Objective and Subjective Sleep Patterns in Adults With Maturity-Onset Diabetes of the Young (MODY)

OBJECTIVE

To examine sleep patterns in adults with maturity-onset diabetes of the young (MODY).

RESEARCH DESIGN AND METHODS

Adults with glucokinase (GCK)-MODY and transcription factor (TF)-related MODY (HNF1A, HNF1B, HNF4A) were recruited (n = 24; age 46.0 years, 79% women, BMI 24.7 kg/m2) from The University of Chicago's Monogenic Diabetes Registry. Sleep patterns were assessed by 2-week wrist actigraphy (total 315 nights), one night of a home sleep apnea test, and validated surveys.

RESULTS

Overall, compared with established criteria, 29% of participants had sleep latency ≥15 min, 38% had sleep efficiency ≤85%, 46% had wake after sleep onset >40 min, all indicating poor objective sleep quality. Among all participants, 54% had a sleep duration below the recommended minimum of 7 h, 88% reported poor sleep quality, 58% had obstructive sleep apnea, and 71% reported insomnia. Compared with GCK-MODY, participants with TF-related MODY had poorer objective sleep quality and increased night-to-night variability in sleep patterns.

CONCLUSIONS

Sleep disturbances appear to be common in adults with MODY despite absent traditional risk factors for sleep disorders. Future research investigating the sleep-diabetes relationship is warranted in this population.

Effects of sleep disruption on stress, nigrostriatal markers, and behavior in a chronic/progressive MPTP male mouse model of parkinsonism

Sleep complaints are an early clinical symptom of neurodegenerative disorders. Patients with Parkinson's disease (PD) experience sleep disruption (SD). The objective of this study was to determine if preexisting, chronic SD leads to a greater loss of tyrosine hydroxylase (TH) within the striatum and the substantia nigra following chronic/progressive exposure with the neurotoxin, 1-methyl-2-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Male mice underwent chronic SD for 4 weeks, then injected with vehicle (VEH) or increasing doses of MPTP for 4 weeks. There was a significant decrease in the plasma corticosterone levels in the MPTP group, an increase in the SD group, and a return to the VEH levels in the SD+MPTP group. Protein expression levels for TH in the striatum (terminals) and substantia nigra pars compacta (dopamine [DA] cell counts) revealed up to a 78% and 38% decrease, respectively, in the MPTP and SD+MPTP groups compared to their relevant VEH and SD groups. DA transporter protein expression increased in the striatum in the MPTP versus VEH group and in the SN/midbrain between the SD+MPTP and the VEH group. There was a main effect of MPTP on various gait measures (e.g., braking) relative to the SD or VEH groups. In the SD+MPTP group, there were no differences compared to the VEH group. Thus, SD, prior to administration of MPTP, has effects on serum corticosterone and gait but more importantly does not potentiate greater loss of TH within the nigrostriatal pathway compared to the MPTP group, suggesting that in PD patients with SD, there is no exacerbation of the DA cell loss.

Abnormal nocturnal behavior due to hypoglycemia: A case report

RATIONALE

Hypoglycemia, which is characterized mainly by palpitations, dizziness, and sweating, is common and easy to identify. However, some other symptoms, such as mental disorder or abnormal behavior, are atypical, which may lead to a misdiagnosis of epilepsy, sleepwalking, infarction, or mental disorder, among others.

PATIENT CONCERNS

We report a case of a patient with type 2 diabetes who presented with abnormal nocturnal behavior due to hypoglycemia.

DIAGNOSIS

Hypoglycemia was diagnosed based on a blood glucose level of 2.1 mmol/L when the patient turned up disoriented unresponsive, unable to understand what was said to him, and producing nonsensical speech. After the patient ate a piece of chocolate, his consciousness returned to normal and all mental symptoms disappeared. Polysomnography (PSG) was synchronously performed. The results of the PSG did not show any signs of abnormality during nonrapid eye movement (NREM) or rapid eye movement (REM) sleep.

INTERVENTIONS

We regulated his dose of insulin.

OUTCOMES

No additional episodes occurred during the 3-month follow-up. Therefore, the abnormal nocturnal behavior of this patient was determined to be due to hypoglycemia, while the cause of the hypoglycemia was insulin overuse.

LESSONS

For physicians, if the cause of abnormal behavior cannot be detected, hypoglycemia should be suspected. Long-term persistent hypoglycemia may cause brain dysfunction and even result in permanent brain damage.

Correlation between allopregnanolone levels and depressive symptoms during late menopausal transition and early postmenopause

OBJECTIVES

This observational, cross-sectional study included 140 women with climacteric symptoms. The aim of the study was to evaluate the correlation between the presence and severity of depressive symptoms and allopregnanolone levels in women during late menopausal transition and early postmenopause.

METHODS

The study group was divided into two groups: 45 women in late menopausal transition and 95 early postmenopausal women. We evaluated Kupperman index, Hamilton scale and serum follicle-stimulating hormone, luteinizing hormone, 17β-estradiol, prolactin, total testosterone, dehydroepiandrosterone sulfate and allopregnanolone levels.

RESULTS

We found that serum allopregnanolone concentration was lower in early postmenopausal women compared to women in late menopausal transition; that there was a correlation between serum allopregnanolone levels in early postmenopausal women and time since last menstruation, intensity of climacteric symptoms, and intensity of depression symptoms and that there was a correlation between serum allopregnanolone levels and several depression symptoms presence (shallow sleep and symptoms of the digestive tract in women during late menopause transition; feelings of guilt, sleep disorders and general somatic symptoms in early postmenopausal women).

CONCLUSION

We concluded that reproductive aging is characterized by a reduction of allopregnanolone circulating levels that correlate to Hamilton depression index in early postmenopause and presence of specific depressive symptoms during late menopausal transition and early postmenopause.

[Evaluation and treatment of sleep problems in children diagnosed with attention deficit hyperactivity disorder: an update of the evidence]

INTRODUCTION

Attention deficit hyperactivity disorder (ADHD) affects approximately 5% of all children and adolescents, and these patients frequently suffer from sleep problems. The association between sleep disorders and ADHD, however, is multifaceted and complex.

AIMS

To explore the relationship between sleep disorders and ADHD.

DEVELOPMENT

Sleep problems in children with ADHD include altered sleep and specific disorders per se or that may be due to comorbid psychiatric disorders or to the stimulants they receive as treatment for their ADHD. Today, an evaluation of the sleep conditions in children with ADHD is recommended before starting pharmacological treatment. The first step in managing their sleep problems is good sleep hygiene and cognitive-behavioural psychotherapy. Another option is to consider modifying the dosage and formulation of the stimulants. Atomoxetine and melatonin are therapeutic alternatives for children with ADHD and more severe sleep problems. Specific treatments exist for respiratory and movement disorders during sleep.

CONCLUSIONS

It is important to evaluate sleep in children who present symptoms suggestive of ADHD, since problems during sleep can play a causal role or exacerbate the clinical features of ADHD. Correct evaluation and treatment of sleep disorders increase the family's and the child's quality of life and can lessen the severity of the symptoms of ADHD.

Systemic lupus erythematosus and exercise

Systemic lupus erythematosus (SLE) is a rheumatic disease characterized by a variety of symptoms, especially fatigue, pain and reduced quality of life. Physical exercise is a useful tool for improving cardiovascular fitness, reducing metabolic abnormalities and fatigue and improving quality of life. However, very few studies have focused on the relationship between SLE and physical exercise. This paper reviews the main SLE symptoms that can be alleviated by exercising, as well as the results of studies seeking to analyse the exercise capacity and physical training possibilities of SLE patients. Considerations for future research are also discussed.

Work-family conflict and sleep disturbance: the Malaysian working women study

This study aimed at assessing effect of the four dimensions of work-family conflicts (strain and time-based work interference into family and family interference into work) on sleep disturbance in Malaysian working women. This cross-sectional study was conducted among 325 Malaysian married working women. Multiple-stage simple random sampling method was used to recruit women from public service departments of Malaysia. Self-administrated questionnaires were used to measure the study variables and data were analyzed using SPSS version 21. We found that high level of the four dimensions of work-family conflicts significantly increase sleep disturbance. Our analyses also revealed an age-dependent effect of the work-family conflict on sleep disturbance. Women in their 20 to 30 yr old suffer from sleep disturbance due to high level of time-based and strain-based work-interference into family. However, the quality of sleep among women aged 30-39 were affected by strain-based family-interference into work. Finally, women older than 40 yr had significantly disturbed sleep due to strain-based work-interference into family as well as time-based family interference into work. Our findings showed that sleep quality of working women might be disturbed by experiencing high level of work-family conflict. However, the effects of inter-role conflicts on sleep varied among different age groups.

[Sluggish cognitive tempo: an updated review]

INTRODUCTION

The study of sluggish cognitive tempo (SCT) arose largely from research carried out on attention deficit hyperactivity disorder (ADHD). This construct is defined by a range of behavioural symptoms such as the appearance of drowsiness, daydreaming, physical hypoactivity, little initiative, lethargy and apathy.

DEVELOPMENT

The construct of SCT is reviewed by means of recently published papers on its clinical characteristics, associated symptoms, evaluation, prevalence, aetiology, comorbidity, neuropsychological profiles and treatment. The latest studies propose that SCT should be understood as a cluster of symptoms that is distinct from ADHD. Although there is no clear consensus on the matter, the evidence is becoming increasingly more consistent and endows SCT with a high degree of external validity, associating it with internalising symptoms.

CONCLUSIONS

We believe the different subtypes of ADHD must be grounded in attentional conceptual models. Hence, the attentional guidance network would be related with SCT, the vigilance or sustained attention network would be linked with the inattentive subtype of ADHD, and executive attention would be involved in the combined subtype of ADHD. The evidence obtained to date, including this review, supports the idea that SCT is an attention disorder distinct from ADHD but, like any dimensional disorder, it can overlap with it in around half the cases.

Clinical and Neurologic Manifestation of Minimal Hepatic Encephalopathy and Overt Hepatic Encephalopathy

Hepatic encephalopathy (HE) shows a wide spectrum of neuropsychiatric manifestations. A combined effort with neuropsychological and psychometric evaluation has to be performed to recognize the syndrome, whereas minimal HE (MHE) is largely under-recognized. Subtle symptoms of MHE can only be diagnosed through specialized neuropsychiatric testing. Early diagnosis and treatment may drastically improve the quality of life for many cirrhotic patients. Further research to gain better insight into the pathophysiology and diagnostic accuracy of HE will help determine future management strategies.

[The atypical developments of rolandic epilepsy are predictable complications]

INTRODUCTION

The development of atypical features in rolandic epilepsy is part of a clinical spectrum of phenotypes that are variable, idiopathic and age-dependent, as well as having a genetically determined predisposition.

AIM

To study the electroclinical characteristics suggesting an atypical development in rolandic epilepsy.

PATIENTS AND METHODS

A retrospective search was performed in 133 children diagnosed with atypical benign focal epilepsy (ABFE), Landau-Kleffner syndrome and continuous spike-wave during sleep (CSWS). Nine patients were selected, all of whom presented atypical clinical features and an electroencephalogram (EEG) pattern of electrical status epilepticus during sleep (ESES) in the course of their rolandic epilepsy.

RESULTS

The average age at onset of rolandic epilepsy was 5 years. Patients showed a deterioration of both their clinical features and their EEG recording one and a half years later, on average. ABFE was observed in three of them and CSWS in six. No cases of Landau-Kleffner syndrome were found. The EEG in wakefulness showed the focus to be in the left centrotemporal region in six patients and in three of them it was on the right-hand side. All the patients presented ESES in the EEG during sleep. An atypical pattern was observed in the regional ESES in three of the patients. Moreover, cognitive and behavioural disorders were detected due to deficits in specific learning areas, such as language, memory, attention and restlessness.

CONCLUSIONS

The early onset of rolandic epilepsy, the appearance of new seizures with an increased frequency and the frontocentrotemporal focus in the EEG, which increases in frequency, both in wakefulness and in sleep, are all electroclinical characteristics of an atypical development.

A prospective study of adverse drug reactions to antiepileptic drugs in children

OBJECTIVES

To prospectively determine the nature and rate of adverse drug reactions (ADRs) in children on antiepileptic drugs (AEDs) and to prospectively evaluate the effect of AEDs on behaviour.

SETTING

A single centre prospective observational study.

PARTICIPANTS

Children (<18 years old) receiving one or more AEDs for epilepsy, at each clinically determined follow-up visit.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was adverse reactions of AEDs. Behavioural and cognitive functions were secondary outcomes.

RESULTS

180 children were recruited. Sodium valproate and carbamazepine were the most frequently used AEDs. A total of 114 ADRs were recorded in 56 of these children (31%). 135 children (75%) were on monotherapy. 27 of the 45 children (60%) on polytherapy had ADRs; while 29 (21%) of those on monotherapy had ADRs. The risk of ADRs was significantly lower in patients receiving monotherapy than polytherapy (RR: 0.61, 95% CI 0.47 to 0.79, p<0.0001). Behavioural problems and somnolence were the most common ADRs. 23 children had to discontinue their AED due to an ADR.

CONCLUSIONS

Behavioural problems and somnolence were the most common ADRs. Polytherapy significantly increases the likelihood of ADRs in children.

TRAIL REGISTRATION NUMBER

EudraCT (2007-000565-37).

[Effect of partial and generalised epileptic seizures on sleep architecture in rats]

INTRODUCTION

It is a well-known fact that epileptic seizures disrupt sleep, yet little information is available about sleep disorders according to the type of epileptic seizures.

MATERIALS AND METHODS

The sleep architecture of rats was evaluated in polysomnography recordings 36 hours after inducing partial and generalised epileptic seizures in them. The epileptic seizures were induced by applying 50-100 IU of sodium G penicillin in the amygdala of the temporal lobe.

RESULTS

Partial and generalised seizures triggered an increase in the latency of slow wave sleep (SWS) and rapid eye movement (REM) sleep. The number of episodes of the phases of wakefulness, SWS and REM sleep was reduced and the mean duration of the episodes of wakefulness and SWS increased, while that of REM sleep diminished. The total percentage of REM sleep diminished significantly. During the first period of light the partial and generalised seizures triggered an increase in wakefulness and a reduction in the phases of SWS and REM sleep. In the period of darkness, the SWS increased and wakefulness decreased, while there were no changes in REM sleep. In the second period of light, the percentages of the phases of wakefulness and SWS returned to control values and the percentage of REM sleep continued to be reduced.

CONCLUSIONS

Changes in the structuring of sleep depend on the type of epileptic seizure that presents. Generalised epileptic seizures caused greater deterioration in REM sleep.

Common questions about the diagnosis and management of fibromyalgia

Fibromyalgia has a distinct pathophysiology involving central amplification of peripheral sensory signals. Core symptoms are chronic widespread pain, fatigue, and sleep disturbance. Most patients with fibromyalgia have muscle pain and tenderness, forgetfulness or problems concentrating, and significant functional limitations. Fibromyalgia is diagnosed using an updated set of clinical criteria that no longer depend on tender point examination; laboratory testing may rule out other disorders that commonly present with fatigue, such as anemia and thyroid disease. Patients with fibromyalgia should be evaluated for comorbid functional pain syndromes and mood disorders. Management of fibromyalgia should include patient education, symptom relief, and regular aerobic physical activity. Serotoninnorepinephrine reuptake inhibitors, tricyclic antidepressants, antiepileptics, and muscle relaxants have the strongest evidence of benefit for improving pain, fatigue, sleep symptoms, and quality of life. Multiple complementary and alternative medicine therapies have been used but have limited evidence of effectiveness. Opioids should be used to relieve pain in carefully selected patients only if alternative therapies are ineffective.

Frequency of dysmenorrhoea, its impact and management strategies adopted by medical students

BACKGROUND

Dysmenorrhea is quite frequent and may affect the daily activities especially during the early years of adolesence. This study aimed to evaluate the prevalence of dysmenorrhoea, its impact, and the management strategies adopted.

METHODS

This cross-sectional study was done with 356 consenting females studying at Mohiuddin Islamic University, Mirpur Azad Kashmir, between 18-25 years of age, with regular menstrual cycles and normal abdomino-pelvic ultrasound and not taking any medication. Information was gathered regarding age, residence, menstrual history, body mass index (BMI), associated symptoms, remedies used and days lost.

RESULTS

A total of 56.1% females had dysmenorrhoea. The mean age of participants was 21.01±1.54 years, mean age of menarche was 12.9±1.65 years, mean duration of menstrual flow was 4.75±1.27 days and mean BMI was 24.1±1.6. 17% of the participants were dieting and 26% had daily milk intake. 25% reported being absent due to pain and number of days lost was 1.5±1.0 days. Common symptoms associated with the dysmenorrhoea were difficulty concentrating in 65%, less involvement in social activities and sleep affected in 64%, mood disturbances in 58% and headache in 56%. Household remedies for dysmenorrhea were used by 43% and 66% used analgesics and only 4% sought medical advice for pain.

CONCLUSION

Dysmenorrhoea is a very common problem affecting academic performance and limiting daily activities requiring appropriate intervention.

Effect of intermittent aerobic exercise on sleep quality and sleep disturbances in patients with rheumatoid arthritis - design of a randomized controlled trial

BACKGROUND

Poor sleep is prevalent in patients with systemic inflammatory disorders, including rheumatoid arthritis, and, in addition to fatigue, pain, depression and inflammation, is associated with an increased risk of co-morbidity and all-cause mortality. Whereas non-pharmacological interventions in patients with rheumatoid arthritis have been shown to reduce pain and fatigue, no randomized controlled trials have examined the effect of non-pharmacological interventions on improvement of sleep in patients with rheumatoid arthritis. The aim of this trial was to evaluate the efficacy of an intermittent aerobic exercise intervention on sleep, assessed both objectively and subjectively in patients with rheumatoid arthritis.

METHODS/DESIGN

A randomized controlled trial including 44 patients with rheumatoid arthritis randomly assigned to an exercise training intervention or to a control group. The intervention consists of 18 session intermittent aerobic exercise training on a bicycle ergometer three times a week. Patients are evaluated according to objective changes in sleep as measured by polysomnography (primary outcome). Secondary outcomes include changes in subjective sleep quality and sleep disturbances, fatigue, pain, depressive symptoms, physical function, health-related quality of life and cardiorespiratory fitness.

DISCUSSION

This trial will provide evidence of the effect of intermittent aerobic exercise on the improvement of sleep in patients with rheumatoid arthritis, which is considered important in promotion of health and well-being. As such, the trial meets a currently unmet need for the provision of non-pharmacological treatment initiatives of poor sleep in patients with rheumatoid arthritis.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01966835.

Disability and sleep duration: evidence from the American Time Use Survey

BACKGROUND

Regular short and long sleep durations are associated with increased mortality and morbidity. While previous research shows significant sleep disparities between people with and without disabilities, less is known about the association between different types of disability and high-risk sleep using nationally representative data.

OBJECTIVE

We examine the association between short and long sleep durations and having a work disability or an impairment in sensory, cognitive, or physical functioning among a nationally representative sample of working-age adults in the United States.

METHODS

We estimate multinomial logistic regression models using data from the 2003-2012 American Time Use Survey to identify how different types of disabling conditions--net of other sociodemographic factors--relate to the likelihood of reporting short (6 h or fewer) or long (9 h or more) sleep, versus mid-range (between 6 and 9 h) sleep.

RESULTS

For respondents with work disabilities versus those without work disabilities, the relative risk of short and long sleep is 1.4 and 1.5 times (respectively) that of those with mid-range sleep. The risk of short and long sleep durations is also higher among respondents with cognitive, physical, or multiple impairments.

CONCLUSIONS

Individuals with disabilities are less likely than those without disabilities to have optimal sleep durations. These results demonstrate the importance of health promotion services among this population, with specific attention to sleep hygiene interventions.

[Sleep disorders and quality of life in refractory partial epilepsy: results of the SLEEP study]

INTRODUCTION

Sleep disorders are frequent among patients with epilepsy and are correlated with a poorer quality of life.

AIMS

To evaluate the prevalence of sleep disorders in patients with refractory and non-refractory focal epilepsy, and to explore the influence of these alterations on the quality of life of these patients.

PATIENTS AND METHODS

An epidemiological, controlled, cross-sectional study was conducted in 150 outpatient neurology services. Patients who had been treated with two antiepileptic drugs since the onset of the disease (18-55 years) were recruited for the study.

RESULTS

The sample included 237 patients with non-refractory focal epilepsy and 264 patients with refractory focal epilepsy. Twenty-two per cent of the non-refractory epilepsy group and 45% of the group with refractory epilepsy (p < 0.0001) suffered from some sleep disorder. The patients with refractory epilepsy had a poorer quality of life (p < 0.001) as measured with the quality of life questionnaire QOLIE-10. A positive significant correlation was observed between quality of life and quality of sleep, in both chronic insomnia (r = 0.65; p < 0.0001) and excessive daytime sleepiness (r = 0.43; p < 0.0001).

CONCLUSIONS

Sleep disorders are more frequent in refractory than in non-refractory epilepsy, and affect the patients' quality of life.

Pediatric insomnia: clinical, diagnosis, and treatment

Pediatric insomnia is an extrinsic sleep disorder subdivided into two categories: behavioral insomnia and insomnia related to medical, neurological, and psychiatric diseases. This review will cover several types of insomnia, comorbidities and specific pediatric therapies according to clinical characteristics and age. Behavioral insomnia should be differentiated from pediatric insomnia due to medical conditions, mostly occurring during the first year of life. Multiple night awakenings and diurnal hypersomnolence are strong indicators of insomnia due to medical conditions. Insomnia during adolescence and pediatric insomnia associated with psychiatric comorbidity, cognitive disabilities and epilepsy, will be discussed in terms of diagnosis, clinical features and implications for treatment.

Fibromylagia

BACKGROUND

Fibromyalgia is a common and debilitating condition. The cardinal feature of fibromyalgia is musculoskeletal pain, usually accompanied by other problems, such as fatigue, sleep disturbance and cognitive difficulties. Fibromyalgia commonly coexists with other chronic illnesses and can result in poorer outcomes if untreated.

OBJECTIVE

The objective of this review is to discuss when fibromyalgia should be considered as a diagnosis, how it is diagnosed, the current understanding of the pathophysiology of fibromyalgia and the management strategies available.

DISCUSSION

The features of fibromyalgia are similar to those of many other chronic illnesses, sometimes resulting in diagnostic confusion. Fibromyalgia can co-exist with other disorders and it is important to consider the possibility of fibromyalgia contributing to symptoms in any chronically ill patient.

Association between pupillometric sleepiness measures and sleep latency derived by MSLT in clinically sleepy patients

OBJECTIVES

The multiple sleep latency test (MSLT) has been employed extensively in clinical and research settings as a gold standard for objectively measuring sleepiness. In a general population or in a variety of work settings, however, a more convenient, rapidly administered measuring method is preferable. We examined the potential utility of pupillometry by comparing its objective measures, pupillary unrest index (PUI) and relative pupillary unrest index (RPUI), with MSLT-derived sleep latency (SL).

METHODS

The study cohort comprised 45 patients (39 males, 6 females, mean age 38.9 ± 11.3 years) referred to the Sleep Disorders Center for the two-nap SL test. SL was measured twice before noon, and pupillometric measurement was performed immediately before each SL test. Subjective sleepiness was measured by using the Epworth Sleepiness Scale (ESS).

RESULTS

The association between PUI and SL was significant and far closer than that between RPUI and SL. A significant difference was observed between the two groups, based on each subject's experience of drowsy driving accidents over the past 3 years in the PUI and RPUI, as well as in SL. The subjective sleepiness measure, ESS, did not relate to any other physiological sleepiness measures.

CONCLUSIONS

In our study cohort, the pupillometric sleepiness measure, PUI, was significantly correlated with, and behaved in a manner equivalent to, MSLT-derived SL in clinically sleepy patients. However, several points remain to be carefully examined before applying pupillometry for screening sleepiness in a general population, or in occupational settings.

Profile of multiple system atrophy in Moroccan patients attending a movement disorders outpatient clinic in Rabat university hospital

INTRODUCTION

Multiple system atrophy (MSA) is a sporadic and rapidly progressive neurodegenerative disorder of poor prognosis, characterised clinically by any combination of parkinsonian, autonomic, cerebellar, or pyramidal signs. We report our experience in movement disorders consultation concerning the clinical presentation and the course of MSA in Moroccan patients.

METHODS

A retrospective review of the medical records of 17 patients with diagnosis of MSA seen in our outpatient clinic from January 2007 to December 2010.

RESULTS

In our 17 patients, 76.5% were men and the mean age of onset was 52±9 years. MSA-P was the major clinical phenotype (82.4%). Eleven patients (64.7%) were classified as having probable MSA and six patients (35.3%) as possible MSA. Dysautonomic features were detected in all patients; urinary symptoms were found in 76.5% of cases and orthostatic hypotension in 64.7%. Treatment regimen included l-Dopa with a mean daily dose of 621.4±346.8mg/day and symptomatic treatment of dysautonomia. The mean duration of disease evolution was of 4.7±1.9 years.

DISCUSSION

Our results show a male predominance and an early age of disease onset. MSA-P was the predominant subtype. Our results are similar to the European MSA series.

CONCLUSION

Multicentre studies are needed to better characterise MSA in Morocco given the rarity of this disease.

[Video electroencephalographic diagnosis of epileptic and non-epileptic paroxysmal episodes in infants and children at the pre-school age]

The main usefulness of video electroencephalographic (video-EEG) monitoring lies in the fact that it allows proper classification of the type of epileptic seizure and epileptic syndrome, identification of minor seizures, location of the epileptogenic zone and differentiation between epileptic seizures and non-epileptic paroxysmal manifestations (NEPM). In infants and pre-school age children, the clinical signs with which epileptic seizures are expressed differ to those of older children, seizures with bilateral motor signs such as epileptic spasms, tonic and myoclonic seizures predominate, and seizures with interruption of activity or hypomotor seizures, and no prominent automatisms are observed. In children with focal epilepsies, focal and generalised signs are often superposed, both clinically and in the EEG. NEPM may be benign transitory disorders or they can be episodic symptoms of different neurological or psychopathological disorders. NEPM are often observed in children with mental retardation, neurological compromise or autism spectrum disorders, who present epileptic seizures and epileptiform abnormalities in the baseline EEG. It then becomes necessary to determine which episodes correspond to epileptic seizures and which do not. The NEPM that are most frequently registered in the video-EEG in infants and pre-school age children are unexpected sudden motor contractions ('spasms'), introspective tendencies, motor stereotypic movements and paroxysmal sleep disorders.

[Fibromyalgia in men and women: comparison of the main clinical symptoms]

The prevalence of fibromyalgia (FM) in males is much lower than in women. Thus, current knowledge about the syndrome has been developed from research with women. The aim of the present study is to analyze whether FM manifestations differ as a function of sex. Two clinical groups with FM (21 males and 21 women) and a control group of healthy men (n= 21) participated in the study. Several aspects of pain, sleep, fatigue, psychopathology, emotional distress and functional impact of FM were evaluated with an algometer and questionnaires. The clinical groups showed a significantly greater impairment than the control group in all the self-report measures. However, the FM patients only showed significant differences in the sensibility threshold to the pain, which was lower in the women. In addition, the best predictor of the experience of pain in males was sleep quality, and in the women, catastrofying pain. Our results suggest that the most effective therapeutic strategies to control pain may be different for men and women.

The impact and management of nonmotor symptoms of Parkinson's disease

Parkinson's disease (PD) is a common neurodegenerative disorder diagnosed by the presence of bradykinesia and at least 1 of the symptoms of rigidity, resting tremor, or postural instability. It is increasingly recognized that nonmotor symptoms are common and can adversely affect quality of life, yet they often are not diagnosed and consequently are often untreated. Nonmotor symptoms include neuropsychiatric issues such as anxiety, depression, hallucinations, impulse control disorders, and cognitive impairment, as well as autonomic dysfunction, which may present as gastrointestinal, urinary, and sexual disturbances. Nonmotor symptoms also include excessive sweating, orthostatic hypotension, and sleep disturbances. Management of PD requires recognition of both motor and nonmotor symptoms as well as an understanding of the relationship between these symptoms and how they can be affected by treatments for PD. Therapy should be individualized for each patient, as treatments for the motor symptoms of PD can improve some nonmotor symptoms while they can worsen others. In many cases, symptom-specific treatments are necessary to control nonmotor symptoms of PD.

The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the non-motor symptoms of Parkinson's disease

The Movement Disorder Society (MDS) Task Force on Evidence-Based Medicine (EBM) Review of Treatments for Parkinson's Disease (PD) was first published in 2002 and was updated in 2005 to cover clinical trial data up to January 2004 with the focus on motor symptoms of PD. In this revised version the MDS task force decided it was necessary to extend the review to non-motor symptoms. The objective of this work was to update previous EBM reviews on treatments for PD with a focus on non-motor symptoms. Level-I (randomized controlled trial, RCT) reports of pharmacological and nonpharmacological interventions for the non-motor symptoms of PD, published as full articles in English between January 2002 and December 2010 were reviewed. Criteria for inclusion and ranking followed the original program outline and adhered to EBM methodology. For efficacy conclusions, treatments were designated: efficacious, likely efficacious, unlikely efficacious, non-efficacious, or insufficient evidence. Safety data were catalogued and reviewed. Based on the combined efficacy and safety assessment, Implications for clinical practice were determined using the following designations: clinically useful, possibly useful, investigational, unlikely useful, and not useful. Fifty-four new studies qualified for efficacy review while several other studies covered safety issues. Updated and new efficacy conclusions were made for all indications. The treatments that are efficacious for the management of the different non-motor symptoms are as follows: pramipexole for the treatment of depressive symptoms, clozapine for the treatment of psychosis, rivastigmine for the treatment of dementia, and botulinum toxin A (BTX-A) and BTX-B as well as glycopyrrolate for the treatment of sialorrhea. The practical implications for these treatments, except for glycopyrrolate, are that they are clinically useful. Since there is insufficient evidence of glycopyrrolate for the treatment of sialorrhea exceeding 1 week, the practice implication is that it is possibly useful. The treatments that are likely efficacious for the management of the different non-motor symptoms are as follows: the tricyclic antidepressants nortriptyline and desipramine for the treatment of depression or depressive symptoms and macrogol for the treatment of constipation. The practice implications for these treatments are possibly useful. For most of the other interventions there is insufficient evidence to make adequate conclusions on their efficacy. This includes the tricyclic antidepressant amitriptyline, all selective serotonin reuptake inhibitors (SSRIs) reviewed (paroxetine, citalopram, sertraline, and fluoxetine), the newer antidepressants atomoxetine and nefazodone, pergolide, Ω-3 fatty acids as well as repetitive transcranial magnetic stimulation (rTMS) for the treatment of depression or depressive symptoms; methylphenidate and modafinil for the treatment of fatigue; amantadine for the treatment of pathological gambling; donepezil, galantamine, and memantine for the treatment of dementia; quetiapine for the treatment of psychosis; fludrocortisone and domperidone for the treatment of orthostatic hypotension; sildenafil for the treatment of erectile dysfunction, ipratropium bromide spray for the treatment of sialorrhea; levodopa/carbidopa controlled release (CR), pergolide, eszopiclone, melatonin 3 to 5 mg and melatonin 50 mg for the treatment of insomnia and modafinil for the treatment of excessive daytime sleepiness. Due to safety issues the practice implication is that pergolide and nefazodone are not useful for the above-mentioned indications. Due to safety issues, olanzapine remains not useful for the treatment of psychosis. As none of the studies exceeded a duration of 6 months, the recommendations given are for the short-term management of the different non-motor symptoms. There were no RCTs that met inclusion criteria for the treatment of anxiety disorders, apathy, medication-related impulse control disorders and related behaviors other than pathological gambling, rapid eye movement (REM) sleep behavior disorder (RBD), sweating, or urinary dysfunction. Therefore, there is insufficient evidence for the treatment of these indications. This EBM review of interventions for the non-motor symptoms of PD updates the field, but, because several RCTs are ongoing, a continual updating process is needed. Several interventions and indications still lack good quality evidence, and these gaps offer an opportunity for ongoing research. © 2011 Movement Disorder Society.

Variability of respiratory symptoms in severe COPD

INTRODUCTION

While it is known that asthma symptoms have a very variable pattern, the general belief is that the respiratory symptoms in COPD patients usually present little or no variability. Nevertheless, COPD patients report having "bad days". The objective of this present study was to evaluate the variability of the respiratory symptoms and their impact on the daily activities of a cohort of Spanish COPD patients.

METHOD

We present the results of the Spanish patients who participated in a cross-sectional epidemiological study carried out in 17 European countries. Pulmonologists and Family Care physicians recruited patients with stable severe COPD (FEV1<50%). The perception of the patients on the variation in their symptoms was recorded by telephone interviews.

RESULTS

A total of 472 patients provided data that was valid for analysis. Mean age was 68.6; 93% were men; mean FEV1(%) was 41%. 84.1% of the patients experimented at least one respiratory symptom in the previous week and 60.9% affirmed that their symptoms varied over the course of the day or week. The moment of the day when the symptoms were perceived to be more intense was during the morning.

CONCLUSIONS

An important proportion of severe COPD patients perceive variability in their respiratory symptoms, with a greater intensity in the morning. The observation can have implications in treating patients with severe COPD as variability can be an initial sign of decompensation of the disease.

Diagnostics and management of sleep-related respiratory disturbances in children with skeletal dysplasia caused by FGFR3 mutations (achondroplasia and hypochondroplasia)

To evaluate the frequency of clinical indicators for sleep-related respiratory disturbances (SRD) and the polysomnographical manifestations of these disorders in children with skeletal dysplasia caused by FGFR3 mutations. From January 1990 to January 2009, 24 patients (22 achondroplasia, 2 hypochondroplasia; 13 boys, 11 girls; age 8 days to 15 years, median age 3.0 years) were examined, including a semi-structured interview, a clinical examination, and a polysomnographic sleep recording (65 polysomnographic sleep recordings (PSG) in 24 patients). We performed PSG in a subgroup of five patients before and after adenoidectomy (AT) and/or tonsilectomy (TE). Daytime symptoms suggestive of SRD (daytime somnolence, attention and concentration problems, behavioural problems, and pallor) were found in 4/24 patients (16.7%). Sleep-related symptoms (snoring, mouth breathing, cyanosis, observed apneas, excessive sweating, enuresis, problems of initiating and maintaining sleep) were present in 18/24 patients (75%). Prior to the first PSG, 11/24 patients (45.8%) had undergone AT, 1/24 (4.2%) TE, 2/24 (8.3%) adenotonsilectomy (ATE), 3/24 (12.5%) liquor drainage, and 6/24 (25%) a craniocervical decompression operation. Clinical examination prior to PSG revealed hypertrophied tonsils in 11/24 patients (45.8%), disturbed nasal breathing in 8/24 patients (33.3), and enlarged cervical lymph nodes as a sign of chronic tonsillitis in 5/24 patients (20.8%). PSG findings were abnormal in 19/24 patients (79.2%) with a nadir of oxygen saturation (pulse oximetry) below 90% and/or a nadir of transcutaneous partial pressure of oxygen below 45 mmHg. Pathologic PSG findings were found in 10/24 patients (41.7%): obstructive sleep apnea syndrome (OSAS) was diagnosed in 8/24 patients (33.3%), central sleep apnea syndrome in 1/24 patients (4.2%), and hypoventilation in 1/24 patients (4.2%). As a consequence, the following therapeutic interventions were performed: AT in 1/24 patients (4.2%), TE in 2/24 (8.3%), ATE in 2/24 (8.3%), and nasal continuous positive airway pressure (continuous positive airway pressure) and bilevel positive airway pressure therapy (bilevel positive airway pressure), respectively, in 3/24 patients(12.5%). SRD, especially OSAS, represent a complication of clinical and prognostic relevance in children with achondroplasia. We therefore think that not only those children with a history suggestive of SRD, but all achondroplastic children should be evaluated by PSG. At least in a part of these patients, the pathophysiological mechanisms of OSAS are connected with the etiology of achondroplasia. Achondroplastic children with OSAS, who do not benefit from AT and/or TE, should be treated with NCPAP therapy.

Alcohol and sleep problems in primary care patients: a report from the AAFP National Research Network

PURPOSE

Hazardous and harmful drinking and sleep problems are common, but their associations among patients seen in primary care have not been examined. We hypothesized that greater levels of alcohol consumption would be associated with several self-reported sleep problems.

METHODS

In a cross-sectional survey in primary care practices, 94 participating clinicians recruited up to 30 consecutive adult patients, and both clinicians and patients completed anonymous postvisit questionnaires. Patients were asked questions on demographics, alcohol consumption, cardinal symptoms of alcohol use disorders, sleep quality, insomnia, sleep apnea, and symptoms of restless leg syndrome. Multivariate analyses explored the associations of drinking status (none, moderate, or hazardous) and sleep problems, adjusting for demographics and clustering of patients within physician.

RESULTS

Of 1,984 patients who responded, 1,699 (85.6%) provided complete data for analysis. Respondents' mean age was 50.4 years (SD 17.4 years), 67% were women, and 72.9% were white. Of these, 22.3% reported hazardous drinking, 47.8% reported fair or poor overall sleep quality, and 7.3% reported a diagnosis or treatment of sleep apnea. Multivariate analyses showed no associations between drinking status and any measure of insomnia, overall sleep quality, or restless legs syndrome symptoms. Moderate drinking was associated with lower adjusted odds of sleep apnea compared with nondrinkers (OR = 0.61; 95% CI, 0.38-1.00). Using alcohol for sleep was strongly associated with hazardous drinking (OR = 4.58; 95% CI, 2.97-7.08, compared with moderate drinking).

CONCLUSIONS

Moderate and hazardous drinking were associated with few sleep problems. Using alcohol for sleep, however, was strongly associated with hazardous drinking relative to moderate drinking and may serve as a prompt for physicians to ask about excessive alcohol use.

The influence of reproductive hormones on brain function in the menopausal transition

Reproductive hormones have long been thought to have a significant impact on brain function in humans. Estrogens, progestins and androgens have all been shown to have effects on nerve growth and function in vitro. The neurofunctional domains of cognition, mood and sleep are now receiving increased study to determine both the relationship of endogenous sex steroids through the menopausal transition and the effect of menopausal hormone therapy on these complex functions. All three domains are the source of frequent concern in midlife women, but the relative contribution of ovarian versus somatic aging is only now being untangled. Cognitive function has been most extensively studied, with mixed results in both observational studies and clinical trials, largely due to the remarkably complex aspects of human cognition requiring extensive and targeted testing of specific components. Both mood and sleep disorders have been associated with the menopausal transition, but observed effects appear modest. To date, clinical trial data are insufficient to support the use of hormone therapy specifically for the prevention or treatment of cognitive, mood or sleep disorders in midlife women.

Case report: Treatment of mild traumatic brain injury with hyperbaric oxygen

Two United States Air Force Airmen were injured in a roadside improvised explosive device (IED) blast in Iraq in January 2008. Both airmen suffered concussive injuries and developed irritability, sleep disturbances, headaches, memory difficulties and cognitive difficulties as symptoms of mild traumatic brain injury (mTBI). Six months after injury, repeat Automated Neuropsychological Assessment Metrics (ANAM) testing showed deterioration, when compared to pre-injury baseline ANAM assessment, in all measured areas (simple reaction time, procedural reaction time, code substitution learning, code substitution delayed, mathematical processing, and matching to sample). The airmen were treated with hyperbaric oxygen in treatments of 100% oxygen for one hour at 1.5 atmospheres absolute, resulting in rapid improvement of headaches and sleep disturbances, improvement in all symptoms and resolution of most symptoms. Repeat ANAM testing after completion of the hyperbaric treatments - nine months after initial injury - showed improvement in all areas, with most measures improving to pre-injury baseline levels. The airmen received no other treatment besides medical monitoring. Repeat neuropsychologic testing confirmed the improvement. We conclude that the improvement in symptoms and ANAM performance is most likely attributable to HBO treatment.

Nonmotor symptoms of Parkinson's disease revealed in an animal model with reduced monoamine storage capacity

Parkinson's disease (PD) is a progressive neurodegenerative disorder that is characterized by the loss of dopamine neurons in the substantia nigra pars compacta, culminating in severe motor symptoms, including resting tremor, rigidity, bradykinesia, and postural instability. In addition to motor deficits, there are a variety of nonmotor symptoms associated with PD. These symptoms generally precede the onset of motor symptoms, sometimes by years, and include anosmia, problems with gastrointestinal motility, sleep disturbances, sympathetic denervation, anxiety, and depression. Previously, we have shown that mice with a 95% genetic reduction in vesicular monoamine transporter expression (VMAT2-deficient, VMAT2 LO) display progressive loss of striatal dopamine, L-DOPA-responsive motor deficits, alpha-synuclein accumulation, and nigral dopaminergic cell loss. We hypothesized that since these animals exhibit deficits in other monoamine systems (norepinephrine and serotonin), which are known to regulate some of these behaviors, the VMAT2-deficient mice may display some of the nonmotor symptoms associated with PD. Here we report that the VMAT2-deficient mice demonstrate progressive deficits in olfactory discrimination, delayed gastric emptying, altered sleep latency, anxiety-like behavior, and age-dependent depressive behavior. These results suggest that the VMAT2-deficient mice may be a useful model of the nonmotor symptoms of PD. Furthermore, monoamine dysfunction may contribute to many of the nonmotor symptoms of PD, and interventions aimed at restoring monoamine function may be beneficial in treating the disease.

[Tinnitus]

Tinnitus is a symptom caused by the dysfunction of the auditory system associated with hyperactive networks of the central auditory tract. Intimate relationship of the auditory tract with the limbic system may lead to a stress reaction with subsequent sleep disturbances, distress and depression. The target of tinnitus treatment shoud be the annoyance caused by tinnitus, not the sensation itself. Optimally, all tinnitus patients should be treated according to the TRT-principles including careful diagnostics, informational counceling and sound-based therapies. Some patients need sleep therapy as well as anti-depressive therapy.

Central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma

A 29-year-old man with a history of resected bulbar hemangioblastoma was admitted to hospital with nighttime breathing disturbance, but with apparently normal breathing while awake. After diagnostic work-up, including polysomnographic testing, he was diagnosed as having central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma. Non-invasive positive pressure ventilation (NIPPV) via oronasal facemask was given for nocturnal ventilatory support. Two months after leaving our hospital, he was readmitted because of aspiration pneumonia. The pneumonia was successfully treated with antibiotics, but the desaturation during sleep worsened despite non-invasive ventilatory support. Higher bi-level positive pressure using a full facemask successfully alleviated sleep hypoventilation and apnea. To the best of our knowledge, this is the first case report of central alveolar hypoventilation syndrome due to surgical resection for bulbar hemangioblastoma.

A review on some of the problems associated with long-distance journeys

Long-distance travel, for business or pleasure, is becoming increasingly common. Any long journey, whether by plane, road or rail, will be associated with "travel fatigue", the combined effects of a changed routine (particularly sleep loss and altered meals) and the general disruption caused by travel. Planning any trip well in advance will minimise many of these problems, but some factors are less easy to guard against; these include sitting in cramped and uncomfortable conditions and, with flights, the hypoxic environment in the cabin. After arrival at a destination in another country, there can be problems with language, altered food and different customs. If the flight has crossed the equator, then there is also likely to be a change in season and natural lighting, and if the flight has, additionally or alternatively, crossed several time zones, then there will also be the problem of "jet lag", caused by a transient dyssynchrony between the "body clock" and the new local time. The new environment might differ from the place of departure with regard to ambient temperature and humidity, altitude, natural lighting (and hence exposure to ultra-violet radiation) and pollution. In all cases, the traveller needs to be aware of these changes before setting off, so that appropriate preparations (different clothing, for example) can be made.

Waking at night to smoke as a marker for tobacco dependence: patient characteristics and relationship to treatment outcome

AIM

This study aimed to describe the characteristics of treatment-seeking patients who wake at night to smoke (night-smoking), identify factors that may be associated with night-smoking, and assess the association between night-smoking and treatment outcome.

METHODS

A total of 2312 consecutive eligible cigarette smokers who sought treatment at a specialist tobacco-dependence clinic declared a Target Quit Date, provided baseline information at assessment, and were then followed-up 4 and 26 weeks after their target quit date.

RESULTS

Of the total sample, 51.1% were identified as night-smokers and 25.1% reported smoking abstinence at 26-week follow-up. Night-smoking was associated with a number of other patient characteristics, including African-American race or Hispanic ethnicity, having smoking-related medical symptoms, having been treated for a behavioural health problem, smoking mentholated cigarettes, smoking within 30 min of waking in the morning, increased cigarettes smoked per day, and not having private health insurance. In multivariate analyses, night-smoking at assessment remained a significant predictor of smoking at 26-week follow-up when controlling for other factors associated with treatment outcome (adjusted odds ratio: 0.77, 95% confidence interval: 0.62-0.96). Night-smokers also experienced a shorter average time to relapse (38.5 vs. 56 days, p<0.0001).

CONCLUSIONS

Several socioeconomic and tobacco use characteristics are shared among patients who wake at night to smoke. This behaviour can be assessed by a simple question and used as a marker for tobacco dependence and as an indicator that more intensive and sustained treatment may be required.

Prevalence of self-reported neuropathic pain and impact on quality of life: a prospective representative survey

BACKGROUND

Data on the incidence of neuropathic pain (NeP) in Austria, its general characteristics and consequences for the quality of life (QOL) are still lacking. The prevalence in the United Kingdom is 8%.

METHODS

A representative survey (n=7707) was carried out. Patients with NeP were identified using previously validated criteria and subsequently asked to complete a questionnaire on QOL and detailed pain characteristics.

RESULTS

The prevalence of NeP was 3.3% (n=260). A higher prevalence was found in 41-50-year-olds (26%) and 51-60 year olds (24%). Pain was long lasting (>1 year: 66%; >5 years: 41%) and severe at onset (mean 6.8; numerical rating scale) as well as later (mean 4.7; 20% 8 or higher). Strong or predominant restriction of daily activities was reported in 65%, strong or predominant sleep disturbances in 60%, feelings of depression in 34% and anxiety in 25%.

CONCLUSION

For the first time, data on the prevalence of NeP in Austria are available. Pain patterns in those affected are characteristic and impact on QOL as well as pain intensity are severe.

Overweight hypothesis in asthma and eczema in young adolescents

BACKGROUND

A positive association between body mass index (BMI) and allergic diseases has recently been suggested; however the sex-dependence of this association remains controversial. The aim of the present study was to explore the relationship between BMI and asthma and eczema, as well as its sex-dependence in young adolescents.

METHODS

Self-reported data obtained through the standardized International Study of Asthma and Allergies in Childhood (ISAAC) Phase Three written questionnaires of 2926 young adolescents aged 13-14 years old from randomly selected schools in Skopje (Republic of Macedonia) were used. The BMI for each individual was calculated and used-both unadjusted and adjusted for confounding factors-as a variable for analysis. The international cut-off points for BMI for overweight and obesity by sex and age were used. Because of the very low prevalence of obesity (1.5 %), obese respondents were included in the overweight group. The data were statistically analyzed by the chi-square test, the t-test for independent samples and odds ratios (OR, 95 % CI) in binary logistic regression.

RESULTS

Being overweight was significantly associated with an increased risk of having a dry night cough without a cold or chest infection (adjusted OR: 1.54; 95 % CI: 1.09-2.16; p = 0.01) and with having had self-reported asthma at some time (adjusted OR: 2.36; 95 % CI: 1.02-5.44; p = 0.04) in boys only. A significant association between overweight and other symptoms of asthma or atopic eczema was not established.

CONCLUSION

These findings suggest a male-specific positive association between overweight and a current dry night cough and having received a diagnosis of asthma at some time. No association was found with other asthma symptoms or atopic eczema in young adolescents.

Sleep Exacerbation of Persistent Sexual Arousal Syndrome in a Postmenopausal Woman

AIM

To investigate possible causes and treatment of persistent sexual arousal syndrome, which was exacerbated by sleep onset, in a postmenopausal subject.

METHODS

A clinical examination and interviews with the patient to obtain her case history and follow-up of the effects of drug treatments. Pretreatment laboratory investigations monitored vaginal blood flow by photoplethysmography and heated electrode. Routine blood chemistry and endocrine assessments were undertaken. Magnetic resonance imaging (MRI) scans of brain, pelvis, and spinal cord and genito-sensory neural analysis of clitoral and vaginal areas were performed. A selective internal iliac artery arteriogram was utilized to check the normality of the pelvic blood supply.

RESULTS

Genitalia appeared normal and uncongested. No structural abnormalities were observed in the MRI scans. Hormonal levels and blood chemistry were commensurate with the subject's postmenopausal status. Basal vaginal blood flow (heat electrode) was within the range of normal premenopausal women and showed (photoplethysmography) normal vasomotion. On becoming drowsy and falling lightly asleep in the laboratory the vaginal pulse amplitude (VPA) increased by 95% of the basal value and the low-amplitude VPAs were replaced by high-amplitude VPAs--all evidence of increased vaginal blood flow and congestion and confirming the subject's complaint of persistent sexual arousal during sleep. A simple cognitive task of repeatedly subtracting 7 from 500 out aloud did not hasten the reversion to the basal level. There was no evidence of malfunction of the brain, spinal cord, or pelvic area by MRI but genito-sensory analysis of the clitoral and vaginal area showed evidence of reduced sensory function.

CONCLUSIONS

Of the treatments tried only risperidone has been effective allowing the subject to sleep throughout the night without disturbance and according to the subject has significantly reduced the aggravation of the arousal during the day.

Late-onset, "Gastaut type", childhood occipital epilepsy: an unusual evolution

We report on two girls and one boy with clinical and electroencephalographic features of late-onset childhood epilepsy with occipital paroxysms of the "Gastaut type", showing an unusual evolution. Neurological examination and brain imaging were normal in all three. At the age of 7.5 years, eight years and ten years respectively, the three children presented with episodes of visual symptoms when awake, and in one of them, the seizures were occasionally followed by oculocephalic deviation. The interictal EEG showed bilateral occipital spike-wave activated by eye closing. In two patients, the occipital seizures had been immediately followed by typical absences, since onset; in the other patient, five months after onset. The ictal EEG showed irregular bilateral occipital spike-wave discharges during the visual symptoms, followed by generalized spike-wave activity during the typical absences. The typical absences were activated by hyperventilation; the EEG did not show continuous spikes and waves during slow sleep. These three patients, with typical electroclinical features of "Gastaut type", childhood occipital epilepsy, demonstrated an evolution which, to our knowledge, has not been previously described. We investigated whether this unusual, age-dependent evolution was due to secondary bilateral synchrony or if these electroclinical features represent two types of idiopathic epileptic syndromes in the same patients.

Ictal video-polysomnography and EEG spectral analysis in a child with severe Panayiotopoulos syndrome

OBJECTIVE

To describe the ictal polysomnographic features of a patient with Panayiotopoulos syndrome, a peculiar epileptic syndrome characterized by infrequent, often single, prolonged, nocturnal, focal seizures comprising an unusual constellation of autonomic symptoms (malaise, nausea, pallor, tachycardia, vomiting) and unilateral deviation of the eyes at the onset of seizures. These clinical, ictal manifestations are rarely followed by post-ictal headache. In the literature, there is little information on the ictal EEG characteristics of Panayiotopoulos syndrome and, in particular, on certain autonomic manifestations, such as tachycardia, as the sole ictal phenomena at the onset of seizures.

METHODS AND RESULTS

One, all-night videopolysomnography, during which one seizure was recorded. Video-EEG data were evaluated visually and by means of quantitative spectral analysis. The spectral analysis of the recorded seizure showed a complex ictal pattern of cortical involvement with focal onset in the right occipital area followed by the recruitment of widespread extra-occipital cortical regions.

CONCLUSIONS

This is the first such analysis of this peculiar epileptic condition. Most of the symptoms were consistent with a diagnosis of severe Panayiotopoulos syndrome, although the patient also presented "atypical findings": a relatively high frequency of seizures, post-ictal headache, no spontaneous remission of seizures with age, and late onset of visual hallucinations; this last finding is more frequent in "Gastaut-type childhood occipital epilepsy", in which onset typically occurs later than in Panayiotopoulos syndrome. [Published with video sequences].

Tonic status epilepticus in patients with idiopathic generalized epilepsy

RATIONALE

Tonic status epilepticus (TSE) in patients with idiopathic generalized epilepsy (IGE) is not well recognized. The objective of this study is to report episodes of TSE in patients with IGE.

METHODS

We retrospectively reviewed the clinical and EEG evaluation of three IGE patients who presented TSE.

RESULTS

The three patients had mainly clinical features of IGE, but had developed, in addition, focal discharges, diffuse EEG abnormalities and some focal or diffuse neuropsychological dysfunction. The tonic attacks eventually responded to treatment, but were not completely controlled in any of the patients.

DISCUSSION

The continuum between IGE and secondary generalized epilepsy is demonstrated in these patients. Most of their clinical and EEG features are however, in keeping with an idiopathic generalized epileptic process with additional focal and diffuse components. Recognition of the significance of TSE in such patients has important therapeutic and prognostic implications. [Published with video sequences].

Opioids for non-operable osteoarthritis and soft-tissue rheumatism

Reviews of oral opioid trials have shown that many side-effects need to be considered when treating patients with non-operable osteoarthritis and soft-tissue problems. European and American guidelines recommend their use with or without paracetamol. The controversy surrounding the use of non-steroidal anti-inflammatory drugs/cyclo-oxygenase-2 inhibitors is limiting physician and patient choices. There is a great need for alternative medication or ways of using current compounds.

Akathisia, restless legs and periodic limb movements in sleep in Parkinson's disease

Restless legs syndrome (RLS) symptoms are often reported in Parkinson's disease (PD), but prevalence studies of RLS in PD are few and the results are inconsistent. In addition, clinical overlapping between RLS, "wearing-off"-related lower limb discomfort and restlessness, and akathisia complicate the clinical assessments of true RLS in PD. Underlying pathophysiology potentially shared by RLS and PD is mainly suggested by similarities in treatment response. Functional imaging studies in RLS are still inconclusive, although some authors have found subtle deficits in nigrostriatal terminal function. Long-term prospective studies of RLS cohorts will clarify whether or not RLS is associated with an increased risk for development of PD.