The use of nasal dilator strips as a placebo for trials evaluating continuous positive airway pressure

OBJECTIVES: The aim of the current study was to compare the objective and subjective effects of continuous positive airway pressure to the use of nasal dilator strips in patients with acromegaly and moderate to severe obstructive sleep apnea. METHODS: We studied 12 patients with acromegaly and moderate to severe obstructive sleep apnea (male/females = 8/4, age = 52 +/- 8 ys, body mass index = 33.5 +/- 4.6 Kg/m(2), apnea-hypopnea index = 38 +/- 14 events/h) who had been included in a randomized, crossover study to receive three months of treatment with continuous positive airway pressure and nasal dilator strips. All patients were evaluated at study entry and at the end of each treatment by polysomnography, and Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index and treatment satisfaction questionnaires. ClinicalTrials.gov: NCT01265121 RESULTS: The apnea-hypopnea index values decreased significantly with continuous positive airway pressure treatment but did not change with the use of nasal dilator strips. All of the subjective symptoms improved with both treatments, but these improvements were significantly greater with continuous positive airway pressure than with the nasal dilator strips. CONCLUSION: The use of nasal dilator strips had a much smaller effect on the severity of obstructive sleep apnea in patients with acromegaly and moderate to severe obstructive sleep apnea in comparison to the use of continuous positive airway pressure. Moreover, the improvement in several subjective parameters without any significant objective improvement in obstructive sleep apnea resulting from the use of nasal dilator strips is compatible with a placebo effect.

Quality of sleep and quality of life in adolescents infected with human immunodeficiency virus

Objectives: To assess sleep characteristics of adolescents infected by HIV, and to ascertain whether psychosocial aspects are associated to the quality of sleep. Methods: A cross-sectional study assessing 102 HIV-infected adolescents of both genders, aged between 10 and 20 years-old and 120 Controls. Data collection was performed by applying the Sleep Disturbance Scale for Children, the Epworth Sleepiness Scale, and the Pediatric Quality of Life Inventory. Results: A sleep disturbance prevalence of 77.4% was found in patients, and a 75% prevalence in controls, and there was correlation between quality of sleep and of life. HIV-infected adolescents scored higher for sleep breathing disorders and had higher prevalence of excessive daytime sleepiness. Conclusions: HIV-infected adolescents had similar quality of sleep compared to healthy adolescents. This may be explained by the steady improvements in daily living as a result of successful anti-retroviral therapy, and by the vulnerability that affects Brazilian adolescents living in major urban centers.

What do medical students think about their quality of life? A qualitative study

Background: Medical education can affect medical students' physical and mental health as well as their quality of life. The aim of this study was to assess medical students' perceptions of their quality of life and its relationship with medical education. Methods: First-to sixth-year students from six Brazilian medical schools were interviewed using focus groups to explore what medical student's lives are like, factors related to increases and decreases of their quality of life during medical school, and how they deal with the difficulties in their training. Results: Students reported a variety of difficulties and crises during medical school. Factors that were reported to decrease their quality of life included competition, unprepared teachers, excessive activities, and medical school schedules that demanded exclusive dedication. Contact with pain, death and suffering and harsh social realities influence their quality of life, as well as frustrations with the program and insecurity regarding their professional future. The scarcity of time for studying, leisure activities, relationships, and rest was considered the main factor of influence. Among factors that increase quality of life are good teachers, classes with good didactic approaches, active learning methodologies, contact with patients, and efficient time management. Students also reported that meaningful relationships with family members, friends, or teachers increase their quality of life. Conclusion: Quality of teachers, curricula, healthy lifestyles related to eating habits, sleep, and physical activity modify medical students' quality of life. Lack of time due to medical school obligations was a major impact factor. Students affirm their quality of life is influenced by their medical school experiences, but they also reframe their difficulties, herein represented by their poor quality of life, understood as necessary and inherent to the process of becoming doctors.

Treatment of snoring and sleep apnea syndrome with a removable mandibular advancement device in patients without TMD

INTRODUCTION: Among the sleep disorders reported by the American Academy of Sleep, the most common is obstructive sleep apnea-hypopnea syndrome (OSAHS), which is caused by difficulties in air passage and complete interruption of air flow in the airway. This syndrome is associated with increased morbidity and mortality in apneic individuals. OBJECTIVE: It was the objective of this paper to evaluate a removable mandibular advancement device as it provides a noninvasive, straightforward treatment readily accepted by patients. METHODS: In this study, 15 patients without temporomandibular disorders (TMD) and with excessive daytime sleepiness or snoring were evaluated. Data were collected by means of: Polysomnography before and after placement of an intraoral appliance, analysis of TMD signs and symptoms using a patient history questionnaire, muscle and TMJ palpation. RESULTS: After treatment, the statistical analysis (t-test, and the "before and after" test) showed a mean reduction of 77.6% (p=0.001) in the apnea-hypopnea index, an increase in lowest oxyhemoglobin saturation (p=0.05), decrease in desaturation (p=0.05), decrease in micro-awakenings or EEG arousals (p=0.05) and highly significant improvement in daytime sleepiness (p=0.005), measured by the Epworth Sleepiness Scale. No TMD appeared during the monitoring period. CONCLUSION: The oral device developed in this study was considered effective for mild to moderate OSAHS.

Sleepwalking in Parkinson's disease: a questionnaire-based survey

Sleepwalking (SW) corresponds to a complex sleep-associated behavior that includes locomotion, mental confusion, and amnesia. SW is present in about 10% of children and 2-3% of adults. In a retrospective series of 165 patients with Parkinson's disease (PD), we found adult-onset ("de novo") SW "de novo" in six (4%) of them. The aim of this study was to assess prospectively and systematically the frequency and characteristics of SW in PD patients. A questionnaire including items on sleep quality, sleep disorders, and specifically also SW and REM sleep behavior disorder (RBD), PD characteristics and severity, was sent to the members of the national PD patients organization in Switzerland. In the study, 36/417 patients (9%) reported SW, of which 22 (5%) had adult-onset SW. Patients with SW had significantly longer disease duration (p = 0.035), they reported more often hallucinations (p = 0.004) and nightmares (p = 0.003), and they had higher scores, suggestive for RBD in a validated questionnaire (p = 0.001). Patients with SW were also sleepier (trend to a higher Epworth Sleepiness Scale score, p = 0.055). Our data suggest that SW in PD patients is (1) more common than in the general population, and (2) is associated with RBD, nightmares, and hallucinations. Further studies including polysomnographic recordings are needed to confirm the results of this questionnaire-based analysis, to understand the relationship between SW and other nighttime wandering behaviors in PD, and to clarify the underlying mechanisms.

Clinical, polysomnographic and genome-wide association analyses of narcolepsy with cataplexy: a European Narcolepsy Network study

The aim of this study was to describe the clinical and PSG characteristics of narcolepsy with cataplexy and their genetic predisposition by using the retrospective patient database of the European Narcolepsy Network (EU-NN). We have analysed retrospective data of 1099 patients with narcolepsy diagnosed according to International Classification of Sleep Disorders-2. Demographic and clinical characteristics, polysomnography and multiple sleep latency test data, hypocretin-1 levels, and genome-wide genotypes were available. We found a significantly lower age at sleepiness onset (men versus women: 23.74 ± 12.43 versus 21.49 ± 11.83, P = 0.003) and longer diagnostic delay in women (men versus women: 13.82 ± 13.79 versus 15.62 ± 14.94, P = 0.044). The mean diagnostic delay was 14.63 ± 14.31 years, and longer delay was associated with higher body mass index. The best predictors of short diagnostic delay were young age at diagnosis, cataplexy as the first symptom and higher frequency of cataplexy attacks. The mean multiple sleep latency negatively correlated with Epworth Sleepiness Scale (ESS) and with the number of sleep-onset rapid eye movement periods (SOREMPs), but none of the polysomnographic variables was associated with subjective or objective measures of sleepiness. Variant rs2859998 in UBXN2B gene showed a strong association (P = 1.28E-07) with the age at onset of excessive daytime sleepiness, and rs12425451 near the transcription factor TEAD4 (P = 1.97E-07) with the age at onset of cataplexy. Altogether, our results indicate that the diagnostic delay remains extremely long, age and gender substantially affect symptoms, and that a genetic predisposition affects the age at onset of symptoms.

Epilepsy and obstructive sleep apnea

A few publications documented the coexistence of epilepsy and obstructive sleep apnea (OSA). The extent, nature, and clinical relevance of this association remain poorly understood. We retrospectively reviewed the database of our sleep center to identify patients with both sleep apnea and epilepsy. Characteristics of epilepsy, sleep history, presence of excessive daytime sleepiness [Epworth Sleepiness Scale (ESS)] and polysomnographic data were assessed. The effect of continuous positive airway pressure (CPAP) on seizure reduction was prospectively analyzed after a median interval of 26 months (range: 2-116 months) from the diagnosis of OSA. OSA was found in 29 epilepsy patients (25 men and 4 women) with a median age of 56 years (range: 37-79). The median apnea hypopnea index was 33 (range: 10-85), the oxygen desaturation index was 12 (range 0-92), and 52% of the patients had an ESS score >10. In 27 patients, epilepsy appeared 1 month to 44 years prior to the diagnosis of OSA. In 21 patients, the appearance of OSA symptoms coincided with a clear increase in seizure frequency or the first appearance of a status epilepticus. Treatment with CPAP was continued with good compliance in 12 patients and led to a significant reduction of both ESS scores and seizure frequency in 4 patients. Our data suggest the importance of considering diagnosis and treatment of OSA in epilepsy patients with poor seizure control and/or reappearance of seizures after a seizure-free interval.

Sleep and wakefulness disturbances in Swiss pharmacy customers

BACKGROUND AND OBJECTIVE: Sleep disturbances are prevalent but often overlooked or underestimated. We suspected that sleep disorders might be particularly common among pharmacy customers, and that they could benefit from counselling. Therefore, we described the prevalence and severity of symptoms associated with sleep and wakefulness disorders among Swiss pharmacy customers, and estimated the need for counselling and treatment. METHODS: In 804 Swiss pharmacies (49% of all community pharmacies) clients were invited to complete the Stanford Sleep Disorders Questionnaire (SDQ), and the Epworth Sleepiness Scale (EPW). The SDQ was designed to classify symptoms of sleep and wakefulness into the four most prevalent disorders: sleep apnoea syndrome (SAS), insomnia in psychiatric disorders (PSY), periodic leg movement disorders/restless legs (RLS) and narcolepsy (NAR). Data were entered into an internet-linked database for analysis by an expert system as a basis for immediate counselling by the pharmacist. RESULTS: Of 4901 participants, 3238 (66.1%) were female, and 1663 (33.9%) were male. The mean age (SD) of females and males was 52.4 (18.05), and 55.1 (17.10) years, respectively. The percentages of female and male individuals above cut-off of SDQ subscales were 11.4% and 19.8% for sleep apnoea, 40.9% and 38.7% for psychiatric sleep disorders, 59.3% and 46.8% for restless legs, and 10.4% and 9.4% for narcolepsy respectively. The prevalence of an Epworth Sleepiness Scale score >11 was 16.5% in females, and 23.9% in males. Reliability assessed by Cronbach's alpha was 0.65 to 0.78 for SDQ subscales, and for the Epworth score. CONCLUSIONS: Symptoms of sleep and wakefulness disorders among Swiss pharmacy customers were highly prevalent. The SDQ and the Epworth Sleepiness Scale score had a satisfactory reliability to be useful for identification of pharmacy customers who might benefit from information and counselling while visiting pharmacies. The internet-based system proved to be a helpful tool for the pharmacist when counselling his customers in terms of diagnostic classification and severity of symptoms associated with the sleeping and waking state.

Screening for sleep disorders in community pharmacies--evaluation of a campaign in Switzerland

BACKGROUND: In 2003 the Swiss federation of pharmacists organized a campaign "sleep disturbances--daytime sleepiness". The goal was to assist pharmacy clients in detecting likely causes of any sleep disturbance or daytime sleepiness through a free of charge screening, and to deliver targeted counselling. For pharmacy practice there are no screening or triage guidelines to assess the severity of sleep and wakefulness disturbances and potential causes for those disturbances. In this paper the outcome of the campaign in terms of feasibility, participation, observed response patterns, sale of over-the-counter (OTC) sleeping pills, and counselling activities is evaluated. METHODS: The Stanford sleep disorders questionnaire and the Epworth sleepiness scale served to identify patterns of symptoms suggestive of four major categories of sleep disorders. The questionnaires were posted on a web-site and the clients' data were entered online in the pharmacies. A report was automatically generated and immediately available online to the pharmacists. The pharmacists documented separately their counselling activities in a pharmacist's activity report. RESULTS: Six hundred and twenty-two (23%) of 2743 pharmacy clients had response patterns suggestive of obstructive sleep apnoea, 418 (15%) of restless-legs-syndrome, 39 (1%) of a sleep disorder potentially associated with a psychiatric condition and 79 (3%) of narcolepsy. An Epworth sleepiness score >10 points was found in 567 (21%). After screening, 2345 (86%) pharmacy clients received targeted counselling. Only 216 (8%) purchased an OTC sleeping pill and 704 (26%) were recommended to consult a physician, but of these, 446 (63%) were already under medical supervision. CONCLUSIONS: The online screening tool for sleep disorders and daytime sleepiness was successfully introduced in Swiss pharmacies. Pharmacies were able to assess the pattern of individual sleep disorders and to identify a possible cause in nearly one-third of the cases.

Sleep-wake habits and disorders in a series of 100 adult epilepsy patients--a prospective study

The aim of the study was to assess sleep-wake habits and disorders and excessive daytime sleepiness (EDS) in an unselected outpatient epilepsy population. Sleep-wake habits and presence of sleep disorders were assessed by means of a clinical interview and a standard questionnaire in 100 consecutive patients with epilepsy and 90 controls. The questionnaire includes three validated instruments: the Epworth Sleepiness Scale (ESS) for EDS, SA-SDQ for sleep apnea (SA), and the Ullanlinna Narcolepsy Scale (UNS) for narcolepsy. Sleep complaints were reported by 30% of epilepsy patients compared to 10% of controls (p=0.001). The average total sleep time was similar in both groups. Insufficient sleep times were suspected in 24% of patients and 33% of controls. Sleep maintenance insomnia was more frequent in epilepsy patients (52% vs. 38%, p=0.06), whereas nightmares (6% vs. 16%, p=0.04) and bruxism (10% vs. 19%, p=0.07) were more frequent in controls. Sleep onset insomnia (34% vs. 28%), EDS (ESS >or=10, 19% vs. 14%), SA (9% vs. 3%), restless legs symptoms (RL-symptoms, 18% vs. 12%) and most parasomnias were similarly frequent in both groups. In a stepwise logistic regression model loud snoring and RL-symptoms were found to be the only independent predictors of EDS in epilepsy patients. In conclusion, sleep-wake habits and the frequency of most sleep disorders are similar in non-selected epilepsy patients as compared to controls. In epilepsy patients, EDS was predicted by a history of loud snoring and RL-symptoms but not by SA or epilepsy-related variables (including type of epilepsy, frequency of seizures, and number of antiepileptic drugs).

Is preeclampsia associated with restless legs syndrome?

OBJECTIVE Restless legs syndrome (RLS) is a common neurologic disorder. Secondary RLS includes pregnancy and iron deficiency. Prevalence of RLS in pregnancy ranges from 11% to 27%. We aimed to assess the frequency and characteristics of RLS in pregnancy in a Peruvian population and to evaluate the possible pregnancy or delivery complications due to RLS. METHODS We assessed 218 consecutive expectant mothers at the inpatient clinic of the Hospital San Bartolome in Lima, Peru. Assessment was performed by using the standard diagnostic criteria for RLS and by using a clinical and diagnostic interview. Questionnaires for RLS severity, idiopathic RLS (IRLS), and excessive daytime sleepiness (EDS) according to the Epworth sleepiness scale (ESS) were used. Blood examination was performed for hemoglobin and hematocrit. For comparison, RLS patients were matched for age and body mass index (BMI) with pregnant women without RLS. RESULTS Out of 218 patients, 40 (18.4%) fulfilled diagnostic criteria for RLS. In RLS patients, prophylactic iron supplementation therapy during pregnancy was less frequently taken (P=.02). Pregnant women with RLS had a higher ESS score than pregnant controls (10.6 +/- 3.1 vs 7.6. +/- 3.6; P<.001). Preeclampsia was more frequent in RLS (7/40 vs 1/39; P=.03). CONCLUSIONS In our study, RLS was frequent in pregnant Peruvian women, especially in those without prophylactic iron supplementation. RLS patients described more EDS. Preeclampsia was more common in RLS. Our study is the first study to indicate a possible association between RLS and preeclampsia.

Prevalence and predictors of fatigue in glioblastoma: a prospective study.

BACKGROUND The main goal of this study was to assess frequency, clinical correlates, and independent predictors of fatigue in a homogeneous cohort of well-defined glioblastoma patients at baseline prior to combined radio-chemotherapy. METHODS We prospectively included 65 glioblastoma patients at postsurgical baseline and assessed fatigue, sleepiness, mean bedtimes, mood disturbances, and clinical characteristics such as clinical performance status, presenting symptomatology, details on neurosurgical procedure, and tumor location and diameter as well as pharmacological treatment including antiepileptic drugs, antidepressants, and use of corticosteroids. Data on fatigue and sleepiness were measured with the Fatigue Severity Scale and the Epworth Sleepiness Scale, respectively, and compared with 130 age- and sex-matched healthy controls. RESULTS We observed a significant correlation between fatigue and sleepiness scores in both patients (r = 0.26; P = .04) and controls (r = 0.36; P < .001). Only fatigue appeared to be more common in glioblastoma patients than in healthy controls (48% vs 11%; P < .001) but not the frequency of sleepiness (22% vs 19%; P = .43). Female sex was associated with increased fatigue frequency among glioblastoma patients but not among control participants. Multiple linear regression analyses identified depression, left-sided tumor location, and female sex as strongest associates of baseline fatigue severity. CONCLUSIONS Our findings indicate that glioblastoma patients are frequently affected by fatigue at baseline, suggesting that factors other than those related to radio- or chemotherapy have significant impact, particularly depression and tumor localization.

The experience of insomnia among older women

Study Objectives: To measure sleeping difficulty and sleep quality among older women, explore experience and attitudes towards sleep, and test for negative association between difficulty sleeping and health-related quality of life. Design: Four-year longitudinal study. Setting: Women were participants in the Australian Longitudinal Study on Women's Health. Participants: Women were sampled according to use of sleeping medication and classified into 4 groups: sleeping badly and using sleeping medications; not sleeping badly, but using sleeping medications; sleeping badly, not using sleeping medications; not sleeping badly, not using sleeping medications. Interventions: None. Measurements and Results: Sleeping difficulty and sleeping-medication use were measured at Survey 1, Survey 2 (3 years later), and Survey 3 (4 years later). Survey 3 included: Nottingham Health Profile Sleep Subscale, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Geriatric Depression Scale, Duke Social Support Index, Medical Outcomes Study Short-Form 36-item Health Survey, and a 21-item life events scale. Survey 3 was returned by 1011 women (84%). Sleeping problems were negatively associated with SF-36 subscale scores. Most associations remained significant after comorbid conditions, Geriatric Depression Scale, life events scores, and medication use were added to models. Most women with sleeping problems (72%) sought help from a doctor, and 54% used prescribed sleeping medications in the past month. Conclusions: Sleeping difficulty is a serious symptom for older women and is associated with poorer quality of life. Some of this effect can be explained by comorbidities, depression scores, life events, and use of sleeping medications.

Influência do horário de trabalho, do gênero e de um programa de educação sobre o sono no ciclo sono/vigília de professores do ensino fundamental e médio

The teaching profession is often associated with extensive workload inside and outside the classroom, poor teaching conditions, among other challenges that can cause sleep problems. These problems may be even greater in women, due to the professional and domestic work hours and to the major sleep necessity. Considering that sleeping problems may result from the practice of poor sleep habits, sleep education programs are conducted with the aim to reduce sleep deprivation, irregularity on sleep schedules, daytime sleepiness and improve sleep quality. In this sense, the objective of this study is to evaluate the influence of working hours, gender and a sleep education program on sleeping habits, quality of sleep, daytime sleepiness and the level of stress in teachers of elementary and secondary education. For that, teachers filled the questionnaires that assessed: 1. Sleeping habits (Sleep & Health), 2. Chronotype (Horne & Ostberg), 3. Daytime sleepiness (Epworth Sleepiness Scale), 4. Sleep Quality (Pittsburgh Sleep Quality Index), 5. Level of stress (The Inventory of Stress for Adults of Lipp) and 6. Daily pattern of sleep/wake cycle (Sleep Diary). The questionnaires 1, 4, 5 and 6 were repeated 3 weeks after the sleep education program. Teachers who begin work in the morning (7:11 ± 0:11 h) wake up earlier in the week and often have poor sleep quality compared to those who start in the afternoon (13:04 ± 00:12 h). Among those who begin work in the morning, the intermediate types and those with an evening tendency were more irregular in the wake up time than morning types and increased sleep duration on weekend. In relation to gender, women had longer sleep duration than men, although the majority presented excessive daytime sleepiness and poor sleep quality. However, when work schedule and age are similar between genders, the difference in sleep duration becomes a tendency and the difference in the percentage of excessive daytime sleepiness disappears, but the poor sleep quality persists in women. With respect to teachers who have gone through the sleep education program, there was an increase in knowledge about the subject, which may have contributed to the reduction in the frequency of coffee consumption close to bedtime and to the sleep quality improved in 18 % of participants. In the control group, there were random differences in knowledge in 3rd stage, and sleep quality improved in only 9% of teachers. The participation in the sleep education program was not enough to change the hours of sleep and decrease stress of teachers. Therefore, the start time school in the morning was preponderant in determining the wake up time of teachers, especially for intermediates types and those with an evening tendency. Furthermore, the poor quality of sleep was more common in women, and the sleep education program contributed to increase knowledge on the subject and to improve sleep quality.

Pressão de sono e perfil acadêmico de estudante de medicina do 1º período da UFRN

Academic demands, new social context, new routines and decrease of the parental control, are factors that may influence the sleep pattern of freshman students at the University. Medical students from the Federal University of Rio Grande do Norte (UFRN) have a full-time course, subjects with high-level content, and, at the first semester, classes begin at 7 a.m. This group composed by young adults who still suffering with delayed sleep phase, common in adolescence, indicating that this class schedule can be inappropriate at this age. The reduction of nocturnal sleep during school days, and the attempt to recover sleep on free days – social jet lag (JLS), suggests that in the first semester, students suffer from high sleep pressure. High sleep pressure may reflect on cognitive tasks and performance. Therefore, the aim of this study was to investigate the relationship between sleep pressure and the academic profile of medical students from the first semester of UFRN, characterizing this population socio-demographically and investigating possible impacts on therestactivity rhytm and academic performance. A sample of 88 students, healthy men and women awswered the following questionnaires: Pittsburgh Sleep Quality (PSQI), Epworth Sleepiness Scale (ESS), Horne & Ostberg Chronotype (HO), Munich Chronotype (MCTQ) and “Health and Sleep” adapted. Actigraphy was used during 14 days to make actogramas and obtain non-parametric variables of the rest-activity rhythm and the grades of the morning schedule were used as academic performance. The JLS was used as a measure of sleep pressure. Statistics significance level was 95%. The population was sociodemographic homogeneous. Most students have healthy lifestyle, practice physical activity, use car to go to the university and take between 15 and 30 minutes for this route. Regarding CSV, most were classify as intermediate (38.6%) and evening (32%) chronotypes, needs to nap during the week, suffer daytime sleepiness and have poor sleep quality. 83% of the sample has at least 1h JLS, which led us to divide into two groups: Group <2h JLS (N = 44) and Group ≥ 2h JLS (N = 44). The groups have differences only in chronotype, showing that most evening individuals have more JLS, however, no differences were found in relation to sociodemographic aspect, rest-activity rhythm or academic performance. The homogeneity of the sample was limited to compare the groups, however, is alarming that students already present in the first half: JLG, poor sleep quality and excessive daytime sleepiness, which can be accentuated through the university years, with the emergence of night shifts and increased academic demand. Interventionsaddressingthe importance of good sleep habits and the change of the class start time are strategies aimed to improve student’s health.