, p<0.001). COPD with RLS patients had more depressive symptoms with a higher patient health questionnaire 2 (PHQ2) score (35.9% vs 14.2%, p<0.001) compared to non-RLS COPD patients. The multiple regression analysis also confirmed that RLS led to insomnia and depressive symptoms in COPD patients. To conclude, RLS is common in COPD patients. RLS leads to insomnia and depression, thus should be identified and treated.

Restless Legs Syndrome among patients receiving antipsychotic and antidepressant drugs

BACKGROUND

Patients with Restless Legs Syndrome (RLS) experience psychological distress and diminished quality of life. Antipsychotics and antidepressants are known to be linked to RLS.

AIMS

This study aims to investigate the presence of RLS in psychiatric patients who receive antipsychotic and antidepressant drugs and to determine potential risk factors for its occurrence.

METHODS

Two hundred patients who received antipsychotic and antidepressant drugs for more than 1 month were recruited from two tertiary psychiatric centers in Cairo, Egypt. One hundred apparently healthy volunteers were also included. All patients and controls were screened using the four-items questionnaire (Arabic version) for RLS. RLS severity was scored according to the validated Arabic version of International Restless Legs Syndrome Study Group rating scale (IRLS). Mimicking conditions were carefully investigated and excluded.

RESULTS

Forty-one percent of the patients who receive antipsychotic and antidepressant drugs were found to have RLS. Family history, past history and smoking are potential risk factors. Trazodone and haloperidol were less associated with RLS.

CONCLUSIONS

Although limited by its cross-sectional design, these findings suggest that patients who receive antipsychotic and antidepressant are susceptible to RLS. However, these results need to be replicated on a wider scale.

Is restless legs syndrome in Parkinson disease patients associated with any specific factor?

BACKGROUND

Restless legs syndrome or Willis-Ekbom disease is a disorder characterized by unpleasant sensations associated with the need to mobilize the lower limbs. In Parkinson disease patients, restless legs syndrome is associated with worse quality of life and excessive sleepiness. Regarding other factors, results of different studies are controversial.

OBJECTIVE

To determine the factors associated with the restless legs syndrome presence in Parkinson disease patients.

METHODS

A cross-sectional study was conducted in 88 consecutive Parkinson disease patients from the outpatient clinic for 21 months. Participants underwent a clinical interview, assessment based on standardized scales (Epworth Sleepiness Scale, Parkinson Disease Questionnaire - 39, Pittsburgh Sleep Quality Index, International Restless Legs Syndrome Study Group rating scale), and video-polysomnography.

RESULTS

Out of the 88 participants, 25 had restless legs syndrome. In the multivariate analysis, restless legs syndrome in Parkinson disease has been associated with the symptom of smell loss and quality of sleep and life. In the univariate analysis, restless legs syndrome in Parkinson disease has occurred more frequently in women with higher frequency of insomnia, constipation, and anosmia than in the group without restless legs syndrome.

CONCLUSION

Restless legs syndrome is a prevalent condition in patients with Parkinson disease and is associated with specific characteristics in this group of patients.

[Differential diagnosis of insomnia from other comorbid primary sleep disorders]

The "insomnia complaint" currently has a very high prevalence in the medical consulting room. This assumes that any doctor must have some basic notions of how to approach it. But currently, there are certain aspects that hinder this approach, especially when the "insomnia disorder" needs to be ruled out from the rest of the primary sleep disorders. This article aims to break with the terminological confusion that encompasses the concept of "insomnia", providing the definitions of the most correct terms to use. This will provide us with good tools for the correct collection of information, which will be of great help for the application of a clinical diagnostic algorithm of "Chronic adult Insomnia disorder". This will be able to differentiate it mainly from the rest of primary sleep disorders, and thus, apply a specific treatment, which will resolved on the basis of the "insomnia complaint" by the patient.

Improvement of Subthalamic Nucleus Deep Brain Stimulation in Sleeping Symptoms in Parkinson's Disease: A Meta-Analysis

Introduction

The aim of this meta-analysis was to evaluate the effects of STN DBS on sleep quality and restless leg symptoms in individuals with PD.

Methods

We searched the PubMed, Web of Science, EMBASE, CNKI, and WANFANG databases published between 1990 and 2019. The articles included were those that contained both pre- and postsurgery data acquired using International RLS Study Group criteria and the Pittsburgh sleep quality index (PSQI) questionnaire with patients' follow-up of at least three months. All studies that met the quality requirements were included in a meta-analysis performed using STATA 12.0 software.

Results

Of 73 articles identified, 7 studies comprising 82 patients were qualified for the current meta-analysis. After adjusting for heterogeneity in study effect sizes, the random effects meta-analysis indicated that STN DBS improved sleep quality and restless leg symptoms significantly (SMD = −1.111, 95% CI: −1.918∼−0.304, P=0.007). Subgroup analysis showed that different sleep scoring criteria had different effects on the condition of sleeping after surgery.

Conclusions

STN DBS is a powerful method in the management of sleep quality and restless leg symptoms in PD patients, but its long-term effects with larger populations must be thoroughly assessed.

Increased Risk for New-Onset Psychiatric Adverse Events in Patients With Newly Diagnosed Primary Restless Legs Syndrome Who Initiate Treatment With Dopamine Agonists: A Large-Scale Retrospective Claims Matched-Cohort Analysis

STUDY OBJECTIVES

Published literature documents increased risk for psychiatric adverse events (P-AEs) following dopamine agonist (DA) initiation for treatment of primary restless legs syndrome (RLS). We examined the association between DA initiation and subsequent new-onset P-AEs among patients with a new diagnosis of RLS who had no history of psychiatric disorder or DA use.

METHODS

Selected were adults (age 18 years or older) enrolled through United States employer-sponsored plans and Medicare Advantage from 7/1/2008-12/31/2014, with ≥ 2 years of claims data preceding their first RLS diagnosis ("preindex period"). Excluded were those with psychiatric diagnoses (International Classification of Diseases, Ninth Revision [ICD-9] 290-319) or DA use during the preindex period, and those with possible secondary RLS. Patients who initiated (DA+) versus did not initiate (DA-) DAs were matched 1:1 on age at index RLS diagnosis, sex, geographic region, and employment status, and preindex period comorbid illness burden and number of non-DA drug fills. Using a validated ICD-9-based severity-of-illness psychiatric disorder classification system, we compared likelihoods of new-onset P-AEs between matched pairs during parallel follow-up periods.

RESULTS

Identified were 889 matched pairs. Compared with their DA- counterparts, DA+ patients were nearly two times more likely to experience development of any P-AE (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.31-2.24, P < .0001); and similarly more likely to experience the development of a severe (OR 1.68, 95% CI 1.03-2.86, P = .04), moderately severe (OR 1.63, 95% CI 1.17-2.29, P = .004), or mild (OR 1.72, 95% CI 1.12-2.65, P = .01) P-AE.

CONCLUSIONS

Compared to DA- matched control patients, patients in whom RLS was newly diagnosed and who initiated de novo DAs demonstrated significantly increased risk for subsequent development of P-AEs of any severity.

CITATION

Hankin C, Lee D, Garcia-Borreguero D, Wang Z. Increased risk for new-onset psychiatric adverse events in patients with newly diagnosed primary restless legs syndrome who initiate treatment with dopamine agonists: a large-scale retrospective claims matched-cohort analysis. J Clin Sleep Med. 2019;15(9): 1225-1232.

Impact, Frequency, and Severity of Restless Legs Syndrome in Patients with Multiple Sclerosis in Argentina

Background

Restless legs syndrome (RLS) frequency, and its association with depression, anxiety, sleep disorders, and fatigue, has not been previously studied in Latin American patients with multiple sclerosis (MS). We aimed to assess RLS frequency in patients with MS living in Argentina and to examine potential associations with depression, anxiety, and sleep disorders.

Methods

A cross-sectional study (n = 427) was conducted using a self-administered questionnaire, including International RLS Study Group criteria, to compare RLS frequency in patients with MS versus controls. The Hospital Anxiety and Depression Scale and the Fatigue Severity Scale were administered to all participants. Insomnia, excessive daytime somnolence, and other risk factors in patients with MS with RLS were analyzed using logistic regression.

Results

We included 189 patients with definite MS and 238 controls. The RLS frequency was 29.1% in patients with MS versus 13.0% in controls (odds ratio [OR] = 2.74, P = .00005). Moreover, clinically significant RLS (csRLS; ie, symptoms present ≥2 days per week) frequency was 19.4% in patients with MS versus 4.2% in controls (OR = 5.37, P < .00001). Longer MS duration and presence of anxiety, depression, insomnia, and smoking cigarettes were all significantly associated with RLS. Multivariate analysis showed that anxiety and fatigue were significantly associated with MS with RLS and MS with csRLS.

Conclusions

Both RLS and csRLS showed strong association with MS, supporting the need to screen for anxiety/depression, sleep quality, and fatigue in this patient population. We believe that identifying the presence and severity of these conditions would contribute to better MS management and treatment.

Treatment of Leg Veins for Restless Leg Syndrome: A Retrospective Review

BACKGROUND

Restless leg syndrome (RLS) and chronic venous insufficiency (CVI) share similar circadian timings and epidemiological characteristics.

OBJECTIVE

The objective of the study was to investigate whether treating superficial venous reflux (SVR) improves the RLS severity in patients with CVI and whether there is an association of the RLS severity with the number of refluxed veins.

MATERIALS AND METHODS

Patients with RLS and duplex ultrasound-proven SVR were identified from a database of 134 patients. All patients underwent endovenous radiofrequency ablation and ultrasound-guided foam sclerotherapy. International RLS (IRLS) rating scale questionnaires were reviewed to assess pre- and post-intervention RLS status.

RESULTS

Thirty-five patients were identified. The average baseline IRLS score was 19.83 (moderate RLS) and improved to 7.89 (mild RLS) after treatment (p < .0001), corresponding to 63% decrease in symptoms. Ten patients (29%) had a follow-up score of 0, indicating complete relief of RLS symptoms. Twenty patients (57%) had decreased IRLS scores of 10 points or more (i.e. 1 grade level of severity). Six patients had no improvement. There was no association of the RLS severity with the number of refluxed veins.

CONCLUSION

The study found that correcting SVR improves RLS symptoms, suggesting an association between CVI and RLS. Venous ultrasound study and intervention should be considered for potential patients.

Exclusion of mimics does not influence Willis-Ekbom disease diagnosis among recent medical graduates

OBJECTIVE

In view of the diagnostic challenge posed by restless legs syndrome/Willis-Ekbom disease (RLS/WED) to health professionals and the challenge of its recognition by patients, the diagnostic criteria have been revised and updated to facilitate identification of this disease. However, in a previous study, we found that self-diagnosis of RLS/WED depends on the very name used to describe the condition. To ascertain whether the presence of the fifth diagnostic criterion of the International Restless Legs Syndrome Study Group (IRLSSG), is necessary for RLS/WED diagnosis when the term "Willis-Ekbom disease" is used.

METHODS

We randomly distributed 705 forms to recent medical graduates, asking them to self-assess whether they had "Willis-Ekbom disease" (WED). In one questionnaire model, we excluded the fifth criterion suggested by the IRLSSG, while in the other, all five criteria were included. No forms contained the term RLS; only WED was used throughout.

RESULTS

Seven hundred and five recent medical graduates participated in the study. Among the 332 who received the form without the fifth criterion, 8 (2.41%) self-diagnosed as having WED (95%CI: 0.8%-4.1%). Of the 373 who received the form with all five of the 2014 IRLSSG criteria, 9 (2.41%) self-diagnosed as having WED (95%CI: 0.8%-4.0%) (p > 0.05).

CONCLUSION

Our data show that presence of the fifth IRLSSG criterion did not influence self-diagnosis of WED among recent medical graduates, suggesting that the name WED reduces the odds of mimics (confounding conditions) being misinterpreted as symptoms of this disease. This finding indicates that for the diagnosis of RLS/WED only four criteria and a systematic use of the name WED are necessary.

Symptoms of Restless Legs Syndrome in A Palliative Care Population: Frequency and Impact

Objectives: We hypothesized that restless legs syndrome (RLS) would be common and associated with impaired quality of life (QOL) among palliative care outpatients. Methods: 76 palliative care clinic patients completed the National Institutes of Health restless legs syndrome (NIH-RLS) screening questionnaire. Questionnaire data was also gathered on RLS severity and RLS-related QOL, and the Short Form Health Survey (SF-12) was used to measure QOL. Analysis was performed for associations between RLS categorization and QOL measures. Results: 31 patients (40.8 percent) met criteria for RLS. RLS-positive patients had moderate-to-severe RLS symptoms and impaired RLS-specific QOL. RLS-positive patients scored lower on the mental component of the SF–12 (39 ± 11 versus 45 ± 12, p=0.03), though not on the physical component. In a multivariate regression analysis, higher levels of RLS severity had 2-point lower SF-12 mental component scores compared to lower levels of RLS severity (p=0.04), with no difference in physical component scores (p=0.47). Conclusion: RLS appears common in palliative care outpatients and is associated with impairments in QOL.

Elevation of tumor necrosis factor alpha levels is associated with restless legs symptoms in clinically depressed patients

BACKGROUND

Restless legs syndrome is a sensorimotor disorder associated with several mental illnesses particularly depression.

METHODS

A cross-sectional study of primary care patients. The prevalence of restless legs symptoms was studied in 706 patients with depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the BDI and the psychiatric diagnosis was confirmed by means of a diagnostic interview (M.I.N.I.). The subjects with elevated depressive symptoms were divided into two groups subjects with depressive symptoms with and without clinical depression.

RESULTS

The prevalence of restless legs symptoms was 24.8% in the controls, 50.0% in the patients with clinical depression and 42.4% in the patients with depressive symptoms. CRP value was significantly higher (p = .003) in the clinically depressed patients than in the other groups. There was a higher concentration of TNF-α in the subjects with restless legs symptoms (7.4 ng/l ± 3.2) compared with the subjects without symptoms (6.7 ng/l ± 2.3)(p < .001). There was a significant difference in the TNF-α levels between the subjects with and without restless legs symptoms in the depression group (p < .001) and among the patients with depressive symptoms but no a depression diagnosis (p = .022). In these groups, restless legs symptoms were associated with elevated levels of TNF-α.

CONCLUSIONS

TNF-α level was associated with restless legs symptoms only among subjects with depressive symptoms whether they had clinical depression or not. We suggest that TNF-α could be an underlying factor between restless legs symptoms and comorbidities.

A direct interaction between two Restless Legs Syndrome predisposing genes: MEIS1 and SKOR1

Restless Legs syndrome (RLS) is a common sleep disorder for which the genetic contribution remains poorly explained. In 2007, the first large scale genome wide association study (GWAS) identified three genomic regions associated with RLS. MEIS1, BTBD9 and MAP2K5/SKOR1 are the only known genes located within these loci and their association with RLS was subsequently confirmed in a number of follow up GWAS. Following this finding, our group reported the MEIS1 risk haplotype to be associated with its decreased expression at the mRNA and protein levels. Here we report the effect of the risk variants of the three other genes strongly associated with RLS. While these variants had no effect on the mRNA levels of the genes harboring them, we find that the homeobox transcription factor MEIS1 positively regulates the expression of the transcription co-repressor SKOR1. This regulation appears mediated through the binding of MEIS1 at two specific sites located in the SKOR1 promoter region and is modified by an RLS associated SNP in the promoter region of the gene. Our findings directly link MEIS1 and SKOR1, two significantly associated genes with RLS and also prioritize SKOR1 over MAP2K5 in the RLS associated intergenic region of MAP2K5/SKOR1 found by GWAS.

Symptom Persistence after Iron Normalization in Women with Restless Legs Syndrome

OBJECTIVE

The aim of this study was to determine the clinical course of restless legs syndrome (RLS) and potential risk factors for the persistence of RLS symptoms after iron normalization in women with RLS and low serum ferritin (<50 μg/L).

METHODS

We reviewed 39 women with RLS and iron deficiency, who achieved iron normalization after oral iron replacement for three months. Risk factors contributing to symptom persistence were estimated by logistic regression analyses. Remission was defined as no RLS symptoms for at least 6 months after the iron normalization.

RESULTS

Over the observation period of 2.5±1.4 years, 15 patients reported no RLS symptom whereas 24 patients still complained of RLS symptoms. The remission rate of RLS with iron replacement was 38.5%. The relative risk of symptom persistence was increased by the duration of RLS symptoms (OR: 1.88, 95% CI: 1.01-3.49) or by the age at RLS diagnosis (OR: 1.25, 95% CI: 1.01-1.56).

CONCLUSION

Almost two-third of RLS patients with iron deficiency showed persistence of the symptom even after iron normalization. Considering that longer duration of RLS symptoms and older age at RLS diagnosis were risk factors for symptom persistence, early intervention of iron deficiency in RLS is warranted.

Prevalence of restless legs symptoms according to depressive symptoms and depression type: a cross-sectional study

BACKGROUND

Restless legs syndrome is a sensorimotor disorder and it is associated with several other diseases especially mental illnesses.

AIMS

To analyze the relationship between the symptoms of restless legs syndrome and the severity of depressive symptoms and the prevalence of restless legs symptoms in depression subtypes.

METHODS

A cross-sectional study of primary care patients in the Central Finland Hospital District. The prevalence of restless legs symptoms was studied in 706 patients with increased depressive symptoms and 426 controls without a psychiatric diagnosis by using a structured questionnaire. The depressive symptoms were evaluated with the Beck Depression Inventory (BDI) and the psychiatric diagnosis was confirmed by means of a diagnostic interview (Mini-International Neuropsychiatric Interview). The subjects with increased depressive symptoms were divided into three groups (subjects with depressive symptoms without a depression diagnosis, melancholic depression and non-melancholic depression).

RESULTS

In the whole study population, the prevalence of restless legs symptoms increased with the severity of depressive symptoms. The prevalence of restless legs symptoms was highest in the melancholic and non-melancholic depressive patients (52 and 46%, respectively) and then in subjects with depressive symptoms without a depression diagnosis (43.4%), but the prevalence was also substantial (24.6%) in subjects without a psychiatric diagnosis.

CONCLUSIONS

Restless legs symptoms are very common in primary care among subjects with depression, regardless of the depression type. The prevalence of restless legs symptoms increased with increasing severity of depressive symptoms, regardless of the diagnosis. These findings should be considered in clinical evaluation and treatment of patients visiting their physician due to restless legs or depressive symptoms.

Effects of rotigotine on clinical symptoms, quality of life and sleep hygiene adequacy in haemodialysis-associated restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a neurological disorder characterised by bothersome symptoms associated with impaired quality of life and sleep hygiene. Rotigotine is a novel therapeutic alternative, although few studies have been published in patients on haemodialysis (HD) with RLS treated with rotigotine.

OBJECTIVES

1.- To establish the prevalence of RLS in our HD unit. 2.- To evaluate the efficacy and safety profile of rotigotine and its effect on symptoms, quality of life and sleep hygiene in our HD population with RLS.

MATERIAL AND METHODS

A single-centre, 12-week prospective study. Two stages (6 weeks): stage 1 (no treatment) and stage 2 (rotigotine). We analysed: 1.- Demographic data, biochemistry data, HD suitability parameters and RLS medical treatment data. 2.- Lower extremity symptoms questionnaire (QS). 3.- RLS severity symptoms scale (SRLSS). 4.- RLS Quality of life: John Hopkins RLS-QoL (JH-QoL). 5.- Sleep hygiene: SCOPA Scale.

RESULTS

We included 66 HD patients, 14 with RLS; 44.4% male, 70.2±9.9 years and 111.1±160.8 months on HD. And 22.9% RLS. Exclusively in stage 2, a significant improvement for QS (10±2.4 vs. 5.7±1.0), SRLSS (21±4 vs. 5.7±4.6), JH-QoL (22.1±4.4 vs. 4.3±4.0) and SCOPA (16±5.3 vs. 6.7±1.9) were observed. A 77.7 and 11.1%, showed partial (> 20%) and complete (> 80%) remission, respectively, while 55.5% achieved «zero» symptoms. Only one patient had gastrointestinal intolerance and none experienced augmentation effect. No changes in biochemical data, suitability for dialysis or medical treatment were found. The inter-group analysis showed a significant improvement in relation to QS, SRLSS, JH-QoL and SCOPA in stage 2.

CONCLUSIONS

RLS showed a considerable prevalence in our HD unit. Rotigotine improved clinical symptoms, quality of life and sleep hygiene in RLS patients on HD and was found to be a safe drug with minimal side effects and total therapeutic compliance. Nevertheless, future studies should be performed to confirm the benefits of rotigotine in RLS patients on haemodialysis.

Depressive Symptoms Are Associated With Objectively Measured Sleep Parameters in Kidney Transplant Recipients

STUDY OBJECTIVES

Both depression and sleep complaints are very prevalent among kidney transplant (kTx) recipients. However, details of the complex relationship between sleep and depression in this population are not well documented. Thus, we investigated the association between depressive symptoms and sleep macrostructure parameters among prevalent kTx recipients.

METHODS

Ninety-five kTx recipients participated in the study (54 males, mean ± standard devation age 51 ± 13 years, body mass index 26 ± 4 kg/m2, estimated glomerular filtration rate 53 ± 19 ml/min/1.73 m2). Symptoms of depression were assessed by the Center for Epidemiologic Studies - Depression Scale (CES-D). After 1-night polysomnography each recording was visually scored and sleep macrostructure was analyzed.

RESULTS

The CES-D score was significantly associated with the amount of stage 2 sleep (r = 0.20, P < .05), rapid eye movement (REM) latency (r = 0.21, P < .05) and REM percentage (r = -0.24, P < .05), but not with the amount of slow wave sleep (r = -0.12, P > .05). In multivariable linear regression models the CES-D score was independently associated with the amount of stage 2 sleep (β: 0.205; confidence interval: 0.001-0.409; P = .05) and REM latency (β: 0.234; confidence interval: 0.001-0.468; P = .05) after adjustment for potential confounders.

CONCLUSIONS

Depressive symptoms among kTx recipients are associated with increased amount of stage 2 sleep and prolonged REM latency. Further studies are needed to confirm our findings and understand potential clinical implications.

Prevalence of Restless Legs Syndrome in Patients with Inflammatory Bowel Disease

BACKGROUND AND AIM

There has been increased interest in sleep disorders in patients with inflammatory bowel disease (IBD). Studies in North America and Europe reported that the prevalence of restless legs syndrome (RLS) is much higher in patients with Crohn's disease (CD) than in the general population. The aim of this study was to reveal the prevalence and clinical features of RLS in Japanese patients with IBD and investigate the influence of RLS on sleep quality and quality of life (QOL).

METHODS

The study included 80 outpatients with IBD who visited Nagasaki University Hospital between December 2012 and July 2014. All patients completed the international RLS study group rating scale, a validated measure of the presence of RLS. Sleep quality was assessed using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI), and health-related QOL was assessed using the Japanese version of the 36-item short form healthy profile (SF-36) version 2.

RESULTS

The prevalence of RLS in patients with IBD was 20%, including rates of 21.7% in patients with ulcerative colitis (UC) and 17.6% in patients with CD. Among patients with CD, the proportion of women and serum level of CRP were higher in the RLS group than in the non-RLS group. Among those with UC, there were no differences in clinical characteristics between the RLS and non-RLS groups. Patients in the RLS group slept significantly less well than those in the non-RLS group (PSQI > 5; 62.5 vs. 34.4%, P < 0.05). No significant relationships were observed between QOL indices and the presence of RLS (SF-36 physical score, 46.8 vs. 50.1; mental score, 43.8 vs. 45.7; role/social score, 48.1 vs. 49.2).

CONCLUSIONS

RLS occurs frequently in Japanese patients with UC as well as CD. RLS affects sleep quality but not QOL, and it should be considered one of the causes of sleep disturbance in patients with IBD.

[Geriatric inpatients with iron deficiency-associated Restless Legs Syndrome. A retrospective analysis]

OBJECTIVE

The Restless Legs Syndrome (RLS) is a clinically relevant condition in geriatric patients. An association between iron deficiency and RLS is largely acknowledged. The clinical and therapeutic management of iron deficiency-associated RLS has been, however, poorly evaluated in geriatric patients.

METHODS

Data from all RLS inpatients admitted to a geriatric unit between 2009 and 2011 were retrospectively collected on demographics and clinical characteristics, iron status, drug treatment including iron substitution, as well as comprehensive geriatric assessment (CGA) scores.

RESULTS

RLS was diagnosed in 56 of the 4,063 admitted patients during the two years. Of the RLS cases, 20 (36%) showed iron deficiency. Thirteen of these were treated with iron substitution according to the existing guidelines. Both RLS patients with and without iron deficiency showed a significant clinical improvement between admission to discharge according to the CGA scores.

CONCLUSION

Iron substituted geriatric patients with iron deficiency-associated RLS substantially benefited from the treatment, similarly to RLS patients without iron deficiency. A multidimensional assessment, careful iron metabolism examination and adequate treatment choice should be equally importantly considered in geriatric patients with RLS.

Clinical management of restless legs syndrome in end-stage renal disease patients

Restless legs syndrome (RLS) is a common neurological movement disorder, characterized by restless and unpleasant sensations in the deep inside of legs. The symptoms of RLS are less noticeable during daytime, but more prevalent at night. Therefore, the disorder can induce low quality of life, insomnia, and impairment of daytime activity. RLS in end-stage renal disease (ESRD) patients is especially problematic due to premature discontinuation of dialysis and increased mortality. The prevalence of RLS among dialysis patients is much higher compared to the prevalence of the same disorder in patients with normal renal functions. Even though there are recommended treatment guidelines for the general population established by Medical Advisory Board of the RLS foundation, which include the use of dopamine agonists, levodopa, gabapentin, benzodiazepines, and opioids, limited information is available on the effects of these therapies in ESRD patients. Since the existing clinical data were extrapolated from small sample sizes in short-term clinical trials, further clinical studies are still needed to better assess the efficacy, safety, and tolerability of these medications in patients with ESRD.

Whole body and local cryotherapy in restless legs syndrome: A randomized, single-blind, controlled parallel group pilot study

OBJECTIVE

Treatment of restless legs syndrome (RLS) is primarily based on drugs. Since many patients report improvement of symptoms due to cooling their legs, we examined the efficacy of cryotherapy in RLS.

PATIENTS AND METHODS

35 patients (28 women, 60.9±12.5years) with idiopathic RLS and symptoms starting not later than 6pm were randomized into three groups: cold air chamber at -60°C (n=12); cold air chamber at -10°C (n=12); local cryotherapy at -17°C (n=11). After a two week baseline, the different therapies were applied three minutes daily at 6pm over two weeks, followed by a four week observation period. The patients completed several questionnaires regarding RLS symptoms, sleep, and quality of life on a weekly basis (IRLS, ESS), VAS and sleep/morning protocol were completed daily, MOSS/RLS-QLI were completed once in each period. Additionally, the PLM index was measured by a mobile device at the end of baseline, intervention, and follow-up. The IRLS score was chosen as primary efficacy parameter.

RESULTS

At the end of follow-up, significant improvement of RLS symptoms and quality of life could be observed only in the -60°C group as compared to baseline (IRLS: p=0.009; RLS-QLI: p=0.006; ESS: p=0.020). Local cryotherapy led to improvement in quality of life (VAS4: p=0.028; RLS-QLI: p=0.014) and sleep quality (MOSS: p=0.020; MOSS2: p=0.022) but not in IRLS and ESS. In the -10°C group, the only significant effect was shortening of number of wake phases per night. Serious side-effects were not reported.

CONCLUSIONS

Whole body cryotherapy at -60°C and, to a less extent, local cryotherapy seem to be a treatment option for RLS in addition to conventional pharmacological treatment. However, the exact mode of cryotherapy needs to be established.

Predictive factors of restless leg syndrome in hemodialysis patients

Introduction: The restless leg syndrome (RLS) is a neurologic disorder suffering the hemodialysis patients. Although the pathophysiology of this syndrome remains unknown yet, an investigation of the parameters pertinent to it may help to develop the related medical knowledge and to improve the therapeutic-care interventions in this regard.

Objectives: The correlation between the RLSs on individual, clinical, and laboratory indices in patients undergoing hemodialysis.

Patients and Methods: This descriptive-analytic study was conducted on 104 hemodialysis patients. Diagnosis of RLS was made using the International RLS Standard Questionnaire. The data on individual, clinical, and laboratory indices were obtained from patients’ recorded files and interviews.

Results: Based on our findings, 28.8% of the patients undergoing hemodialysis were affected with mild RLS, 41.7% with moderate RLS, and 29.5% with severe RLS. There was a statistically significant correlation between affliction with RLS on the one hand, and age and gender, on the other (P < 0.05). However, there was no significant correlation between RLS and education level, occupation, length of hemodialysis, fasting blood sugar (FBS), hepatitis B and C, serum blood urea nitrogen (BUN), creatinine (Cr), iron, hemoglobin (Hb) level and also KT/Vor URR (P < 0.05).

Conclusion: Regarding the high prevalence of RLS among the hemodialysis patients, there is the necessity for taking more care of these patients to reduce the somatic complications of the RLS especially among the elderly and female patients and to control the blood sugar of these patients at the normal level.

Association of incident restless legs syndrome with outcomes in a large cohort of US veterans

Restless legs syndrome is a common sleep disorder, but there is a paucity of large cohort studies examining the association of restless legs syndrome with clinical outcomes, including all-cause mortality, incident coronary heart disease, stroke and chronic kidney disease. From a nationally representative prospective cohort of over 3 million US veterans [93% male, median follow-up time of 8.1 years (interquartile range: 7.0-8.5 years)] with baseline estimated glomerular filtration rate ≥ 60 mL min(-1) 1.73 m(-2), a propensity-matched cohort of 7392 patients was created, and the association between incident restless legs syndrome and the following was examined: (1) all-cause mortality; (2) incident coronary heart disease; (3) incident strokes; and (4) incident chronic kidney disease defined as estimated glomerular filtration rate <60 mL min(-1) 1.73 m(-2). Associations were examined using Cox models. The mean ± SD age of the propensity-matched cohort at baseline was 59 ± 12 years; 89 and 8% of patients were white and black, respectively; 31% of the patients were diabetic; and the mean baseline estimated glomerular filtration rate was 83.9 ± 15.1 mL min(-1) 1.73 m(-2). Propensity matching resulted in a balanced cohort, with the disappearance in baseline differences in comorbidities. Compared with restless legs syndrome-negative patients, incident restless legs syndrome was associated with 88% higher mortality risk [hazard ratio and 95% confidence interval: 1.88 (1.70-2.08)], and almost four times higher risk of coronary heart disease and stroke [hazard ratio: 3.97 (3.26-4.84) and 3.89 (3.07-4.94), respectively]. The risk of incident chronic kidney disease was also significantly higher in incident restless legs syndrome patients [hazard ratio: 3.17 (2.74-3.66)] compared with restless legs syndrome-negative counterparts. In this large and contemporary cohort of US veterans, incident restless legs syndrome was associated with higher risk of mortality, incident coronary heart disease, stroke and chronic kidney disease.

A Collaborative Paradigm for Improving Management of Sleep Disorders in Primary Care: A Randomized Clinical Trial

OBJECTIVES

To test a collaborative care model for interfacing sleep specialists with primary care providers to enhance patients' sleep disorders management.

METHODS

This study used a randomized, parallel group, clinical intervention trial design. A total of 137 adult (29 women) VA outpatients with sleep complaints were enrolled and randomly assigned to (1) an intervention (INT) consisting of a one-time consultation with a sleep specialist who provided diagnostic feedback and treatment recommendations to the patient and the patient's primary care provider; or (2) a control condition consisting of their usual primary care (UPC). Provider-focused outcomes included rates of adherence to recommended diagnostic procedures and sleep-focused interventions. Patient-focused outcomes included measures taken from sleep diaries and actigraphy; Pittsburgh Sleep Quality Index (PSQI) scores; and self-report measures of sleepiness, fatigue, mood, quality of life, and satisfaction with health care.

RESULTS

The proportions of provider-initiated sleep-focused interventions were significantly higher in the INT group than in the UPC group for polysomnography referrals (49% versus 6%; P < 0.001) and mental health clinic referrals (19% versus 6%; P = 0.02). At the 10-mo follow up, INT recipients showed greater estimated mean reductions in diary total wake time (-17.0 min; 95% confidence interval [CI]: -30.9, -3.1; P = 0.02) and greater increases in sleep efficiency (+3.7%; 95% CI: 0.8, 6.5; P = 0.01) than did UPC participants. A greater proportion of the INT group showed ≥ 1 standard deviation decline on the PSQI from baseline to the 10-mo follow-up (41% versus 21%; P = 0.02). Moreover, 69% of the INT group had normal (≤ 10) Epworth Sleepiness Scale scores at the 10-mo follow-up, whereas only 50% of the UPC group fell below this clinical cutoff (P = 0.03).

CONCLUSIONS

A one-time sleep consultation significantly increased healthcare providers' attention to sleep problems and resulted in benefits to patients' sleep/wake symptoms.

CLINICAL TRIALS REGISTRATION

This study is registered with clinicaltrials.gov with identifier # NCT00390572.

Sleep apnea syndrome and restless legs syndrome in kidney transplant recipients

Background:

This study was aimed to evaluate the prevalence of obstructive sleep apnea (OSA) and restless legs syndrome (RLS) in patients with end-stage renal disease (ESRD) after kidney transplantation.

Materials and Methods:

Two hundred kidney transplant recipients were enrolled in this cross-sectional study. Data on age, gender, etiology of ESRD, history of previous kidney transplantation, serum creatinine, and the presence or absence of OSA and RLS were collected. Symptoms of RLS were identified using the RLS questionnaire which was completed by the patients. The Berlin questionnaire and polysomnography were used for diagnosing OSA.

Results:

The mean age of the studied patients was 45.86 ± 10.24 years. The prevalence of OSA was 26% (52 of 200 studied patients) and of RLS was 51.5% (103 of 200 studied patients). Majority of the patients with high-risk OSA were male and significantly older than the patients with low-risk OSA (P < 0.05). The prevalence of RLS was higher in patients with high-risk OSA and a higher level of creatinine compared to that in those with a low risk of OSA (P < 0.0001). Level of creatinine in patients with positive RLS was significantly higher than in those with negative RLS (P < 0.0001). OSA was observed in almost 42% of patients with positive RLS, compared to 9% of patients with negative RLS (P < 0.0001).

Conclusion:

In summary, our results indicate that the prevalence of OSA and RLS in kidney transplant recipients was higher than in the general population. Also, there was a significant association between OSA and RLS in these patients.

Restless-legs syndrome and insomnia in hemodialysis patients

AIM/BACKGROUND

Restless legs syndrome (RLS) is a common neurological movement disorder which is commonly seen in hemodialysis (HD) patients. Insomnia, depression, and anxiety disorders frequently show concurrence. In this study, we aimed to investigate RLS and insomnia prevalence and related factors in HD patients.

SUBJECTS AND METHODS

Patients who were under HD treatment and healthy controls with similar mean age, sex ratio, and hypertension and diabetes mellitus frequency were included in this study. Depression, insomnia, and daytime sleepiness assessments were performed by using Beck Depression Inventory, Insomnia Severity Index, and Epworth Sleepiness Scale. The diagnosis of RLS was made using the International RLS Study Group consensus criteria.

RESULTS

About 156 HD patients and 35 controls were enrolled. The mean age was 50.6 in the HD group and 49.7 in the control group. Female sex was 43.9% in the HD group and 57.1% in the control group. RLS was significantly more frequent in HD patients compared with controls. The rate of sub-threshold insomnia and insomnia with moderate severity was higher in HD patients. While insomnia severity score and diabetes mellitus were significantly associated with the presence of RLS, depression, RLS, older age, and being under HD treatment were independently associated with insomnia severity.

CONCLUSIONS

HD patients commonly have RLS and insomnia. Insomnia and diabetes mellitus seem to be major factors underlying RLS in HD patients. Furthermore, depression and RLS seem to be closely related to insomnia in these patients. Treatment of depression, insomnia, and RLS may be beneficial to improve quality of life in HD patients.

Restless legs syndrome in Egyptian medical students using a validated Arabic version of the Restless Legs Syndrome Rating Scale

OBJECTIVE

Restless legs syndrome (RLS) is a common movement disorder that has a variable prevalence and impact reported from different countries and specific populations. The current study validated an Arabic version of the International Restless Legs Syndrome Study Group (IRLSSG) rating scale (IRLS) and investigated the prevalence and impact of RLS in medical students at Ain Shams University in Cairo.

METHODS

Translation of IRLS was done according to standard recognized guidelines provided by the publisher. A total of 389 medical students (217 female and 172 male) participated in the study and answered four questions to detect RLS as proposed by the IRLSSG. Subjects who answered positively the first three questions were recruited for face-to-face interview to exclude RLS mimics and to answer the IRLS.

RESULTS

A total of 46 subjects (11.8%; 27 female and 19 male) met the four criteria for RLS. Of these, 39 subjects (10%) had idiopathic RLS. Five subjects (1.3%) and two subjects (0.5%) reported association with history of anemia and diabetes mellitus respectively. Their mean total IRLS score was 16.33 ± 5.3, with moderate severity (11.62 ± 3.9) and low impact (3.1 ± 1.8). The prevalence of individuals who had two or more episodes of RLS of at least moderate severity per week was 5.9%.

CONCLUSION

In this specific population of Egyptian medical students, a within-average prevalence of RLS was found with low impact on quality of life similar to worldwide reported populations. RLS sufferers were of high prevalence among this cohort. The Arabic version of IRLS is reliable and valid for further research in Arabic countries.

Sleep disorders in chronic obstructive pulmonary disease: etiology, impact, and management

ABSTRACT

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality and may frequently be complicated by sleep disorders. Insomnia and obstructive sleep apnea are commonly encountered in patients with COPD. Nocturnal hypoxemia is also prevalent in COPD may occur despite adequate awake oxygenation and can be especially severe in rapid eye movement sleep. Additionally, several factors--some of them unique to COPD--can contribute to sleep-related hypoventilation. Recognition of hypoventilation can be vital as supplemental oxygen therapy itself can acutely worsen hypoventilation and lead to disastrous consequences. Finally, accruing data establish an association between restless leg syndrome and COPD--an association that may be driven by hypoxemia and/or hypercapnia. Comorbid sleep disorders portend worse sleep quality, diminished quality of life, and multifarious other adverse consequences. The awareness and knowledge regarding sleep comorbidities in COPD has continued to evolve over past many years. There are still several lacunae, however, in our understanding of the etiologies, impact, and therapies of sleep disorders, specifically in patients with COPD. This review summarizes the latest concepts in prevalence, pathogenesis, diagnosis, and management of diverse sleep disorders in COPD.

Restless legs syndrome in end stage renal disease patients on haemodialysis

Objective: This study was cross sectional survey conducted to find the prevalence of Restless legs syndrome (RLS) in end stage renal disease (ESRD) patients on haemodialysis (HD).

Methods: Data were obtained from 250 patients on chronic maintenance HD. To assess the prevalence of RLS, Clinical diagnostic criteria for RLS was used which is established by the International RLS Study Group.

Results: Total 250 patients were included in this study. 153 (61.2%) patients were male and 97 (38.8%) were females. Mean age of the patients was 45.27 years. Mean duration of HD was 26.10 months. Total162 (64.8%) patients were found to be suffering from RLS. Out of 153 males, 87(56%) were suffering from RLS and among 97 females, 75(77.3%) were suffering from RLS. In our study, gender was statistically significantly associated with RLS (p-value 0.001). In age groups 159(63.6%) patients were below 51 years; among them 102(64.1%) were suffering from RLS; whereas 91(36.4%) patients were equal or above 51 years of age and among this group 60(65.9%) patients were suffering from RLS. There was no statistically significant association between RLS and age groups (p-value 0.776).

Conclusions: RLS is common in patients undergoing regular HD. It is more commonly seen in females.

Effect of Renal Transplantation in Restless Legs Syndrome

OBJECTIVES

Restless legs syndrome is a disorder in which patients have irresistible urge to move legs during rest. Restless legs syndrome seems to be common in end-stage renal disease. After a successful renal transplant, symptoms ameliorate with renal function improvement and restless legs syndrome is seen less in this population. Here, we aimed to investigate restless legs syndrome frequency and associated factors in renal transplant patients.

MATERIALS AND METHODS

In a cross-sectional study with 193 patients (116 hemodialysis patients, 45 transplant patients, and 32 controls), the presence of restless legs syndrome was assessed using the Restless Legs Syndrome Questionnaire. Medical history, demographic, and laboratory data were collected from the patients' medical records. Patients were questioned about the presence of restless legs syndrome using the Restless Legs Syndrome Questionnaire. Patients were evaluated with Beck Depression Scale for depression and Pittsburgh tests for sleep disturbances.

RESULTS

While the rate of restless legs syndrome was similar between transplants and controls, it was significantly greater in hemodialysis patients. Hemodialysis patients and controls had similar depression scores that were higher compared with transplant patients. Pittsburgh score was similar in transplant patients and controls and significantly increased in the hemodialysis patients. The rate of insomnia was significantly higher in the hemodialysis patients compared with the other 2 groups. Logistic regression analysis revealed independent correlates of restless legs syndrome as insomnia, Beck depression score, and being on hemodialysis. Linear regression analysis showed that independent correlates of higher Pittsburgh score were higher depression score, higher age, and presence of restless legs syndrome.

CONCLUSIONS

The prevalence of restless legs syndrome is significantly lower in transplant patients than it is in patients on maintenance dialysis. In renal transplant patients, restless legs syndrome frequency was found to be lower because of improved renal functions (normalization of uremia), psychological symptoms, and sleep disturbances.

Self-reported sleep bruxism and nocturnal gastroesophageal reflux disease in patients with obstructive sleep apnea: relationship to gender and ethnicity

Study Objectives :

Nocturnal bruxism is associated with gastroesophageal reflux disease (GERD), and GERD is strongly associated with obstructive sleep apnea (OSA). Gender and ethnic differences in the prevalence and clinical presentation of these often overlapping sleep disorders have not been well documented. Our aim was to examine the associations between, and the symptoms associated with, nocturnal GERD and sleep bruxism in patients with OSA, and to examine the influence of gender and ethnicity.

Methods :

A retrospective chart review was performed of patients diagnosed with OSA at an academic sleep center. The patients completed a sleep questionnaire prior to undergoing polysomnography. Patients with confirmed OSA were evaluated based on gender and ethnicity. Associations were determined between sleep bruxism and nocturnal GERD, and daytime sleepiness, insomnia, restless legs symptoms, and markers of OSA severity in each group.

Results :

In these patients with OSA, the prevalence of nocturnal GERD (35%) and sleep bruxism (26%) were higher than the general population. Sleep bruxism was more common in Caucasians than in African Americans or Hispanics; there was no gender difference. Nocturnal GERD was similar among all gender and ethnic groups. Bruxism was associated with nocturnal GERD in females, restless legs symptoms in all subjects and in males, sleepiness in African Americans, and insomnia in Hispanics. Nocturnal GERD was associated with sleepiness in males and African Americans, insomnia in females, and restless legs symptoms in females and in Caucasians.

Conclusion :

Patients with OSA commonly have comorbid sleep bruxism and nocturnal GERD, which may require separate treatment. Providers should be aware of differences in clinical presentation among different ethnic and gender groups.

A review of current treatment strategies for restless legs syndrome (Willis-Ekbom disease)

Restless legs syndrome (RLS), recently renamed Willis-Ekbom disease (WED), is a common movement disorder. It is characterised by the need to move mainly the legs due to uncomfortable, sometimes painful sensations in the legs, which have a diurnal variation and a release with movement. Management is complex. First, centres should establish the severity of RLS using a simple 10-item RLS severity rating scale (IRLS). They should also exclude secondary causes, in particular ensuring normal iron levels. Mild cases can be managed by lifestyle changes, but patients with a IRLS score above 15 usually require pharmacological treatment. Dopaminergic therapies remain the mainstay of medical therapies, with recent evidence suggesting opioids may be particularly effective. This article focuses on the different treatment strategies in RLS, their associated complications and ways to manage them.

Racial differences in the prevalence of restless legs syndrome in a primary care setting

STUDY OBJECTIVE

To assess the prevalence of restless legs syndrome (RLS) in a primary care clinic and in African American (AA) and non-African American (NAA) racial groups.

METHODS

We examined the prevalence of RLS using 1-on-1 interviews in general medicine clinics. Subjects were interviewed using John Hopkins Telephone Diagnostic Interview. All interviews were conducted by trained physicians.

RESULTS

A total of 190 patients were interviewed: 103 AA (58.3% were female) and 87 NAA (59.8% were female). The overall prevalence of definite RLS was 22.6%. The average age was 53 years (standard deviation, 15) in AA and 50 years (standard deviation, 13) in NAA. Among AA, the diagnosis of RLS was definite in 11.65%, probable in 3.88%, negative in 83.5%, and unknown in 0.97%. Among NAA, patients were either identified as definite RLS (35.63%) or not RLS (64.37%); no patients were diagnosed as probable RLS or unknown. Logistic regression analysis was done to determine whether age, race, and sex were statistically significant predictors of an RLS diagnosis. When accounting for the other variables, the association between NAA and RLS prevalence was statistically significant (P = 0.002).

CONCLUSION

Restless legs syndrome is common among primary care clinic patients. Its prevalence in the NAA population is approximately 3 times higher than in the AA group. We found the association between NAA race and RLS prevalence to be statistically significant. Larger studies are needed to further examine the relation between race and RLS prevalence.

Restless legs syndrome in an appalachian primary care population: prevalence, demographic and lifestyle correlates, and burden

BACKGROUND

Restless legs syndrome (RLS) is a common and distressing sensorimotor disorder of unknown etiology. While the epidemiology of RLS has been examined in several North American and European studies, research on RLS and RLS burden in poor, rural populations, including those residing in Appalachia, remains sparse. In this study, we investigated RLS prevalence in an Appalachian primary care population and examined the association of RLS to demographic factors, lifestyle characteristics, sleep quality, and mood disorders.

METHODS

Participants of this anonymous survey study were community-dwelling adults aged ≥ 18 years visiting one of 4 West Virginia primary care clinics. Data gathered included detailed information on sleep patterns, demographic characteristics, lifestyle factors, and health/medical history; the survey also included questions specific to RLS diagnosis and severity. Response rates were excellent, with 68% of eligible adults contacted returning completed surveys (N = 1,424/2,087). Pregnant women (N = 65) and those with missing data on key variables (N = 142) were excluded from the analyses.

RESULTS

Of the 1,217 participants included in the final analytic sample, 19.6% (18.2% with symptoms at least once/month) met the 4 IRLSSG diagnostic criteria in the absence of positional discomfort or leg cramps; 14.5% reported RLS symptoms at least once/week and 10.1% indicated symptoms ≥ 3×/week. Excluding respondents with diabetes, kidney disease, or anemia reduced these rates only slightly. Those with RLS were more likely to be older, female, lower income, unemployed, disabled, non-Hispanic white, and less likely to be college educated than those without RLS. Mood and sleep impairment were significantly elevated in those with RLS; after adjustment for demographic and lifestyle characteristics, health history, and other factors, those with RLS remained significantly more likely to indicate a history of depression (adjusted odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.4, 2.6) and anxiety (OR = 1.6, CI 1.1, 2.2), to report sleep impairment both 4 (OR = 2.4, CI 1.6, 3.7) and 7 days/week (OR = 1.8, CI 1.3, 2.4), and a mean sleep duration < 5 h/night (OR = 1.7, CI 1.2, 2.3). These associations increased in both strength and magnitude with increasing symptom frequency (p's for trend ≤ 0.01).

CONCLUSIONS

Findings of this preliminary anonymous survey study suggest that RLS prevalence is high in this Appalachian primary care population and that RLS is associated with significant burden in terms of both mood and sleep impairment.