Positional therapy for obstructive sleep apnea: an objective measurement of patients' usage and efficacy at home.

BACKGROUND: Positional therapy that prevents patients from sleeping supine has been used for many years to manage positional obstructive sleep apnea (OSA). However, patients' usage at home and the long term efficacy of this therapy have never been objectively assessed.¦METHODS: Sixteen patients with positional OSA who refused or could not tolerate continuous positive airway pressure (CPAP) were enrolled after a test night study (T0) to test the efficacy of the positional therapy device. The patients who had a successful test night were instructed to use the device every night for three months. Nightly usage was monitored by an actigraphic recorder placed inside the positional device. A follow-up night study (T3) was performed after three months of positional therapy.¦RESULTS: Patients used the device on average 73.7 ± 29.3% (mean ± SD) of the nights for 8.0 ± 2.0 h/night. 10/16 patients used the device more than 80% of the nights. Compared to the baseline (diagnostic) night, mean apnea-hypopnea index (AHI) decreased from 26.7 ± 17.5 to 6.0 ± 3.4 with the positional device (p<0.0001) during T0 night. Oxygen desaturation (3%) index also fell from 18.4 ± 11.1 to 7.1 ± 5.7 (p = 0.001). Time spent supine fell from 42.8 ± 26.2% to 5.8 ± 7.2% (p < 0.0001). At three months (T3), the benefits persisted with no difference in AHI (p = 0.58) or in time spent supine (p = 0.98) compared to T0 night. The Epworth sleepiness scale showed a significant decrease from 9.4 ± 4.5 to 6.6 ± 4.7 (p = 0.02) after three months.¦CONCLUSIONS: Selected patients with positional OSA can be effectively treated by a positional therapy with an objective compliance of 73.7% of the nights and a persistent efficacy after three months.

Sleep disorders in boys with Duchenne muscular dystrophy

Introduction La dystrophie musculaire de Duchenne (DMD) est une myopathie progressive liée au chromosome X qui atteint environ un garçon sur 3500. Des troubles du sommeil (TDS) sont fréquemment rapportés par ces patients Les études effectuées à ce jour se sont essentiellement concentrées sur les troubles respiratoires liés au sommeil. Les TDS débutent toutefois fréquemment avant l'installation d'un trouble ventilatoire nocturne et de nombreux autres facteurs peuvent en être la cause. Objectif L'objectif de cette étude est d'évaluer la fréquence des TDS chez les garçons avec une DMD et d'en identifier les facteurs de risque. Méthode II s'agit d'une étude transversale effectuée par questionnaire postal adressé aux parents de tout garçon âgé de 4-18 ans avec une DMD, suivi dans deux centres tertiaires de réhabilitation pédiatrique (Lausanne et Dublin). Les TDS sont évalués à l'aide de la 'Sleep Disturbance Scale for Children' (SDSC), validée sur 1157 enfants sains. Elle permet d'obtenir un score total et des scores pour six facteurs représentant les TDS les plus fréquents (troubles de l'endormissement et du maintien du sommeil (TEMS), éveil nocturne-cauchemars, transition veille-sommeil, somnolence diurne excessive, troubles respiratoires associés au sommeil (TRS), hyperhidrose du sommeil). Un T- score supérieur à 70 (>2DS) est considéré comme pathologique. Les associations potentielles entre des scores pathologiques et des facteurs individuels (âge, mobilité diurne et nocturne, douleur), thérapeutiques (orthèses nocturnes, ventilation non-invasive, médication) et environnementaux (facteurs socio-familiaux) sont évaluées à l'aide d'analyses univariées (χ2) et de régressions logistiques ascendantes. Résultats Seize garçons sur 63, soit 25.4%, présentent un score total pathologique en comparaison au 3% attendus dans la population générale. Les TEMS (29.7%), les TRS (15.6%) et l'hyperhidrose du sommeil (14.3%) sont les TDS les plus prévalent. Le besoin d'être mobilisé la nuit par un tiers (OR=9.4; 95%CI: 2.2-40.7; p=0.003) et être l'enfant d'une famille monoparentale (OR=7.2; 95%CI: 1.5-35.1; p=0.015) sont des facteurs de risque indépendants pour un score total pathologique. Le besoin d'être mobilisé la nuit par un tiers (OR=18.0; 95%CI: 2.9¬110.6; p=0.002), le traitement par corticostéroïdes (OR=7.7; 95%CI: 1.4-44.0; p-0.021) et être l'enfant d'une famille monoparentale (OR=7.0; 95%CI: 1.3-38.4; p=0.025) sont des facteurs de risque indépendants pour un TEMS. Discussion Cette étude montre une prévalence élevée des TDS chez les garçons avec une DMD (25% contre 3% attendus dans la population générale). Le besoin d'être mobilisé la nuit par un tiers est identifié comme un facteur de risque important pour un score total pathologique et un TEMS. Il reflète vraisemblablement un degré d'atteinte motrice tel qu'il limite les mouvements spontanés et les adaptations posturales du sommeil, ayant pour conséquence une diminution importante de la qualité du sommeil. Les enfants vivant dans un foyer monoparental présentent plus fréquemment un score total pathologique et des TEMS, possiblement en lien avec un stress psychologique plus important dans ces familles. Le traitement par corticostéroïdes est identifié comme facteur de risque pour un TEMS. Une adaptation du schéma ou du dosage permet généralement de limiter cet effet secondaire. Si nécessaire, un traitement par Mélatonine peut être instauré. Aucune association n'a pu être mise en évidence entre les facteurs analysés et les TRS, possiblement en raison du petit nombre de garçons ayant rapporté de tels symptômes et du fait que certains symptômes d'hypoventilation nocturne ne sont pas évalués par la SDSC. Par ailleurs, la valeur prédictive de l'anamnèse, comme celle des fonctions pulmonaires diurnes, est connue pour être limitée, raison pour laquelle une oxy-capnométrie est effectuée de routine en dessous d'une capacité vitale forcée de 50%. Elle permet, si nécessaire, l'instauration précoce d'une ventilation non-invasive, limitant ainsi vraisemblablement l'impact de ('hypoventilation nocturne sur la qualité du sommeil dans notre population. Plusieurs limitations sont à évoquer. Le petit nombre de patients ne permet pas d'exclure d'autres associations potentielles. La nature transversale de l'étude augmente le risque de causalité inverse. Cette étude n'inclut pas de mesure quantitative du sommeil. Les questionnaires adressés aux parents ont toutefois pu être démontrés comme fiables hormis pour les TRS. Un biais de non-réponse ne peut pas être totalement exclu, bien que le taux de réponse soit élevé (86,5%) et qu'il n'y ait pas de différence significative entre les populations de répondeurs et non-répondeurs. Conclusion La prévalence des TDS est élevée chez les garçons avec une DMD et leurs causes sont multiples. Les facteurs de risques sont physiques (immobilité nocturne), pharmacologiques (corticothérapie) et environnementaux (famille monoparentale). Compte tenu de son impact sur la qualité de vie, l'évaluation du sommeil doit être systématique en consultation et ne pas se limiter aux seuls troubles ventilatoires nocturnes.

Genetics of normal and pathological sleep in humans.

The complexity of sleep-wake regulation, in addition to the many environmental influences, includes genetic predisposing factors, which begin to be discovered. Most of the current progress in the study of sleep genetics comes from animal models (dogs, mice, and drosophila). Multiple approaches using both animal models and different genetic techniques are needed to follow the segregation and ultimately to identify 'sleep genes' and molecular bases of sleep disorders. Recent progress in molecular genetics and the development of detailed human genome map have already led to the identification of genetic factors in several complex disorders. Only a few genes are known for which a mutation causes a sleep disorder. However, single gene disorders are rare and most common disorders are complex in terms of their genetic susceptibility, environmental factors, gene-gene, and gene-environment interactions. We review here the current progress in the genetics of normal and pathological sleep and suggest a few future perspectives.

Sleep deprivation (SD) on focal brain ischemia in the rat : effects of different SD protocols

Sleep-wake disturbances are frequently observed in stroke patients and are associated with poorer functional outcome. Until now the effects of sleep on stroke evolution are unknown. The purpose of the present study was to evaluate the effects of three sleep deprivation (SD) protocols on brain damages after focal cerebral ischemia in a rat model. Permanent occlusion of distal branches of the middle cerebral artery was induced in adult rats. The animals were then subjected to 6h SD, 12h SD or sleep disturbances (SDis) in which 3 x 12h sleep deprivation were performed by gentle handling. Infarct size and brain swelling were assessed by Cresyl violet staining, and the number of damaged cells was measured by terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) staining. Behavioral tests, namely tape removal and cylinder tests, were performed for assessing sensorimotor function. In the 6h SD protocol, no significant difference (P > 0.05) was found either in infarct size (42.5 ± 30.4 mm3 in sleep deprived animals vs. 44.5 ± 20.5 mm3 in controls, mean ± s.d.), in brain swelling (10.2 ± 3.8 % in sleep deprived animals vs. 11.3 ± 2.0 % in controls) or in number of TUNEL-positive cells (21.7 ± 2.0/mm2 in sleep deprived animals vs. 23.0 ± 1.1/mm2 in controls). In contrast, 12h sleep deprivation increased infarct size by 40 % (82.8 ± 10.9 mm3 in SD group vs. 59.2 ± 13.9 mm3 in control group, P = 0.008) and number of TUNEL-positive cells by 137 % (46.8 ± 15/mm in SD group vs. 19.7 ± 7.7/mm2 in control group, P = 0.003). There was no significant difference (P > 0.05) in brain swelling (12.9 ± 6.3 % in sleep deprived animals vs. 11.6 ± 6.0 % in controls). The SDis protocol also increased infarct size by 76 % (3 x 12h SD 58.8 ± 20.4 mm3 vs. no SD 33.8 ± 6.3 mm3, P = 0.017) and number of TUNEL-positive cells by 219 % (32.9 ± 13.2/mm2 vs. 10.3 ± 2.5/mm2, P = 0.008). Brain swelling did not show any difference between the two groups (24.5 ± 8.4 % in SD group vs. 16.7 ± 8.9 % in control group, p > 0.05). Both behavioral tests did not show any concluding results. In summary, we demonstrate that sleep deprivation aggravates brain damages in a rat model of stroke. Further experiments are needed to unveil the mechanisms underlying these effects.

Self-reported non-adherence to antiretroviral therapy repeatedly assessed by two questions predicts treatment failure in virologically suppressed patients.

BACKGROUND: The aim of this study was to explore the predictive value of longitudinal self-reported adherence data on viral rebound. METHODS: Individuals in the Swiss HIV Cohort Study on combined antiretroviral therapy (cART) with RNA <50 copies/ml over the previous 3 months and who were interviewed about adherence at least once prior to 1 March 2007 were eligible. Adherence was defined in terms of missed doses of cART (0, 1, 2 or >2) in the previous 28 days. Viral rebound was defined as RNA >500 copies/ml. Cox regression models with time-independent and -dependent covariates were used to evaluate time to viral rebound. RESULTS: A total of 2,664 individuals and 15,530 visits were included. Across all visits, missing doses were reported as follows: 1 dose 14.7%, 2 doses 5.1%, >2 doses 3.8% taking <95% of doses 4.5% and missing > or =2 consecutive doses 3.2%. In total, 308 (11.6%) patients experienced viral rebound. After controlling for confounding variables, self-reported non-adherence remained significantly associated with the rate of occurrence of viral rebound (compared with zero missed doses: 1 dose, hazard ratio [HR] 1.03, 95% confidence interval [CI] 0.72-1.48; 2 doses, HR 2.17, 95% CI 1.46-3.25; >2 doses, HR 3.66, 95% CI 2.50-5.34). Several variables significantly associated with an increased risk of viral rebound irrespective of adherence were identified: being on a protease inhibitor or triple nucleoside regimen (compared with a non-nucleoside reverse transcriptase inhibitor), >5 previous cART regimens, seeing a less-experienced physician, taking co-medication, and a shorter time virally suppressed. CONCLUSIONS: A simple self-report adherence questionnaire repeatedly administered provides a sensitive measure of non-adherence that predicts viral rebound.

Dreaming without REM sleep.

To test whether mental activities collected from non-REM sleep are influenced by REM sleep, we suppressed REM sleep using clomipramine 50mg (an antidepressant) or placebo in the evening, in a double blind cross-over design, in 11 healthy young men. Subjects were awakened every hour and asked about their mental activity. The marked (81%, range 39-98%) REM-sleep suppression induced by clomipramine did not substantially affect any aspects of dream recall (report length, complexity, bizarreness, pleasantness and self-perception of dream or thought-like mentation). Since long, complex and bizarre dreams persist even after suppressing REM sleep either partially or totally, it suggests that the generation of mental activity during sleep is independent of sleep stage.

Sleep function: current questions and new approaches.

The mammalian brain oscillates through three distinct global activity states: wakefulness, non-rapid eye movement (NREM) sleep and REM sleep. The regulation and function of these 'vigilance' or 'behavioural' states can be investigated over a broad range of temporal and spatial scales and at different levels of functional organization, i.e. from gene expression to memory, in single neurons, cortical columns or the whole brain and organism. We summarize some basic questions that have arisen from recent approaches in the quest for the functions of sleep. Whereas traditionally sleep was viewed to be regulated through top-down control mechanisms, recent approaches have emphasized that sleep is emerging locally and regulated in a use-dependent (homeostatic) manner. Traditional markers of sleep homeostasis, such as the electroencephalogram slow-wave activity, have been linked to changes in connectivity and plasticity in local neuronal networks. Thus waking experience-induced local network changes may be sensed by the sleep homeostatic process and used to mediate sleep-dependent events, benefiting network stabilization and memory consolidation. Although many questions remain unanswered, the available data suggest that sleep function will best be understood by an analysis which integrates sleep's many functional levels with its local homeostatic regulation.

CD40 activation induces NREM sleep and modulates genes associated with sleep homeostasis.

The T-cell derived cytokine CD40 ligand is overexpressed in patients with autoimmune diseases. Through activation of its receptor, CD40 ligand leads to a tumor necrosis factor (TNF) receptor 1 (TNFR1) dependent impairment of locomotor activity in mice. Here we report that this effect is explained through a promotion of sleep, which was specific to non-rapid eye movement (NREM) sleep while REM sleep was suppressed. The increase in NREM sleep was accompanied by a decrease in EEG delta power during NREM sleep and by a decrease in the expression of transcripts in the cerebral cortex known to be associated with homeostatic sleep drive, such as Homer1a, Early growth response 2, Neuronal pentraxin 2, and Fos-like antigen 2. The effect of CD40 activation was mimicked by peripheral TNF injection and prevented by the TNF blocker etanercept. Our study indicates that sleep-wake dysregulation in autoimmune diseases may result from CD40 induced TNF:TNFR1 mediated alterations of molecular pathways, which regulate sleep-wake behavior.

NPAS2 as a transcriptional regulator of non-rapid eye movement sleep: genotype and sex interactions.

Because the transcription factor neuronal Per-Arnt-Sim-type signal-sensor protein-domain protein 2 (NPAS2) acts both as a sensor and an effector of intracellular energy balance, and because sleep is thought to correct an energy imbalance incurred during waking, we examined NPAS2's role in sleep homeostasis using npas2 knockout (npas2-/-) mice. We found that, under conditions of increased sleep need, i.e., at the end of the active period or after sleep deprivation (SD), NPAS2 allows for sleep to occur at times when mice are normally awake. Lack of npas2 affected electroencephalogram activity of thalamocortical origin; during non-rapid eye movement sleep (NREMS), activity in the spindle range (10-15 Hz) was reduced, and within the delta range (1-4 Hz), activity shifted toward faster frequencies. In addition, the increase in the cortical expression of the NPAS2 target gene period2 (per2) after SD was attenuated in npas2-/- mice. This implies that NPAS2 importantly contributes to the previously documented wake-dependent increase in cortical per2 expression. The data also revealed numerous sex differences in sleep; in females, sleep need accumulated at a slower rate, and REMS loss was not recovered after SD. In contrast, the rebound in NREMS time after SD was compromised only in npas2-/- males. We conclude that NPAS2 plays a role in sleep homeostasis, most likely at the level of the thalamus and cortex, where NPAS2 is abundantly expressed.

Prevalence of measured and reported multimorbidity in a representative sample of the Swiss population.

BACKGROUND: Little is known on the prevalence of multimorbidity (MM) in the general population. We aimed to assess the prevalence of MM using measured or self-reported data in the Swiss population. METHODS: Cross-sectional, population-based study conducted between 2003 and 2006 in the city of Lausanne, Switzerland, and including 3714 participants (1967 women) aged 35 to 75 years. Clinical evaluation was conducted by thoroughly trained nurses or medical assistants and the psychiatric evaluation by psychologists or psychiatrists. For psychiatric conditions, two definitions were used: either based on the participant's statements, or on psychiatric evaluation. MM was defined as presenting ≥2 morbidities out of a list of 27 (self-reported - definition A, or measured - definition B) or as the Functional Comorbidity Index (FCI) using measured data - definition C. RESULTS: The overall prevalence and (95% confidence interval) of MM was 34.8% (33.3%-36.4%), 56.3% (54.6%-57.9%) and 22.7% (21.4%-24.1%) for definitions A, B and C, respectively. Prevalence of MM was higher in women (40.2%, 61.7% and 27.1% for definitions A, B and C, respectively, vs. 28.7%, 50.1% and 17.9% in men, p < 0.001); Swiss nationals (37.1%, 58.8% and 24.8% for definitions A, B and C, respectively, vs. 31.4%, 52.3% and 19.7% in foreigners, all p < 0.001); elderly (>65 years: 67.0%, 70.0% and 36.7% for definitions A, B and C, respectively, vs. 23.6%, 50.2% and 13.8% for participants <45 years, p < 0.001); participants with lower educational level; former smokers and obese participants. Multivariate analysis confirmed most of these associations: odds ratio (95% Confidence interval) 0.55 (0.47-0.64), 0.61 (0.53-0.71) and 0.51 (0.42-0.61) for men relative to women for definitions A, B and C, respectively; 1.27 (1.09-1.49), 1.29 (1.11-1.49) and 1.41 (1.17-1.71) for Swiss nationals relative to foreigners, for definitions A, B and C, respectively. Conversely, no difference was found for educational level for definitions A and B and abdominally obese participants for all definitions. CONCLUSIONS: Prevalence of MM is high in the Lausanne population, and varies according to the definition or the data collection method.

Key electrophysiological, molecular, and metabolic signatures of sleep and wakefulness revealed in primary cortical cultures.

Although sleep is defined as a behavioral state, at the cortical level sleep has local and use-dependent features suggesting that it is a property of neuronal assemblies requiring sleep in function of the activation experienced during prior wakefulness. Here we show that mature cortical cultured neurons display a default state characterized by synchronized burst-pause firing activity reminiscent of sleep. This default sleep-like state can be changed to transient tonic firing reminiscent of wakefulness when cultures are stimulated with a mixture of waking neurotransmitters and spontaneously returns to sleep-like state. In addition to electrophysiological similarities, the transcriptome of stimulated cultures strikingly resembles the cortical transcriptome of sleep-deprived mice, and plastic changes as reflected by AMPA receptors phosphorylation are also similar. We used our in vitro model and sleep-deprived animals to map the metabolic pathways activated by waking. Only a few metabolic pathways were identified, including glycolysis, aminoacid, and lipids. Unexpectedly large increases in lysolipids were found both in vivo after sleep deprivation and in vitro after stimulation, strongly suggesting that sleep might play a major role in reestablishing the neuronal membrane homeostasis. With our in vitro model, the cellular and molecular consequences of sleep and wakefulness can now be investigated in a dish.

Systematic review o f the Perforation Risk in S tenosing Eosinophilic Esophagitis: D ilation is much s afer than initially reported

Background a nd A ims: D ilation of stenosing EosinophilicEsophagitis (EoE) is considered a high-risk procedure asperforation rates o f up to 9% of patients h ave been reported.Goal: To systematically e valuate the dilation-associatedperforation risk in stenosing EoE.Methods: A systematic review of the literature was performedusing pubmed and Embase. Keywords used were "eosinophilicesophagitis", "dilation", "perforation", and "complications".Results: F rom 2002 to 2007 7 case s eries including 85patients r eported perforations i n 5 patients ( perforation r ate6%). The highest perforation rate was reported in a series of 36patients d ocumenting 3 perforations ( 9%). In 2 010 and 2011three large studies r eporting o n a total o f 404 patientsdocumented a perforation in 3 patients (0.74%). The perforationrate reported in small case series before 2010 was significantlyhigher compared to the r ates since 2 010 ( P <0.001). Theoverall p erforation frequency is 8 /489 patients (1.6%). Amedian of 3 endoscopic sessions with dilations were performedper patient, thereby leading to a perforation rate of 0.53% perendoscopy. Follow-up information on EoE p atients w ithperforation was available in 6 s tudies, all patients c ould bemanaged conservatively, dilation-associated mortality waszero.Conclusions: D ilation of stenosing EoE h as a m uch lowerperforation risk as r eported in e arlier c ase series. Theperforation rate per endoscopy (0.53%) is much lower than theone reported for d ilation of achalasia ( 2-4%). T aking intoaccount t he latest data, dilation of stenosing EoE c an beregarded as a safe procedure.

How to keep the brain awake? : pharmacogenomics and aging effects on sleep-wake regulation in inbred mice

ABSTRACT : Genetic approach in the sleep field is at the beginning of its wide expansion. Transitions between sleep and wakefulness, and the maintenance of these states are driven by complex neurobiologic mechanisms with reciprocal interactions. Impairment in both transitions and maintenance of behavioral states leads to debilitating conditions. The major symptom being excessive daytime sleepiness, characterizing most sleep disorders but also a wide variety of psychiatric and neurologic disorders, as well as the elderly. Until now, most wake-promoting drugs available directly (e.g., amphetamines and possibly modafinil) or indirectly (e.g., caffeine) provokes dopamine release which is believed to influence the abuse potential of these drugs. The effects of genetic components were assessed here, on drug-induced wakefulness and age-related sleep changes in three inbred mouse strains [AKR/J, C57BL/6J, DBA/2J] that differ in their major sleep phenotypes. Three wake-promoting drugs were used; d-amphetamine, a classical stimulant, modafinil, the most widely-prescribed stimulant, and YKP-10A, a novel wake-promoting agent with antidepressant proprieties. Electrical activity (Electroencephalogram) and gene expression of the brain were assessed and indicate a highly genotype-dependant response to wake promotion and subsequent recovery sleep. Aging effects on sleep-wake regulation were also strongly influenced by genetic determinants. By assessing the age-dependant effects at several time points (from 3 months to 2 years old mice), we found a strong genetic effect on vigilance states. These studies demonstrate a critical role for genetic factors neglected till now in the fields of pharmacology and aging effects on vigilance states.

Corynebacterium bovis shoulder prosthetic joint infection: the first reported case.

We report the first case of Corynebacterium bovis shoulder prosthetic joint infection. The organism was isolated from intraoperative tissue culture and from the removed prosthesis using sonication. A 2-stage exchange and 3 months of antibiotic therapy were performed. C. bovis may cause implant-associated infections, which can manifest as low-grade infection.