Sleep-related adverse events of smoking cessation drugs: A network meta-analysis of randomized controlled trials

Smoking cessation medications have the potential to affect the functioning of the nervous system, leading to sleep disturbances. Our study aimed to compare the sleep-related side effects (such as insomnia, abnormal dreams, nightmares, and somnolence) induced by different smoking cessation medications in non-psychiatric smokers. We conducted a thorough search of five electronic databases (Cochrane, EMBASE, PubMed, PsycInfo, and Web of Science) for randomized controlled trials. This study was registered with the PROSPERO (registration number CRD42022347976). A total of 79 full-text articles, encompassing 36,731 participants, were included in our analysis. Individuals using bupropion, bupropion in combination with a nicotinic acetylcholine receptor agonist (NRA), and bupropion in conjunction with nicotine replacement therapy (NRT) exhibited a higher likelihood of experiencing insomnia compared to those using NRT alone. Bupropion plus NRA had the highest ranking on the surface under the cumulative ranking curve (SUCRA) for insomnia risk, while placebo had the lowest ranking. Additionally, NRA plus NRT ranked first for abnormal dream outcomes, NRA alone for nightmares, and nortriptyline for somnolence, based on the SUCRA results. Healthcare providers should exercise caution when prescribing smoking cessation drugs, particularly in consideration of their potential sleep-related side effects.

The Global Prevalence of Metabolic Syndrome in Connection with Sleep Duration: A Systematic Review and Meta-Analysis

The duration and quality of sleep are believed to significantly influence the onset of metabolic syndrome (MetS), but existing data lack consistency. The meta-analysis aims to evaluate the prevalence of the MetS in association with sleep duration. We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines. A comprehensive search of PubMed, Google Scholar, and Research Gate databases was performed to identify cohort and cross-sectional studies published in English between 2013 and 2023. We included studies that examined the association between sleep duration/quality and MetS, and two independent reviewers assessed study quality and bias using the Newcastle-Ottawa scale. The systematic review included 11 studies with a total of 343,669 participants, including 4 cohort studies and 7 cross-sectional studies. Sample sizes varied widely, ranging from 293 to 162,121 individuals. The studies had different follow-up periods, participant ages ranging from 10 to 80 years, and predominantly male populations. The prevalence of MetS was higher in average sleepers [52%, 95% confidence interval (CI): 40%-64%] compared with short sleepers (13%, 95% CI: 8%-18%) and long sleepers (15%, 95% CI: 9%-24%). Globally, North American countries exhibit the highest prevalence of MetS across short- (25.3%, 95% CI: 4.2%-72.4%) and long-sleeper (22.4%, 95% CI: 2.8%-74.1%) categories, whereas Asian countries experience the highest prevalence among the average sleeper category (58.7%, 95% CI: 44.1%-71.9%). Our meta-analysis indicates an elevated prevalence of MetS in average sleepers. Future research endeavors address delve into the underlying mechanisms and incorporate objective measures to understand the multifaceted connection between sleep patterns and MetS, guiding more effective preventive and management strategies.

Sleep disorders and mortality: A prospective study in the Canadian longitudinal study on aging

BACKGROUND AND OBJECTIVES

Sleep disorders are commonly linked to various health conditions, although it remains unclear to what degree they are linked with overall mortality. We compared mortality in different self-reported sleep disorders in a large population-based prospective study.

METHODS

In this case-control study within the CLSA cohort, participants completed a questionnaire at baseline (2011-2015) measuring overall sleep satisfaction, daily sleep duration, sleep-onset and sleep-maintenance insomnia, daytime somnolence, REM sleep behavior disorder (RBD), restless leg syndrome (RLS), and obstructive sleep apnea (OSA). The vital status of participants was assessed in July 2019. Baseline sleep problems of participants who died (cases) were compared to those who survived (controls). For each case, five age/sex-matched controls were selected. Binary logistic regression was used to estimate the association between sleep symptoms and mortality, adjusting for age, sex, marital status, province, education, alcohol consumption, smoking, caffeine, and body mass index. In a complementary model, anxiety and depression were also added.

RESULTS

Among 30,097 participants at baseline, 974 deaths were reported in 2019 (60.7 % male, age = 72.3 ± 9.4 years). In the initial analysis, mortality cases reported more baseline sleep-maintenance insomnia (12.1 % vs. 8.0 %, Adjusted OR[95%CI] = 1.62[1.15,2.29]), daytime somnolence (2.4 % vs. 1.1 %, AOR = 2.70[1.34,5.44]), and higher possible RLS (16.4 % vs. 12.4 %, AOR = 1.50[1.09,2.05]). They were also more likely to screen positive for possible OSA (33.8 % vs. 24.2 %, AOR = 1.32[1.07,1.64]); however, this effect was not related to core apnea symptoms. Sleep durations exceeding 10 h/day were also associated with increased mortality (3.4 % vs. 1.9 %, AOR = 1.83[1.04,3.24]). Other sleep symptoms/disorders, such as sleep-onset insomnia (7.3 % vs. 4.3 %, AOR = 1.54 [1.00,2.37]), possible RBD (5.3 % vs. 5.1 %, AOR = 1.02[0.62,1.69]), and overall sleep dissatisfaction (26.5 % vs. 22.6 %, AOR = 1.14[0.93,1.41]) were not different among these groups. After adding anxiety and depression to the adjustment model, all differences attenuated to become statistically non-significant, except for daytime somnolence disorder. When stratified by sex, the association between sleep disorders and mortality was only observed in women, with men showing no association.

DISCUSSION

We confirm a relationship between numerous sleep disorders and mortality. This effect is most evident in women, and appears to be strongly related to co-existing anxiety and depression.

Predictors for delayed awakening in adult glioma patients receiving awake craniotomy under monitored anesthesia care

PURPOSE

Delayed awakening after anesthetic discontinuation during awake craniotomy is associated with somnolence during functional brain mapping. However, predictors of delayed awakening in patients receiving monitored anesthesia care for awake craniotomy are unknown.

METHODS

This retrospective cohort study analyzed 117 adult patients with supratentorial glioma in or near eloquent areas who received monitored anesthesia care for awake craniotomy between July 2020 and January 2023 at Linkou Chang Gung Memorial Hospital. These patients were divided into two groups according to their time to awakening (ability to speak their names) after propofol cessation: longer or shorter than 20 min (median duration). Because propofol was solely used anesthetic from skin incision to dural opening, parameters in Schnider model for propofol target-controlled infusion, such as age, sex, and BMI, were adjusted or propensity-matched to compare their anesthetic, surgical, and histopathological profiles.

RESULTS

After propensity-matched comparisons of age and BMI, significant predictors of delayed awakening included IDH1 wild-type tumors and repeated craniotomies. Subgroup analysis revealed that older age and larger T2 volume were predictors in patients undergoing the first craniotomy, while lower preoperative Karnofsky performance scale scores and depression were predictors in repeated craniotomy cases. Delayed awakening was also associated with somnolence and a lower gross total resection rate.

CONCLUSION

Our retrospective analysis of patients receiving monitored anesthesia care for awake craniotomy revealed that delayed awakening after propofol discontinuation occurred more often in patients with IDH1 wild-type tumors and repeated craniotomies. Also, delayed awakening was associated with somnolence during functional mapping and a lower gross total resection rate.

Hyperactivity in patients with narcolepsy and idiopathic hypersomnia: an exploratory study

Introduction

Patients with either Idiopathic Hypersomnia or Narcolepsy demonstrate excessive daytime somnolence (EDS) with resultant inattention mimicking Attention Deficit Hyperactivity Disorder (ADHD). Patients with ADHD also often express sleep problems including EDS. Thus, patients with ADHD and patients with idiopathic hypersomnia or narcolepsy may share inattention and daytime drowsiness as common features. However, it is not known whether EDS patients with idiopathic hypersomnia or narcolepsy also have increased movement (hyperactivity) like ADHD patients, the determination of which is the purpose of this study.

Methods

We studied 12 patients (7 Narcolepsy type 2 and 5 Idiopathic Hypersomnia) with EDS as shown by Multiple Sleep Latency Test which served as the gold standard for entry into the study. Twelve subjects without symptoms of EDS served as the control group. None of the participants had a previous history of ADHD. Each participant underwent a one-hour session laying at 45 degrees with surveys about the need to move and actigraphy as an objective measure of movement.

Results

Sleep-disordered patients with EDS reported more symptoms of inattention and hyperactivity on the ADHD Self-Report Scale. At each of the time points patients with EDS had a clear trend to express the need to move more than controls on the Suggested Immobilization Test (SIT). For the total 60 minutes, a large effect size for the need to move during the SIT test was found between patients and controls (Cohen's d = 0.61, p=0.01). Patients with EDS did not express a need to move more to combat drowsiness than controls, nor did actigraphy show any difference in objective movement between patients and controls during the SIT.

Conclusion

Patients with EDS express inattention and a need to move more than controls. However, hyperactivity was not verified by objective measurement, nor did the EDS patients express a need to move to combat drowsiness more than controls. Thus, a hypothesis to be further tested, is whether narcolepsy and idiopathic hypersomnia may be more a model of the inattentive form of ADHD rather than the combined or inattentive/hyperactive form of ADHD. Further studies are needed to explore the relationship between EDS and hyperactivity.

Factors associated with increased risk of lurasidone-induced somnolence: Two case-control studies based on one bioequivalence trial in healthy volunteers

Somnolence is a common adverse effect of antipsychotic drugs used to treat psychotic disorders. It causes problems in many areas of life, such as gainful employment, driving, childcare, and social interactions. Somnolence is a major problem for a relatively new antipsychotic drug, lurasidone, whose dose-effect relationship remains unclear. Based on data from a bioequivalence study of two 40 mg lurasidone hydrochloride tablets, we designed two case-control studies to explore the correlation between somnolence and exposure to lurasidone and determine the factors associated with lurasidone-induced somnolence. In the first case-control study, lurasidone was administered to healthy volunteers; 30 experienced somnolence (as pre-defined) but 29 did not. Moreover, plasma concentration at 1 h was significantly associated with somnolence (OR = 1.124; p = 0.001). In the second case-control study, 48 volunteers administered lurasidone were classified into somnolence and no-somnolence groups based on different time-related criteria. We observed a positive association between plasma concentration at 0.75 h and somnolence (OR = 1.024; p = 0.002). Receiver operating characteristic analysis revealed that a plasma lurasidone concentration >21.65 ng/mL 1 h after administration strongly predicted somnolence. Our findings in healthy volunteers need to be further validated in patients in clinical settings to determine the optimal dose and duration of lurasidone administration.

[Central anticholinergic, neuroleptic malignant and serotonin syndromes]

Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day-1) is the recommended treatment.

French Sleepiness Scale for Adolescents-8 items: A discriminant and diagnostic validation

The objective of the present study was to validate the Short Version of French Sleepiness Scale for Adolescents (FSSA) with eight items (FSSA8).

METHODS

A total of 384 adolescents, aged between 12 and 18 years, completed the FSSA8. These included 269 nonclinical adolescents and 115 adolescents admitted for overnight polysomnography and Multiple Sleep Latency Test (MSLT) because of suspected hypersomnia (85 patients with narcolepsy and 30 with other sleep disorders). Item response theory (IRT) assumptions were tested and psychometric properties were analysed. Matching on sex ratio and age was conducted to estimate concurrent criterion, diagnostic validity and cut-offs.

RESULTS

IRT assumptions were validated confirming the one-dimensionality of the FSSA8. The latent continuum sleepiness for which the scale and its items are reliable encompassed most of the clinical subjects. FSSA8 is weakly correlated with MSLT. Distribution of scores for the nonclinical group and the clinical group differed significantly; the FSSA8 had very good screening validity in sleep disorders. The cut-off was seven points.

CONCLUSION

The FSSA8 appeared to be more reliable for patients than for nonclinical participants and to be a good tool for screening excessive daytime sleepiness in sleep disorders.

Sleep-wake cycle and daytime sleepiness in patients with epilepsy after initiating perampanel as adjunctive therapy

BACKGROUND

Antiseizure medications (ASMs) may affect nocturnal sleep and daytime vigilance. Perampanel (PER), a third-generation ASM, showed to improve nocturnal sleep in patients with epilepsy (PWE). Although ASMs can have beneficial effects on nocturnal sleep and daytime sleepiness, no study investigated the effect of PER on both sleep-wake cycle and daytime sleepiness. Therefore, this study aimed to objectively evaluate the sleep-wake cycle and daytime sleepiness in PWE treated with PER as adjunctive therapy.

METHODS

This prospective study included adult PWE who received PER as add-on treatment. Sleep-wake cycle was assessed through actigraphic monitoring and daytime sleepiness by the multiple sleep latency test (MSLT) performed at the end of the actigraphic recording. All patients performed both tests at baseline and at 6-month follow-up.

RESULTS

Ten patients (mean age: 44.50 ± 22.71 years, 50.0% female) were included. The mean monthly seizure frequency was 3.20 ± 5.94. Six of ten patients started PER as a first add-on treatment. The final PER dose was 5.11 ± 2.02 mg/day, and nine of ten patients achieved seizure freedom at follow-up. There was a significant decrease in mean monthly seizure frequency from baseline to follow-up (p = 0.004). No significant changes were found in the sleep-wake cycle parameters. An increase in sleep latency mean was observed at MSLT at 6-month follow-up (p = 0.005).

CONCLUSIONS

This study confirms that adjunctive PER is effective on seizures without pathologically change of the sleep-wake cycle in PWE and can even improve daytime sleepiness. This effect can be mediated by the achievement of seizure control. Therefore, PER may be promising in PWE with sleep disturbances and daytime sleepiness.

[Sleepiness among adolescents: etiology and multiple consequences]

Over the past century a dramatic decline in sleep duration among adolescents, such as more than one hour of sleep loss per night, has been reported. A debt in sleep duration could lead to sleep deprivation, a major risk factor associated with daytime sleepiness. Sleepiness refers to the inability to maintain an adequate level of alertness during the day which may result in more or less being able to control falling asleep at inappropriate times. This literature review updates on sleepiness regarding its characteristics, etiology and consequences on adolescents. Studies revealed that from 25 % to 78 % of adolescents had reported sleepiness. Its manifestations may include heavy lids, yawns, difficulties to concentrate and emotional irritability. In addition, while it is recommended that adolescents under 18 years-old should sleep from eight to ten hours a night, only 63 % of them actually do so. The etiology of sleep deprivation and sleepiness in this population can be explained by various biological and societal factors. First, the sleep-wake cycle of adolescents shows a biological shift from the beginning of pubertal maturation, described as a perfect storm. It refers to a social jetlag by going to sleep and waking up later and accumulating a sleep debt during weekdays which they try to reimburse during weekends. This phenomenon can be explained by physiological changes such as a slower accumulation of sleep pressure. In addition to this perfect storm, environmental and societal factors contribute to the social jetlag and reduce sleep duration in adolescents. Screen exposure before bedtime can delay sleep and wake onset, which is a risk factor for sleeping debt. Substance use such as caffeine, cigarettes or electronic vaporizer, ADHD or freely available medication, alcohol, cannabis use or drug consumption could further disrupt sleep-wake cycle by stimulating, depressing or otherwise disrupting the central nervous system. Early, before 8:30 am, class start times have been associated with chronic sleep deprivation, higher level of sleepiness and delayed melatonin peak secretion. Adolescents working or doing extracurricular occupations for more than 20hours a week are more at risk for reduced sleep duration and sleepiness. Parental supervision about sleep during the weekdays were associated with more appropriate bedtime. Adolescents from low socio-demographic characteristics and from minority ethnic groups have reported displaying a shorter sleep duration. Finally, sleep disorders of a physiological origin such as narcolepsy, sleep apnea or restless legs syndrome, may explain the sleep deprivation and sleepiness. Sleep deprivation and sleepiness in adolescents have consequences on their health. Cognitive functioning, such as problem solving, attention or memory, as well as school performance, can be compromised by sleep deprivation and sleepiness. At the psychological level, adolescents reporting sleepiness are more prone to display mental health problems: associations were found between sleepiness and subjective perception of depression, anxiety, somatic complaints as well as with antisocial behaviors. Finally, 68 % of 16 year-old adolescents reported they drove a car, and the reported sleepiness could lead to road accidents due to reduced attentional functioning, reaction time and decision-making abilities. In the United-States, from 7 % to 16.5 % of deadly accidents were related to driving while drowsy. Highlighting etiology and problems associated with sleep deprivation and sleepiness in adolescents could guide researchers and clinicians towards the development of possible interventions. Public health measures and knowledge transfer programs regarding modifiable psychosocial and societal factors associated with sleep-wake bioregulation could increase awareness in parents as well as in political and societal decision makers.

[Central anticholinergic, neuroleptic malignant and serotonin syndromes : Important differential diagnoses in postoperative impairment of consciousness]

Impaired consciousness is a frequent phenomenon after general anesthesia. In addition to the classical causes (e.g., overhang of sedatives), an impairment of consciousness can also be an adverse side effect of drugs. Many drugs used in anesthesia can trigger these symptoms. Alkaloids, such as atropine can trigger a central anticholinergic syndrome, opioids can promote the occurrence of serotonin syndrome and the administration of a neuroleptic can lead to neuroleptic malignant syndrome. These three syndromes are difficult to diagnose due to the individually very heterogeneous symptoms. Mutual symptoms, such as impaired consciousness, tachycardia, hypertension and fever further complicate the differentiation between the syndromes; however, more individual symptoms, such as sweating, muscle tension or bowl sounds can be helpful in distinguishing these syndromes. The time from the trigger event can also help to differentiate the syndromes. The central anticholinergic syndrome is the fastest to appear, usually taking just a few of hours from trigger to clinical signs, serotonin syndrome takes several hours up to 1 day to show and neuroleptic malignant syndrome usually takes days. The clinical symptoms can range from mild to life-threatening. Generally, mild cases are treated with discontinuation of the trigger and extended observation. More severe cases can require specific antidotes. The specific treatment recommended for central anticholinergic syndrome is physostigmine with an initial dose of 2 mg (0.04 mg/kg body weight, BW) administered over 5 min. For serotonin syndrome an initial dose of 12 mg cyproheptadine followed by 2 mg every 2 h is recommended (maximum 32 mg/day or 0.5 mg/kgBW day^-1) but this medication is only available in Germany as an oral formulation. For neuroleptic malignant syndrome 25-120 mg dantrolene (1-2.5 mg/kgBW maximum 10 mg/kgBW day^-1) is the recommended treatment.

A novel case of prolonged Ifosfamide encephalopathy and long-term treatment with methylene blue: a case report and review of literature

Background

Encephalopathy following Ifosfamide treatment is a well-described phenomenon that is typically treated with Methylene Blue (MB). Chloroacetaldehyde, a potentially neurotoxic metabolite of Ifosfamide is hypothesized to cause this encephalopathy. Current guidelines for treatment is to stop Ifosfamide and provide supportive care. MB acts to inhibit Chloroacetaldehyde formation and has been described as a therapy and prophylaxis for Ifosfamide-encephalopathy. MB is effective within 30 min and lasts up to 3 days. Prolonged encephalopathy and MB therapy has not been described in the literature as lasting longer than 30 days following treatment.

Case presentation

We present the case of an 11-year-old female with autistic spectrum disorder and recurrent episodes of severe somnolence for 7 months following Ifosfamide therapy for her Non-Germinomatous Germ Cell Tumor (GCT). Periods of somnolence occurred prior to receiving cranial RT. Administration of MB gave immediate but limited response, with resolution of somnolence lasting 1-2 days between administrations. The somnolence could not be explained by neuroimaging or laboratory evaluation, but EEG indicated persistent encephalopathy.

Conclusion

A literature review determines that neurotoxicity is a side effect of Ifosfamide, but this effect has not been described persisting longer than 30 days. Our case continued to require treatment with MB for 7 months following cessation of therapy. We report these novel clinical findings, and hypothesize that there could be a genetic/metabolic component linking this reaction to Ifosfamide with the case patient’s pre-existing autism. This possible association may also correlate to the already-established link between autism and the development of GCTs. This hypothesis leads to further discussion on the suitable usage of Ifosfamide in children with co-morbidities and the necessity of screening prior to its usage.

Safinamide improves sleep and daytime sleepiness in Parkinson's disease: results from the SAFINONMOTOR study

Background and objective

Some studies observed a benefit of PD patients after treatment with safinamide in some non-motor symptoms. Our aim was to analyze the effectiveness of safinamide on sleep and daytime sleepiness in Parkinson’s disease (PD) patients.

Material and methods

SAFINONMOTOR is a prospective open-label single-arm study conducted in 5 centers from Spain. In this analysis, a secondary objective of the study, the score in the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS) at V1 (baseline) and V4 (6 months ± 1 month) were compared.

Results

Fifty patients were included between May/2019 and February/2020 (age 68.5 ± 9.12 years; 58% women; 6.4 ± 5.1 years from diagnosis). At 6 months, 44 patients completed the follow-up (88%). The PSQI total score was reduced by 19.8% (from 10.43 ± 4.02 at V1 to 8.36 ± 4.41 at V4; p = 0.001). By domains, improvement was observed in subjective sleep quality (PSQI-C1; − 23.9%; p = 0.009), sleep latency (PSQI-C2; − 25%; p = 0.025), sleep duration (PSQI-C3; − 40%; p = 0.001), and habitual sleep efficiency (PSQI-C4; − 25.9%; p = 0.023). A significant reduction (− 24.7%) in the ESS total score from V1 to V4 was observed as well (from 9.20 ± 5.64 to 6.93 ± 5.11; p = 0.012). Specifically, the improvement in daytime sleepiness was observed in sitting and reading (p = 0.024) and sitting inactive in a public space (p = 0.027). A total of 21 adverse events in 11 patients (22%) were reported, 5 of which were severe (not related to safinamide).

Conclusion

Safinamide was well-tolerated and improved sleep and daytime sleepiness in PD patients at 6 months.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10072-021-05607-2.

Factors associated with somnolence during brain function mapping in awake craniotomy

Somnolence during brain function mapping is one of the factors that inhibit the accomplishment of the goals of awake craniotomy. We examined the effect of anesthesia depth measured by bispectral index (BIS) during pre-awake phase on somnolence during brain function mapping and also explored the factors associated with somnolence. We examined the association between BIS values during pre-awake phase and somnolence during the first 30 min of brain function mapping in 55 patients who underwent awake craniotomy at Kyoto University Hospital from 2015 to 2018. The pre-awake BIS value was defined as the mean BIS value for 60 min before the removal of the airway. Somnolence during brain function mapping was the primary outcome, defined as either of the following conditions: inability to follow up, disorientation, or inability to assess speech function. Additionally, we compared patient or perioperative variables between patients with/without somnolence. Somnolence occurred in 14 patients (25.5%), of which 6 patients (10.9%) were unable to complete brain function mapping. There was no significant difference in the pre-awake BIS value between patients with/without somnolence (median: 46 vs. 49, P = 0.192). Somnolence was not significantly associated with age, gender, and the number of preoperative anticonvulsive drugs, but patients with somnolence had a significantly lower preoperative Western Aphasia Battery (WAB) aphasia quotient score (median 93.8 vs. 98.6, P = 0.011). We did not find an association between pre-awake BIS value and somnolence during brain function mapping. Somnolence likely occurs in patients with a low preoperative WAB aphasia quotient score.

[Overlooked compartment syndrome of the hand after burn injury and known polytoxicomania]

A young man suffered the fatal combination of burn injuries and acute kidney failure caused by substantial rhabdomyolysis after lying on the floor in a somnolent condition for 12 h. This symptom constellation should always make physicians aware of a potential compartment syndrome.

The development and validation of a revised version of the Medical Outcomes Study Sleep Scale (MOS Sleep-R)

Background

The 12-item Medical Outcomes Study Sleep Scale (MOS Sleep Scale) has been used to capture patient-reported sleep problems in hundreds of studies. A revised version of the MOS Sleep Scale (MOS Sleep-R) was developed that uses simplified response sets, provides interpretable norm-based scoring, and has two recall versions (one-week or four-week). The objective of this study was to evaluate the psychometric properties (reliability and construct validity) of the MOS Sleep-R using data from a representative sample of U.S. adults.

Methods

Standardization of raw scores into norm-based T-scores (mean = 50, standard deviation = 10) was based on data from a 2009 U.S. internet-based general population survey. The internal consistency reliability of multi-item subscales and global sleep problems indices for both one-week and four-week recall forms of the MOS Sleep-R were examined using Cronbach’s alphas and inter-item correlations. Construct validity was tested by comparing item-scale correlations between items within subscales with item-scale correlations across subscales. Scale-level convergent validity was tested using correlations with measures including generic health-related quality of life (i.e., SF-36v2) and other relevant outcomes (e.g., job performance, number of days in bed due to illness or injury, happiness/satisfaction with life, frequency of stress/pressure in daily life, the impact of stress/pressure on health, and overall health).

Results

The one-week and four-week recall forms of the MOS Sleep-R were completed by 2045 and 2033 respondents, respectively. The psychometric properties of the one-week and four-week forms were similar. All multi-item subscales and global index scores showed adequate internal consistency reliability (all Cronbach’s alpha > 0.75). Patterns of inter-item and item-scale correlations support the scaling assumptions of the MOS Sleep-R. Patterns of correlations between MOS Sleep-R scores with criterion measures of health-related quality of life and other outcomes indicated adequate construct validity.

Conclusions

The MOS Sleep-R introduces a number of revisions to the original survey, including simplified response sets, the introduction of a one-week recall form, and norm-based scoring that enhances interpretability of scores. Both the one-week and four-week recall period forms of the MOS Sleep-R demonstrated good internal consistency reliability and construct validity in a U.S. general population sample.

Sleep and physical activity in university students: A systematic review and meta-analysis

University students have low levels of physical activity and report disturbances to sleep, which are independently associated with poor health outcomes. Some research suggests that there is a bi-directional relationship between sleep and physical activity in adults. However, the relationship between sleep and physical activity in university students has not yet been evaluated. Therefore, the aim of this systematic review and meta-analysis was to qualitatively synthesise and quantitatively evaluate the evidence for the association between sleep and physical activity in university students. Twenty-nine eligible studies were included, with a total of 141,035 participants (43% men and 57% women). Only four studies used device-based measures of sleep and/or physical activity, with the remainder including self-report measures. Qualitative synthesis found that the majority of studies did not find any association between sleep and physical activity in university students. However, random-effects meta-analysis showed that moderate-to-high intensity physical activity was associated with lower PSQI scores (e.g., better sleep quality) [r = -0.18, 95% CI (-0.37, 0.03), p = 0.100]. Further, a weak negative association between moderate-to-vigorous physical activity level and sleep duration was also found [r = -0.02, 95% CI (-0.16, 0.12), p = 0.760]. As the findings of this review are predominantly derived from cross-sectional investigations, with limited use of device-based measurement tools, further research is needed to investigate the relationship between sleep and physical activity in university students. Future studies should employ longitudinal designs, with self-report and device-based measures, and consider the intensity and time of physical activity as well as records of napping behaviour.

Immune status, well-being and gut microbiota in military supplemented with synbiotic ice cream and submitted to field training: a randomised clinical trial

Strenuous physical activity, sleep deprivation and psychological stress are common features of military field training. The present study aimed to evaluate the effects of supplementation with a synbiotic ice cream on salivary IgA, gastrointestinal symptoms, well-being indicators and gut microbiota in young military participants undergoing field training. Sixty-five military completed the study: one group was supplemented for 30 d with synbiotic ice cream containing: 2·1 × 108 CFU/g for Lactobacillus acidophilus LA-5 and 2·7 × 109 CFU/g for Bifidobacterium animalis BB-12 and 2·3 g of inulin in the 60 g of ice cream at manufacture, and the other with a placebo ice cream. Volunteers were evaluated at pre-supplementation (baseline), post-supplementation and after a 5-d military training. Bifidobacterium and Lactobacillus genera were measured in stool samples and both showed a higher differential abundance post-supplementation and training. Salivary IgA and gastrointestinal symptoms decreased at post-training in both groups (P < 0·05; main effect of time); however, supplementation with synbiotic did not mitigate this effect. Tenseness and sleepiness were decreased in the synbiotic-treated group, but not in the placebo group at post-military training (P = 0·01 and 0·009, respectively; group × time effect). The other well-being indicators were not affected by the synbiotic supplementation. In conclusion, 30 d of synbiotic ice cream supplementation containing inulin, L. acidophilus LA-5 and B. animalis BB-12 favourably modulated gut microbiota and improved tenseness and sleepiness in healthy young military undergoing a 5-d field training. These improvements may be relevant to this population as they may influence the decision-making process in an environment of high physical and psychological stress.

The effectiveness of oropharyngeal exercises compared to inspiratory muscle training in obstructive sleep apnea: A randomized controlled trial

BACKGROUND

Inspiratory muscle training (IMT) and oropharyngeal exercises (OE) have different advantages and disadvantages and a comparison of these modalities has been recommended. The aim of this study was to compare the effects of IMT and OE on important outcomes for patients with OSAS.

METHODS

This was a randomized controlled clinical trial. Forty-one clinically stable OSAS patients not receiving CPAP therapy were randomly divided into three groups. Patients in the IMT group (n = 15) trained with a threshold loading device 7 days/week for 12 weeks. Patients in the OE group (n = 14) practiced exercises 5 days/week for 12 weeks. Twelve patients served as control group. Apnea-hypopnea index (AHI), respiratory muscle strength, snoring severity and frequency (Berlin Questionnaire), daytime sleepiness (Epworth Sleepiness Scale; ESS), sleep quality (Pittsburg Sleep Quality Index; PSQI), impact of sleepiness on daily life (Functional Outcomes of Sleep Questionnaire; FOSQ), and fatigue severity (Fatigue Severity Scale; FSS) were evaluated before and after the interventions.

RESULTS

AHI and sleep efficiency did not change significantly in any of the groups. Significant decreases in snoring severity and frequency, FSS and PSQI total scores were found in the IMT and OE groups after the treatments (p < 0.05). There was a significant reduction in neck and waist circumference and significant improvement in respiratory muscle strength (MIP and MEP) in IMT group compared to control group (p < 0.05). The%MEPpred value and FOSQ total score significantly increased and ESS score reduced after the treatment in OE group compared to control group (p < 0.05).

CONCLUSIONS

Our results indicate that both OE and IMT rehabilitation interventions are applicable in rehabilitation programs for OSAS patients who do not accept CPAP therapy. Our findings could lead to increase these methods' use among rehabilitation professionals and decrease in cost of CPAP treatment in OSAS.

Frequency and characteristics of drowsiness, somnolence, or daytime sleepiness in patients with advanced cancer

INTRODUCTION

Cancer-related drowsiness (CRD) is a distressing symptom in advanced cancer patients (ACP). The aim of this study was to determine the frequency and factors associated with severity of CRD. We also evaluated the screening performance of Edmonton Symptom Assessment Scale-drowsiness (ESAS-D) item against the Epworth Sedation Scale (ESS).

METHOD

We prospectively assessed 180 consecutive ACP at a tertiary cancer hospital. Patients were surveyed using ESAS, ESS, Pittsburgh Sleep Quality Index, Insomnia Severity Index, and Hospital Anxiety Depression Scale.

RESULT

Ninety of 150 evaluable patients had clinically significant CRD (ESS); median (interquartile ratio): ESS. 11 (7-14); ESAS-D. 5 (2-6); Pittsburgh Sleep Quality Index. 8 (5-11); Insomnia Severity Index. 13 (5-19); Stop Bang Scoring 3 (2-4), and Hospital Anxiety Depression Scale-D 6 (3-10). ESAS-D was associated with ESAS (r, p) sleep (0.38, <0.0001); pain (0.3, <0.0001); fatigue (0.51, <0.0001); depression (0.39, <0.0001); anxiety (0.44, <0.0001); shortness of breath (0.32, <0.0001); anorexia (0.36, <0.0001), feeling of well-being [(0.41, <0.0001), ESS (0.24, 0.001), and opioid daily dose (0.19, 0.01). Multivariate-analysis showed ESAS-D was associated with fatigue (odds ratio [OR] = 9.08, p < 0.0001), anxiety (3.0, p = 0.009); feeling of well-being (OR = 2.27, p = 0.04), and insomnia (OR = 2.35; p = 0.036). Insomnia (OR = 2.35; p = 0.036) cutoff score ≥3 (of 10) resulted in a sensitivity of 81% and 32% and specificity of 70% and 44% in the training and validation samples, respectively.

SIGNIFICANCE OF RESULTS

Clinically significant CRD is frequent and seen in 50% of ACP. CRD was associated with severity of insomnia, fatigue, anxiety, and worse feeling of well-being. An ESAS-D score of ≥3 is likely to identify most of the ACP with significant CRD.

Association of sleep among 30 antidepressants: a population-wide adverse drug reaction study, 2004-2019

Background

Sleep is one of the most essential processes required to maintain a healthy human life, and patients experiencing psychiatric illness often experience an inability to sleep. The aim of this study is to test the hypothesis that antidepressant compounds with strong binding affinities for the serotonin 5-HT2C receptor, histamine H1 receptors, or norepinephrine transporter (NET) will be associated with the highest odds of somnolence.

Methods

Post-marketing cases of patient adverse drug reactions were obtained from the United States Food and Drug Administration Adverse Events Reporting System (FAERS) during the reporting window of January 2004 to September 2019. Disproportionality analyses of antidepressants reporting somnolence were calculated using the case/non-case method. The reporting odds-ratios (ROR) and corresponding 95% confidence interval (95% CI) were computed and all computations and graphing conducted in R.

Results

There were a total of 69,196 reported cases of somnolence out of a total of 7,366,864 cases reported from January 2004 to September 2019. Among the 30 antidepressants assessed, amoxapine (n = 16) reporting odds-ratio (ROR) = 7.1 (95% confidence interval [CI] [4.3–11.7]), atomoxetine (n = 1,079) ROR = 6.6 (95% CI [6.2–7.1]), a compound generally approved for attention deficit hyperactivity disorder (ADHD), and maprotiline (n = 18) ROR = 6.3 (95% CI, 3.9–10.1) were the top three compounds ranked with the highest reporting odds of somnolence. In contrast, vortioxetine (n = 52) ROR = 1.3 (95% CI [1.0–1.8]), milnacipran (n = 58) ROR = 2.1 (95% CI [1.7–2.8]), and bupropion (n = 1,048) ROR = 2.2 (95% CI [2.1–2.4]) are least significantly associated with somnolence. Moreover, levomilnacipran (n = 1) ROR = 0.4 (95% CI [0.1–2.9]) was not associated with somnolence.

Conclusion

Among the thirty tested antidepressants, consistent with the original hypothesis, amoxepine has strongest 5-HT2C receptor binding affinity and has the highest reporting odds of somnolence. Atomoxetine, ranked second in reporting odds of somnolence overall, binds to the NET with with the strongest binding affinity among the thirty compounds. Mirtazapine, a tetracyclic antidepressant, was ranked 11th in reporting odds of somnolence and had the strongest H1 receptor binding affinity. This study provides an informative ranking of somnolence among thirty antidepressant compounds with an already wide array of clinical indications as well as provides insight into potential drug repurposing in psychopharmacology.

Overview of Sleep and Circadian Rhythm Disorders in Parkinson Disease

Sleep disorders are common among PD patients and affect quality of life. They are often under-recognized and under-treated. Mechanisms of sleep disorders in PD remain relatively poorly understood. Improved awareness of common sleep problems in PD. Tailored treatment and evidence for efficacy are lacking. The purpose of this review is to provide an overview and update on the most common sleep disorders in PD. We review specific features of the most common sleep disorders in PD, including insomnia, excessive daytime sleepiness, sleep-disordered breathing, restless legs syndrome, circadian rhythm disorders and REM sleep behavior disorders.

Efficacy and tolerability of perampanel in pediatric patients with Dravet syndrome

PURPOSE

In the present study, we aimed to investigate the efficacy and tolerability of perampanel in patients with Dravet syndrome.

METHODS

We retrospectively reviewed data regarding seizure frequency and adverse effects in 10 patients (four boys, six girls) with Dravet syndrome following treatment with perampanel. Perampanel treatment was considered effective when seizure frequency had been reduced by more than 50%.

RESULTS

The mean age of patients at perampanel introduction was 11.5 ± 2.2 years. Seizure types were as follows: generalized tonic-clonic seizure (n = 8), unilateral clonic seizure (n = 6), myoclonic seizure (n = 3), atypical absence seizure (n = 3), and focal impaired awareness seizure (n = 1). The average number of concomitant anti-epileptic drugs (AEDs) was 3 ± 0.9. The mean duration of perampanel use was 11.1 ± 3.8 months. Seizure frequency was reduced by more than 50% in five patients (50%). The efficacy of perampanel for each seizure type was as follows: generalized tonic-clonic seizure: 50% (4/8), unilateral clonic seizure: 50% (3/6), myoclonic seizure: 33% (1/3), atypical absence seizure: 33% (1/3), and focal impaired awareness seizure: 100% (1/1). The effects of perampanel in each patient occurred between 3 and 6 months following the initiation of treatment. Seizure reduction was observed beginning at perampanel doses of 0.1 ± 0.07 mg/kg/day. Adverse events were observed in seven of 10 patients. Although somnolence was noted in 50% of patients, most events were mild.

CONCLUSIONS

The results of this retrospective observational study indicate that perampanel treatment may be promising in some patients with Dravet syndrome. Additional studies are necessary to verify the actual efficacy of perampanel for Dravet syndrome.

[Sleepiness, continuous positive airway pressure and the obstructive sleep apnea hypopnea syndrome]

Excessive daytime sleepiness is a major symptom in cases of the obstructive sleep apnea-hypopnea syndrome. Most often, it is vastly improved by treatment with continuous positive airway pressure (CPAP). The most effective way to confirm its disappearance is through wakefulness maintenance testing. If residual sleepiness remains, despite CPAP, further diagnostic investigation must be carried out. Firstly, it must be assessed whether the treatment is fully effective (apnea hypopnea index<10/h) by examining flow limitations under treatment (polysomnography) and whether it is sufficiently used (>6h/night). If this is the case, the possibility of other situations responsible for excessive daytime sleepiness must be reviewed and eliminated, whether they are depression, sleep insufficiency, use of intoxicants, obesity, restless legs syndrome, or circadian sleep-wake cycle disorder. If not, the multiple sleep latency tests make it possible to assess sleepiness (latency<8min) and can lead to a diagnosis of central hypersomnia (narcolepsy, idiopathic hypersomnia, hypersomnia due to a medical pathology). In some rare cases (about 6% of patients) investigations will reveal central hypersomnia due to the obstructive sleep apnea-hypopnea syndrome or "lesional" hypersomnia due to intermittent hypoxia. Since 2011, medications treating excessive sleepiness have had marketing authorization only for narcolepsy in France. However, they can be administered by way of derogation to other neurological hypersomnias on prescription by a reference centre or a centre with expertise in hypersomnia.

Risks associated with use of stimulant medications in patients with obstructive sleep apnea and cardiomyopathy: a case-control study

OBJECTIVES

Stimulant medications are indicated in patients with obstructive sleep apnea (OSA) who experience sleepiness despite optimal control of sleep-disordered breathing. The safety of stimulant medications in patients with OSA and co-morbid cardiomyopathy is unknown. We performed a case-control study to assess cardiovascular outcomes and mortality risk associated with stimulant use in this group of patients.

METHODS

A total of 162 subjects with OSA and cardiomyopathy were identified. Subjects who used stimulant medications for ≥1 month were designated as cases. Age-and-sex-matched controls not taking these medications were randomly chosen from the same cohort. Outcomes assessed were mortality, implantable cardioverter-defibrillator (ICD) and pacemaker insertion.

RESULTS

Twenty-two cases and 44 controls were included in the analyses. Mean age was 62.6 ± 15 years, 72% were male. Median duration of medication use was 27 months (range 1-98). There were four deaths among cases versus eight among controls. Four cases had a pacemaker and six had an ICD inserted, compared to six and eight respectively in the control group. Age (p = 0.01) and positive airway pressure (PAP) compliance (p = 0.01), but not stimulant medication use (p = 1.00) were associated with mortality on univariate analysis. In multiple logistic regression analyses accounting for body mass index, apnea-hypopnea index/respiratory disturbance index, PAP compliance, ejection fraction and duration of follow up, use of stimulant medication was not associated with mortality (p = 0.50), pacemaker (p = 0.20) or ICD (p = 0.90) implantation.

CONCLUSIONS

Stimulant medications were not associated with elevated risk of mortality, pacemaker or ICD implantation in this case-control study, even after accounting for multiple confounders.

Hemiplegic Migraine Presenting with Prolonged Somnolence: A Case Report

Hemiplegic migraine is a rare and complex disease, characterized by migraine with a reversible motor aura. Hemiplegic migraine can be easily misdiagnosed at its first presentation with an atypical severe form of migraine, a stroke, multiple sclerosis, metabolic disorders, conversion disorder or an epilepsy. We present the case of a young 24-year-old male patient, who since the age of 4 years had been having multiple episodes of migraine associated with hemiparesis, paraesthesia, prolonged somnolence, aphasia and confusion. We review the literature and discuss important diagnostic findings in hemiplegic migraine to help establishing a prompt diagnosis.

Sleep quality and daytime sleepiness in patients treated with adjunctive perampanel for focal seizures

PURPOSE

The purpose of this study was to evaluate subjective sleep quality and daytime sleepiness in patients receiving adjunctive perampanel for focal seizures.

METHODS

We conducted a multicenter, prospective, interventional, open-label study in patients aged >16 with focal seizures who received adjunctive perampanel (flexible dosing: 2-12mg). Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness with the Epworth Sleepiness Scale (ESS) at baseline and 3 and 6months after initiating perampanel. Patients with modifications in their baseline AEDs or sleep medications were excluded.

RESULTS

In 72 patients with drug-resistant focal seizures, mean baseline PSQI score (±standard deviation) was 7.26 (±4.6), and ESS was 6.19 (±4.2). At 3months (median perampanel dose: 4mg), there was no significant mean change from baseline in ESS score (n=61) and a significant improvement in PSQI (-1.51 points; n=44; p=0.007), driven mainly by improved sleep efficiency (p=0.012). In the 31 patients with 6-month data, ESS (but not PSQI) improved significantly at 6months vs baseline (p=0.029). The only factor significantly correlated with sleep parameters was number of baseline AEDs (higher number correlated with worse daytime sleepiness). Seizure frequency was reduced significantly from baseline at 3 and 6months. In bivariate analysis, neither PSQI nor ESS was associated with seizure frequency, suggesting that the changes in daytime sleepiness and sleep quality may be independent of the direct effect on seizures.

CONCLUSION

Adjunctive perampanel did not worsen sleep quality or daytime sleepiness at 3months and reduced daytime sleepiness in patients continuing perampanel for 6months. Perampanel may be a suitable AED in patients with sleep disorders, in addition to refractory focal seizures.

Adverse Effects of Psychotropic Medications on Sleep

Psychotropic medications such as antidepressants, antipsychotics, stimulants, and benzodiazepines are widely prescribed. Most of these medications are thought to exert their effects through modulation of various monoamines as well as interactions with receptors such as histamine and muscarinic cholinergic receptors. Through these interactions, psychotropics can also have a significant impact on sleep physiology, resulting in both beneficial and adverse effects on sleep.

Chronic fatigue syndrome and sleep disorders: clinical associations and diagnostic difficulties

INTRODUCTION

Chronic fatigue syndrome (CFS) is characterised by the presence of intractable fatigue and non-restorative sleep, symptoms which are also very prevalent in multiple diseases and appear as side effects of different drugs. Numerous studies have shown a high prevalence of sleep disorders in patients with CFS. However, non-restorative sleep and fatigue are frequently symptoms of the sleep disorders themselves, so primary sleep disorders have to be ruled out in many cases of CFS.

DEVELOPMENT

This review was performed using a structured search of the MeSH terms ([Sleep]+[Chronic fatigue syndrome]) in the PubMed database.

CONCLUSION

Identifying primary sleep disorders in patients meeting diagnostic criteria for CFS will allow for a more comprehensive treatment approach involving new diagnostic and therapeutic strategies that may improve quality of life for these patients.

A retrospective study to identify risk factors for somnolence and dizziness in patients treated with pregabalin

Background

Pregabalin is a therapeutic drug for neuropathic pain that is associated with somnolence and dizziness. These adverse events are often experienced shortly after initiating pregabalin, and may lead to treatment discontinuation. The purpose of this study was to explore factors that influence the incidence of somnolence and dizziness induced by pregabalin, and to identify patients at higher risk of adverse events.

Methods

A retrospective analysis was conducted of patient characteristics (age, gender, renal function, initial daily dose of pregabalin, co-administration of strong opioids and hypnotics) and the incidence of somnolence and dizziness during the first week of pregabalin treatment. An electronic chart was used to collect data from 204 inpatients prescribed pregabalin at Nagoya University Hospital from June 2011 to November 2012.

Results

Among 36 patients who regularly received strong opioids, 18 (50.0 %) reported somnolence or dizziness during the first week of pregabalin treatment. The remaining 168 patients did not regularly receive strong opioids, and 25 (14.9 %) had an adverse event. In multivariate analysis, age (≧65 years, adjusted odds ratio: 2.507, 95 % CI: 1.164-5.397, p = 0.019) and regular co-administration of strong opioids (adjusted odds ratio: 5.507, 95 % CI: 2.460-12.328, p < 0.001) correlated with somnolence or dizziness.

Conclusions

These data suggest that age (≧65 years) and co-administration of strong opioids are risk factors for somnolence or dizziness during pregabalin treatment for neuropathic pain. More careful dose titration is recommended for elderly patients and those receiving concomitant strong opioids.

[Continuous positive airways pressure treatment for obstructive sleep apnoea]

Continuous positive airway pressure (CPAP) still remains the most frequently used and the most efficient treatment for obstructive sleep apnea syndrome. However, its efficiency is conditioned by healthcare quality depending on many factors such as medical specificities of the patients as well as the severity of sleep-related breathing disorders. In order to optimize CPAP efficiency, it is necessary to be aware of the functional abilities of the different devices, and to perform a close monitoring of the patients, particularly during the first weeks of treatment, by maximally using the data provided by the CPAP apparatus. Some questions remain unsolved, such as the impact of nasal CPAP on glucose metabolism or cardiovascular prognosis. Furthermore, the strategy of CPAP use should be improved according to future results of studies dedicated to the interest of home telemonitoring and taking into account the validated mode of CPAP initiation.

ALG3-CDG (CDG-Id): clinical, biochemical and molecular findings in two siblings

Congenital disorders of glycosylation (CDG) represent an expanding family of metabolic disorders with a wide range of biochemical, molecular and clinical phenotypes. ALG3-CDG (CDG-Id), due to a defect in endoplasmic reticulum (ER) mannosyltransferase VI, is one of the less common types of CDG-I. We describe two Vietnamese siblings with confirmed ALG3-CDG (CDG-Id) by molecular testing. As far as we are aware, they are the oldest reported patients in the literature at 15 and 21years. They share similar clinical features with previously reported patients including facial dysmorphism, severe psychomotor retardation, microcephaly, seizures, and gastrointestinal symptoms. Furthermore, our sibling pair highlights the intrafamilial variability, the natural clinical course of ALG3-CDG (CDG-Id) and the benefit of reassessing patients with undiagnosed and complex syndromes, particularly when they present with neurological deterioration.