Prospective monitoring of BK virus reactivation in renal transplant recipients in North India.

BACKGROUND: BK nephropathy (BKN) is an important complication of renal transplantation with a reported incidence between 1% and 10% in different parts of the world. Early diagnosis is important to plan early therapeutic strategies. The epidemiology and evolution of BKN is relatively unknown in India and hence, the present study has been designed to prospectively monitor the activation of BK virus (BKV) in renal transplant recipients in India. PATIENTS AND METHODS: In this study, 32 renal allograft recipients were prospectively monitored with protocol biopsies of allografts, BKV DNA load in plasma, and viral particles in urine by electron microscopy (EM) on day 1, and at 1, 3, and 6 months. Additionally, the baseline BKV DNA load in plasma was quantitated in 21 corresponding donors. RESULTS: On follow-up in 32 recipients, 9.7%, 23.8%, 19.2%, and 13.3% of patients showed viral profiles by EM at day 1, 1 month, 3 months, and 6 months, respectively. BKV DNA positivity in plasma was 25.8%, 42.9%, 15.4%, and 20% at day 1, 1 month, 3 months, and 6 months, respectively, with mean BKV copy number/mL plasma of 1796, 1029, 2611, and 3318, respectively. A total of 15.7% (17/108) urine samples of 32 renal recipients were positive by urine EM. Out of 100 protocol biopsies, none developed histologically demonstrable cytopathic effects of BKN, although 8% biopsies were SV-40 large T antigen (SV-40 T Ag) positive. By quantitative real-time polymerase chain reaction assay, 27/108 (25%) of recipients' plasma samples were positive for BKV. Peak viremia and viruria occurred at 1-3 months post transplantation. The baseline viremia in donors was predictive of viremia positivity in the post-transplantation period at 1 month. Twenty-four episodes of graft dysfunction were attributed mainly to rejection. CONCLUSION: The study shows a total of 15.7% and 25% urine and plasma samples were positive for BKV at any time during a 6-month follow-up. The highest incidence of BK viruria and viremia occurred at 1 month. In protocol biopsies, focal positivity of SV-40 T Ag was seen in 8% biopsies.

The utility of 1- and 3-month protocol biopsies on renal allograft function: a randomized controlled study.

Identification of pathological events in the renal allograft using protocol biopsies at predetermined time intervals may yield useful information and improve outcomes. We examined the influence of decisions taken on the basis of 1- and 3-month protocol biopsies findings on 1-year renal allograft function in a prospective randomized study. Out of 102 living-donor allograft recipients, 52 were randomized to undergo protocol biopsies and 50 controls had only indicated biopsies. All acute rejection (AR) episodes (clinical and subclinical) were treated. Calcineurin inhibitor (CNI) dose adjustments were made on clinical judgment. Baseline recipient and donor characteristics, immunosuppressive drug usage, HLA matches and 2-h cyclosporine levels were similar in both groups. At 1 and 3 months, protocol biopsies revealed borderline (BL) changes in 11.5% and 14% patients, AR in 17.3% and 12% and chronic allograft nephropathy (CAN) in 3.8% and 10%. The incidence of clinically evident AR episodes was similar in the two groups, but biopsy group had lower serum creatinine at 6 months (p = 0.0003) and 1 year (p < 0.0001). The renal functions were similar in those with normal histology and BL changes. Protocol biopsies are helpful in detecting subclinical histological changes in the graft and improving short-term renal allograft function.

Incidence of glucose metabolic abnormalities in Indian living renal allograft recipients on tacrolimus-based triple drug immunosuppression.

OBJECTIVE: The prevalence of glucose metabolic abnormalities (GMA) and overt diabetes in the Indian population is higher than the Western population. Tacrolimus (generic form), which is known to cause GMA, was recently introduced in India and data on its use in India are scarce. Herein we have presented our experience of the use of tacrolimus in renal transplantation. PATIENTS AND METHODS: We performed a retrospective analysis of 122 consecutive patients receiving tacrolimus-based triple drug immunosuppression at a single center. Target levels were 10 to 15 ng/mL in the first month, 8 to 10 ng/mL in the second to third months, and 5 to 8 ng/mL thereafter. GMA was defined as fasting blood sugar >110 mg% or postprandial blood sugar >140 on more than one occasion. All episodes of graft dysfunction were evaluated by graft biopsy. In addition, all consenting patients underwent protocol biopsy at 1, 3, and 6 months. Overall mean age of recipients was 34.5 +/- 10.1 years; male to female ratio 108:14; mean donor age 40.1 +/- 10.1 years; and mean follow-up 16.8 +/- 5.9 months. RESULTS: The patient and graft survivals at 18 months were 96.7% and 94.8%, respectively. Incidence of clinical biopsy-proven acute rejection was 5.7%. In addition, 8.13% patients had subclinical rejection. The mean serum creatinine at last follow-up was 1.3 +/- 0.6 mg%. Of the nondiabetic recipients, 54.5% developed GMA and 32.7% required drug therapy for glycemic control, of which only 5.5% were insulin dependent. The prevalence of hepatitis C virus (HCV) infection was 20.0% in the cohort. CONCLUSION: Use of tacrolimus results in a low incidence of clinical acute rejection but a high incidence of GMA in Indian transplant recipients.

Impact of anti-hepatitis C virus (HCV) antibody on outcomes in renal transplant recipients infected with HCV.

OBJECTIVE: Hepatitis C virus (HCV) infection remains an important risk factor for mortality and morbidity in transplant recipients. In this study, we retrospectively analyzed the impact of pretransplantation hepatitis C antibody status in HCV-infected renal allograft recipients on graft and patient survivals. PATIENTS AND METHODS: From February 1998 to August 2007, 933 renal transplantations were performed at our center. Of these, 104 patients were identified to be harboring HCV infection: 59 (group I) were anti-HCV positive prior to transplantation and 45 (group II) were HCV RNA/antibody positive in the posttransplantation period. The patients transplanted in different eras received different immunosuppressive regimens. Complete follow-up data were available for 72.3% (43/59) in group I and 80% (36/45) in group II. Both groups had a similar number of patients on cyclosporine (62.8% vs 61.1%), tacrolimus (37.2% vs 38.8%), and mycophenolate mofetil (MMF; 58.1% vs 61.1%). These patients were analyzed for differences in patient and graft survivals by log-rank test. RESULTS: The overall mean ages were 35.1 +/- 10.4 and 32.4 +/- 10.4 years, male to female ratios 37:6 and 31:5, mean donor ages 41.5 +/- 10.9 and 41.2 +/- 13.1 years, and mean follow-up durations 29.4 +/- 24 (range, 1-107.7) and 32.6 +/- 24.2 (range, 3.1-97.2) months in groups I and II, respectively. The patients in group I had received a significantly greater number of blood transfusions compared with patients in group II (6.2 +/- 5.7 vs 2.1 +/- 2.9) and a significantly greater number of dialysis treatments prior to transplantation (84.5 +/- 62.0 vs 33.8 +/- 43.2), respectively. Liver function tests--SGOT (22.6 +/- 16.1 vs 18.3 +/- 12.1 IU/L) and SGPT (24.2 +/- 28.9 vs 20.4 +/- 20.2 IU/L)-were similar in the 2 groups in the pretransplantation period, respectively. The patient and graft survivals at 5 years were similar: 88.6% vs 82.3% (P = .81) and 60.1% vs 62.5% (P = .75) in groups I and II, respectively. The serum creatinine values at last follow-up were 1.38 +/- 0.6 vs 1.7 +/- 2.4 mg% (P = not significant), SGOT 33.4 +/- 25.6 vs 38.3 +/- 47 IU/L, and SGPT 39.3 +/- 46.7 vs 59.2 +/- 89 IU/L in groups I and II, respectively. Liver decompensation occurred in 4 patients, 2 in each group at a mean duration of 36.5 months. CONCLUSION: Absence of HCV antibody does not confer any survival disadvantage in HCV-infected renal allograft recipients undergoing renal transplantation.

[Screening for Y chromosome microdeletions in assisted reproductive techniques]. / Recherche des microdélétions du chromosome Y en Assistance médicale à la procréation.

In case of infertility due to azoospermia, clinical, sonographical and biological examinations suggest obstructive or non obstructive causes. In cases of non obstructive azoospermia, genomic microdeletions must be determined particularly in the Y chromosome long arm, as well as autosomal abnormality. A constitutional karyotype must also be done. The so-called Y AZFa, AZFb and AZFc zones could be partially or totally absent. Genotype is mostly correlated with histology. Thus, when large AZFa and AZFb microdeletions are detected there is theoretically no chance to find testicular spermatozoa. If only AZFc microdeletions are present, testicular biopsy is possible with a good chance of mature spermatozoa retrieval before microinjection, and AZFc microdeletions are also often present (10%) in cases of severe oligospermia. Couples must be informed of genomic deletions and a genetic counseling is essential to explain the potential childhood risks after assisted reproductive techniques. This problem has been discussed by the French "High Authority of Health". It recommends determination of these Y microdeletions when oligozoospermia is severe (lower than one million spermatozoa per milliliter).

Recurrent glomerulopathy in the renal allograft.

The renal allograft is prone to develop almost all forms of glomerular diseases either as recurrent or de novo disease, with the exception of Alport's syndrome. Identification of recurrent glomerulonephritis requires an accurate diagnosis of pretransplant disease, which may not always be possible as it presents as end-stage renal disease at the time of transplantation. Posttransplantation glomerular diseases such as chronic allograft nephropathy, malignant hypertension, and thrombotic microangiopathy due to various causes may be mistaken for primary glomerulonephritis. In this article, an attempt has been made to identify the glomerular diseases that were detected in renal allografts over a 9-year period, comprising 950 cases in a tertiary care center in north India.

A Single-center Experience of Kidney Transplantation from Donation after Circulatory Death: Challenges and Scope in India.

Donation after circulatory death (DCD) has never been attempted in India because of legal constraints and lack of guidelines for the withdrawal of life support in end-of-life situations. The present report describes the initial experience of transplantation of organs from DCD donors in a tertiary care center in India. Between 2011 and 2015, five donors had kidneys retrieved after cardiac arrest. These patients were declared dead after waiting for 5 min with no electrocardiographic signal on monitor following cardiopulmonary resuscitation (CPR), which was restarted in three patients till organ retrieval. All donors received heparin and underwent rapid cannulation of aorta, infusion of preservative cold solution, and immediate surface cooling of organs during retrieval surgery. 9/10 kidneys were utilized. Mean donor age was 29.6 ± 16.3 years, M:F 4:1 and mean age of recipients was 38.7 ± 10.8 years, M:F 7:2. Seven patients required dialysis in postoperative period. Mean postoperative day 0 urine output was 1.9 ± 2.6 L. Baseline creatinine achieved was 1.38 ± 0.35 mg/dl after a mean duration of 26.12 ± 15.4 days. Kidneys from donors where CPR was continued after the declaration of death (n = 3) had better recovery of renal function (time to reach baseline creatinine 21.2 ± 7.2 vs. 34.3 ± 23.7 days, baseline creatinine 1.36 ± 0.25 vs. 1.52 ± 0.45 mg%). In donors without CPR, one kidney never functioned and others had patchy cortical necrosis on protocol biopsy, which was not seen in the kidneys from donors with CPR. Kidneys from DCD donors can serve as a useful adjunct in deceased donor program. Continuing CPR after the declaration of death seems to help in improving outcomes.

Comparison of enteric-coated mycophenolate sodium with mycophenolate mofetil in living renal allograft transplantation.

OBJECTIVE: Enteric-coated mycophenolate sodium (MPS) has been developed to decrease the GI side effects of mycophenolate mofetil (MMF). We did a retrospective analysis of 112 patients to compare the safety and efficacy of enteric coated MPS vs MMF in living renal transplantation. METHODS: Patients were divided into two groups. Group A who received MPS [Novartis, Basel, Switzerland] [1.08-1.44 g/d] included 53 patients of mean age 33.5 +/- 11.9 yrs, and M:F gender ratio 37:15 with a mean donor age of 43.2 +/- 9.9 years. Group B who received MMF [1.5-2.0 g/d] included 59 subjects of mean age 33.2 +/- 9.9 yrs and M:F gender ratio 57:6, with a mean donor age of 41.4 +/- 10.9 years. All patients received cyclosporine and prednisolone in addition to mycophenolate. Mean follow-up in the two groups was 11.6 +/- 7.0 and 12.6 +/- 8.5 months, respectively. RESULTS: There were 11 (20.7%) rejection episodes in Group A and 12 (20.3%) rejection episodes in Group B (P = NS). Incidence of CMV disease was 9.61% and 10.1%, and of other infections, 88.7% and 74.7% in Groups A and Group B, respectively [P = NS]. The incidence of GI (18.9% & 20.3%) and hematologic toxicities (9.4% & 5.1%) were similar in the groups. Patient and graft survivals in Group A were 91.9% & 86.6%, and in Group B was 91.3% & 91.3%, respectively [P = NS]. CONCLUSION: Mycophenolate sodium is an alternative immunosuppressant to mycophenolate mofetil in kidney transplant recipients with a similar efficacy and safety profile.

Comparison of generic cyclosporine microemulsion versus neoral in de novo renal transplant recipients managed by 2-hour postdose monitoring.

INTRODUCTION: The bioequivalence of generic formulations is established by measuring pharmacokinetic parameters in healthy volunteers. Cyclosporine (CsA) absorption and exposure is known to differ between healthy volunteers and transplant recipients. Therefore bioequivalence testing may be inadequate to ensure therapeutic equivalence. We sought to compare the efficacy of generic cyclosporine (ArpimuneME, RPG Life Sciences) versus Sandimmune Neoral in de novo renal transplant recipients. METHODS: A prospective single-center, open-label study enrolled 20 de novo renal transplant patients (group 1: mean age 30.55 +/- 9.81 years, M:F 19:1, mean donor age 43.4 +/- 10.8). All patients received ArpimuneME along with azathioprine and prednisolone. The results were compared with 17 matched controls (group 2: mean age 28.1 +/- 9.5 years, M:F 13:4, mean donor age 47.8 +/- 6.8) who received Neoral and were transplanted during the same period. C(2) levels were monitored by the cloned enzyme donor immunoassay (CEDIA). RESULTS: Patient and graft survivals were 100% and 100% and 100% and 92.8% in groups 1 and 2, respectively (P = NS). Six patients (30%) experienced rejection in group 1 as compared eight patients (47.1%) in group 2. Mean CsA levels (ng/mL) during the first month were 1419.1 +/- 213.6 and 1460.5 +/- 290.7 and at 3 months, 1296.3 +/- 227.8 and 1342.4 +/- 303.4 in the two groups, respectively (P = NS). The mean serum creatinine levels (mg%) in group 1 and group 2 were 1.6 +/- 0.8 and 2.0 +/- 1.4 at discharge and 1.5 +/- 0.4 and 1.5 +/- 0.8 at 6 months, respectively (P = NS). CONCLUSION: Use of a generic microemulsion form of CsA provided safe and effective immunosuppression compared with Sandimmune Neoral when drug monitoring was performed by C(2) levels.

Oxidative status in stable renal transplantation.

Increased oxidative stress and hyperhomocysteinemia are frequently observed in patients with end-stage renal disease. The effects of kidney transplantation on oxidative state are incompletely understood. With an aim to evaluate the prevalence and severity of oxidative stress in living donor renal transplant recipients, we conducted a cross-sectional study. Thirty-five renal transplant recipients (mean age 34 years; body mass index 21.93 +/- 1.92) with normal renal function (mean serum creatinine 1.41 +/- 0.33 mg%) were enrolled in the study. All patients were on cyclosporine-based immunosuppression. We assessed serum nitric oxide (NO) levels, plasma total homocysteine levels (tHCy), and malonaldehyde (MDA) levels. We evaluated the antioxidant power ferric reducing ability of plasma (FRAP) assay. The mean duration to the first sampling was 9.23 months after transplantation. Fourteen age- and sex-matched normotensive people were used as controls. The mean tHCy was significantly higher among patients (15.29 +/- 0.66 mmol/L compared with controls (9.58 +/- 2.90 mmol/L; P < .05). The MDA levels in patients (6.405 +/- 2.05 nmol/mL) were comparable to controls (6.093 +/- 1.93 nmol/mL; P = .099). The status of antioxidative power as measured by FRAP showed a trend to higher antioxidative status (697.57 +/- 103.07 mmol/L) in patients compared with controls (518 +/- 120.99 mmol/L; P = NS). The mean NO levels in patients (545.01 +/- 281.49 mmol/mL) were significantly higher than controls (183.49 +/- 64.53 nmol/mL; P < .05). Stable renal transplant recipients display a pattern of increased oxidant stress that may be counterbalanced by an enhanced antioxidant mechanisms.

Treatment of oropharyngeal cancer in renal transplant recipients without cessation of immunosuppressive therapy.

INTRODUCTION: Renal transplantation and immunosuppression are associated with an increased incidence of malignancy. Reduction or cessation of immunosuppressive therapy has been advocated in these cases to prevent tumor progression and recurrence. We evaluated the outcome of treatment of oropharyngeal cancer (OC) after renal transplantation without cessation of immunosuppressive therapy. METHODS: The database of patients with OC after renal transplantation was analyzed with respect to age, sex, type of immunosuppression, interval between transplantation and diagnosis of cancer, as well as method of treatment and survival. RESULTS: Thirty one (2.06%) renal transplant recipients developed malignancy including 6 (20%) with OC. Lingual cancer was seen in three, and one each showed an isolated tonsillar lymphoma, a parotid carcinoma, or a carcinoma of the larynx with only the last having had two other malignancies in the past. Three subjects were on immunosuppression with azathioprine and prednisolone, and the others were prescribed cyclosporine and prednisolone. Average time from transplantation to diagnosis of OC was 106 months. The interval was the shortest (2 years) for tonsillar lymphoma in an 18-year-old patient who received cyclosporine and showed features of left follicular tonsillitis. The patient with advanced carcinoma of the larynx did not receive any treatment and succumbed within 3 months. The dose of cyclosporine was reduced in the lymphoma case but immunosuppression was not altered in the other patients. All subjects were treated with a standard protocol. During a mean follow-up of 33 months, one had local recurrence of parotid carcinoma and the others showed well functioning renal grafts. CONCLUSION: Comprehensive treatment of OC after renal transplantation without withdrawing the immunosuppression prolonged the life of these patients with functioning grafts.

Prospective psychosocial evaluation of related kidney donors: Indian perspective.

With increasing acceptance of living organ transplantation and growing numbers of organ donors, it becomes important to look for any adverse outcomes in this population. Prospective psychosocial evaluation of living related donors and assessment of the outcome of donation process was done. We also tried to identify any risk factors associated with any adverse event. Between January 2003 and December 2003, 75 consecutive donors (mean age 42.8 +/- 11.6 years; M:F 54:21) were interviewed preoperatively and at 3 months postoperatively based on a 57-item questionnaire. Objective assessment of anxiety, depression, and social support was done with "modified Beck's depression inventory," "Speilberg's state and trait anxiety," and "social support" questionnaires. The majority (85.3%) of donors had volunteered for donation. There were no major depressive or anxiety disorders following donation. Though 21.3% donors perceived some negative impact on their health, none regretted the decision to donate and most (96%) would encourage organ donation. Prolonged donor hospitalization, persistent pain, poor recipient reciprocation, or recipient death were associated with a poor psychosocial outcome.

Successful live related renal transplant in a case of tuberous sclerosis.

Tuberous sclerosis (TS) is an autosomal dominant multisystemic disease involving primarily the skin, the brain and the kidneys. Inspite of the kidney being involved in 40-80% of patients with this disease, the incidence of end stage renal disease is only about 1%. There are only 34 reported cases of successful renal transplantation in tuberous sclerosis patients with end stage renal disease. We report a case of successful renal transplantation in a patient of tuberous sclerosis with bilateral polycystic kidneys presenting with renal failure who also underwent bilateral native nephrectomies on follow up.

Laryngeal tuberculosis in renal transplant recipients.

BACKGROUND: Tuberculosis is the most common non-pyogenic infection encountered among renal transplant recipients in India. Although the lung is the most common site of involvement, a number of extrapulmonary organs can be involved. There is often a delay in diagnosis and institution of effective chemotherapy when there is an unusual site of involvement. METHODS AND RESULTS: We report two renal transplant recipients with laryngeal tuberculosis who presented with prolonged hoarseness of voice and painful dysphagia. Acid-fast bacilli were demonstrated on laryngeal biopsy and smear. Fever and pulmonary involvement were seen in only one patient. This is the first report of laryngeal tuberculosis in renal transplant recipients. CONCLUSIONS: Laryngeal tuberculosis should be suspected in renal transplant recipients who develop hoarseness of voice and odynophagia. Demonstration of acid-fast bacilli on biopsy or smear obtained by direct laryngoscopy helps in determining the diagnosis.

Modafinil in diurnal sleepiness. A study of 123 patients.

The efficacy of modafinil, a psychostimulant drug acting on postsynaptic alpha-1 adrenergic receptors, as a treatment for excessive daytime sleepiness was studied in 123 patients. Subjects included 94 narcoleptic patients (76 with cataplexy), 23 hypersomnia patients and 6 patients with disrupted nocturnal sleep (DNS) and excessive daytime sleepiness (EDS). Clinical efficacy of the treatment on each symptom (EDS, cataplexy and DNS) was evaluated on a four-point scale from excellent to absent. The effectiveness of modafinil as a treatment for EDS was excellent in 17% of all patients, good in 63%, fair in 17% and absent in 3%. The incidence of side effects was rather low (14 of 123 patients) and most of them disappeared (11 patients) when doses were reduced.

[Effect of modafinil in narcoleptic patients. Electrophysiologic and psychometric studies]. / Effet du modafinil chez des patients narcoleptiques. Etudes électrophysiologique et psychométrique.

Clinical efficiency of Modafinil was clearly demonstrated in narcoleptic patients but only a few electrophysiological studies were carried out to confirm these observations. Since Modafinil did not change the propensy to fall asleep, the aim of this work was to study maintenance of wakefulness and performance levels in treated narcoleptic patients. Of the 16 treated patients, 12 responded as expected to Modafinil. These 12 patients were studied. After a one night polysomnography, electrophysiological tests included: baseline spectral analysis, maintenance of wakefulness tests carried out respectively eyes open in diffused light and eyes closed in darkness during which sleep latency, duration of test and changes in the theta/alpha ratio were measured. Psychometric performances were evaluated using verbal or non verbal tests: visual and auditory reaction time tests. Trail Making Test, Stroop, verbal Fluency and WAIS-R. Modafinil improved the ability of narcoleptic patients to remain awake only when the situation or the environmental conditions were favorable. Some psychometric performances also trended towards on improvement.

[Sleep abnormalities and evoked potentials (VEP-BAER-SEP) in progressive supranuclear palsy]. / Etude des anomalies du sommeil et des potentiels évoqués (PEV-PEAp-PES) dans la paralysie supranucléaire progressive (PSP).

Few physiological studies have been performed in PSP. We studied: sleep abnormalities in 36 h polygraphic recordings; changes of PEV after pattern-reversal stimulation, of BAER and of short latency SEP after stimulation of the median nerve. The population was for the 1st group: 18 patients with full typical symptomatology, for the 2nd group: 7 patients with likely diagnose of PSP and for the 3rd group: 10 normal subjects as control sample. All patients of the 1st group had sleep abnormalities: decrease of total sleep time; decrease of the percentage of REM sleep; morphological abnormalities (specially horizontal ocular square wave jerks). Detail is given of the repartition of such abnormalities in the two groups of patients. There is no correlation between sleep abnormalities and the natural history of the disease. The PEV and BAER, abnormalities were present in 50% of the cases. The PES were always normal. The help that can be provided by electrophysiological studies in the diagnose of PSP is discussed (particularly in group 2).

[Electrophysiologic study in a patient presenting with expanding cerebral lacunae]. / Etude électrophysiologique chez un patient présentant des lacunes cérébrales expansives.

A 42-year-old man was affected with multiple cerebral lesions suggesting expanding lacunae. He had suffered for about 15 years of headaches and blurred vision. Neurological examination showed a Parinaud syndrome and a skew deviation. Magnetic resonance imaging showed an enlargement of the third and lateral ventricles and multiple intraparenchymatous lesions with a signal similar to that of the cerebrospinal fluid. These lesions were located in the mesencephalon and right thalamic region. Important discrepancies between the topography of the lesion and the clinical data were observed. Neurological examination, ocular movements during wake and neuropsychological testing suggested sub-cortical dysfunction. These results suggest functional rather than lesional repercussion of expansive lacunae.

Effect of age on auditory evoked responses (AER) and augmenting-reducing.

Auditory evoked responses (AER) were obtained from Cz and Fz in 30 adults (14 male, 16 female) from 20-80 years old. Sound bursts (1000 Hz-200 msec) of four different intensities were used. Peak to trough amplitudes of P1N1 and N1P2 and latencies of P1, N1 and P2 peaks were measured with increasing stimulus intensity and slopes of amplitude - intensity and latency - intensity curves were analysed for assessment of an age effect. The main result is that the increase in P1N1 amplitude with increasing stimulus intensity is more pronounced in older persons. Previous studies have established a negative correlation between the augmenting-reducing responses and HVA levels in the CSF (with lower amounts of HVA in the CSF of "augmenters"). Decreased dopamine metabolism in old subjects could account for our results, so further studies should focus on patients with pathological dopamine deficiencies.

[Efficacy of uvulopalatopharyngoplasty (UPPP) and modifications in sleep structure in the sleep apnea syndrome (SAS)]. / Efficacité de l'uvulopalatopharyngoplastie (UPPP) et modifications de la structure du sommeil dans le syndrome d'apnée du sommeil (SAS).

Thirty-four patients (32 male, 2 female; mean age 53 +/- 7 years) with confirmed sleep apnea syndrome (SAS) were studied before and after uvulopalatopharyngoplasty (UPPP). Clinical symptoms were tiredness, excessive daytime sleepiness and snoring. All patients were overweight. Patients underwent a thorough physical and oropharyngeal examination and polysomnography before and 3 months after surgery. On the basis of post-operative results, patients are divided into 3 groups: --group 1: 16 cured patients: apnea index (A.I./h) 38 +/- 17 before and 4.4 +/- 4 apneas/h sleep after surgery. Improved nocturnal hypoxemia: mean minimum oxyhemoglobin saturation (SAO2) before and after UPPP in NREM sleep 83 +/- 4% v. 90 +/- 4% in REM sleep 76 +/- 11% v. 85 +/- 7%. Uninterrupted sleep is restored; --group 2: 8 improved patients: A.I./h of 64 +/- 11 before and 20 +/- 6 after UPPP: improved nocturnal hypoxemia: mean minimum SAO2 in NREM sleep 74 +/- 10% before and 86 +/- 6% after UPPP: in REM sleep 59 +/- 9% before and 79 +/- 6% after UPPP, lower amount and percentage of fragmented sleep; --group 3: 10 non-improved patients: A.I./h unchanged 55 +/- 22% before and 50 +/- 20% after UPPP. Persistent nocturnal hypoxemia: mean minimum SAO2 in NREM sleep 76 +/- 13 before and 81 +/- 12% after UPPP: in REM sleep 63 +/- 16% before and 65 +/- 24% after UPPP. Sleep remains fragmented. In this last group patients are more overweight and all suffer from severe SAS with greater nocturnal oxyhemoglobin desaturation. Surgical treatment by UPPP is shown to be effective for 70% of our patients. Better results are obtained when SAS is less severe and overweight less important.