Nocturnal erections, differential diagnosis of impotence, and diabetes.

In this study it is shown that monitoring of nocturnal penile tumescence (NPT) is an objective method for determining the erectile status of patients who complain of impotence. The characteristics of 11 diabetic patients with abnormal NPT, 11 patients with normal NPT and no medical disorders, and 11 normal men are presented. Also described are several sociodemographic characteristics of the first 100 patients undergoing an NPT evaluation as part of a screen for patients seeking implantation of a penile prosthesis. It is suggested that NPT monitoring should be a component of the differential diagnosis procedure for every patient who complains of impotence and that it provides a tool for the concentrated study of the mechanisms of erection and impotence.

Nocturnal penile tumescence and diagnosis in diabetic impotence.

The authors conducted a study of nocturnal penile tumescence (NPT) in 35 diabetic men, aged 33 to 70, who complained of impotence and in 35 age-matched control subjects. EEGs and other measurements showed that the diabetic men as a group exhibited significant reductions in the total amount of NPT and in the amount and frequency of full erection, thus suggesting that impotence in this cohort was organogenic. Although NPT monitoring represents an advance over the less precise traditional procedures for the differential diagnosis of impotence, the authors stress the need for more research in this area.

Destructive bruxism: sleep stage relationship.

Despite apparent similar amounts of bruxism, two groups that had been evaluated polysomnographically differed dramatically in symptomatology. Patients with severe symptoms were referred to as the destructive bruxism group and were compared with (a) a group with sleep disturbance complaints who had bruxism and (b) a group of insomniac depressed patients chosen without regard to bruxism. It was hypothesized that not only the presence of bruxism during sleep but its pattern and sleep stage relationship were factors affecting clinical symptoms. The results indicated that the sleep stage relationship was an important factor. Patients with severe symptoms attributed to nocturnal bruxism were likely to have more bruxism in REM sleep than the other groups. These results if replicated prospectively would help explain some of the discrepancies in the literature concerning sleep stage relationship of bruxism, as well as help explain differences in symptomatology of bruxism patients.

Peripheral vasoconstriction in patients with sleep related periodic leg movements.

Two patients complaining of insomnia had sleep-related periodic leg movements (nocturnal myoclonus) on polysomnographic evaluation. Both also complained of cold feet and had abnormal peripheral pulse examinations. Treatment with phenoxybenzamine, alpha-adrenergic blocker, normalized the peripheral pulse responses, reduced the complaint of insomnia, and reduced the sleep related leg movements but resulted in only mild sleep improvements. Peripheral pulse examinations of ten other patients with sleep-related periodic leg movements revealed abnormal responses in four. From these and other results, it is hypothesized that the sympathetic nervous system may mediate the periodicity of sleep related periodic leg movements.

Differentiating psychological characteristics of patients with sleep apnea and narcolepsy.

Fifty male subjects were group-matched for age and socioeconomic status. Twenty of the subjects were diagnosed as having sleep apnea and 20 were diagnosed as having narcolepsy on the basis of sleep studies. The remaining 10 subjects served as normal controls. Differences among the groups were evaluated on the bases of two psychological instruments designed to assess personality characteristics and mood states. The findings suggest that narcoleptics and apneics both present discriminatively different psychological profiles than do normals. Moreover, personality characteristics of these two groups are distinguishable from one another. Apneics tend to be individuals with hypochondriacal and hysterical characteristics, whereas narcoleptics are more easily characterized by anxiety and social introversion. Both severity of psychological disturbance (mean Minnesota Multiphasic Personality Inventory elevations) and personality pattern (two-point codes) distinguish the groups. Key Words: Sleep apnea-Narcolepsy-Psychological profiles.

Driving simulation with EEG monitoring in normal and obstructive sleep apnea patients.

STUDY OBJECTIVES: To measure simulated driving performance in obstructive sleep apnea patients and its relationship with EEG defined attention lapses. DESIGN: Prospective, mixed design comparing apnea patients and control subjects over a 60-minute driving simulation task while continuously recording both driving performance and EEG measures. SETTING: Sleep disorders center. PARTICIPANTS: 15 polysomnographically diagnosed obstructive sleep apnea patients (mean age 42 +/- 6 yrs.) and 15 healthy volunteers (mean age 38 +/- 6 yrs.). INTERVENTIONS: NA. MEASUREMENTS AND RESULTS: A computer based driving simulator recorded lane position variability, speed variability, steering rate variability, and crash frequency. The frequency and duration of EEG-defined attention lapses were also measured. The results demonstrated that the apnea group had significantly greater variability in lane position, steering rate, and speed than the control group. The apnea group also had more crashes. In addition, the apnea group had more EEG-defined attention lapses of longer duration. Except for speed and steering rate variability, these differences increased over the 60-minute task. Measures of lane position variability and crash frequency had a significant positive correlation with attention lapse frequency and duration. CONCLUSIONS: The driving simulation task unmasked and quantified marked performance impairments in the sleep apnea group that increased over time. The poor performance appeared related to the EEG-defined attention lapses. Lane position variability appeared to be the most sensitive measure for assessing and quantifying impairment. This study suggests that poorer driving performance and crashes are not entirely due to overt sleep, but inattention due to sleepiness.

The acute effects of nefazodone, trazodone and buspirone on sleep and sleep-related penile tumescence in normal subjects.

This study examined the effects of nefazodone, trazodone and buspirone on sleep and sleep-related penile tumescence. Trazodone is a sedating antidepressant without anticholinergic properties. Nefazodone is a new antidepressant that is a structural analogue of trazodone but is less sedating. Buspirone is a nonsedating, nonbenzodiazepine anxiolytic with antidepressant properties. Nefazodone was compared to trazodone and buspirone in a double-blind, placebo-controlled crossover study in 12 normal healthy males. Nefazodone increased rapid eye movement (REM) sleep, whereas trazodone and buspirone suppressed REM sleep. The drugs only minimally affected other sleep stages. Trazodone increased total tumescence time by delaying the onset of detumescence; nefazodone increased total tumescence time only insofar as it increased REM sleep; buspirone did not change total tumescence time when compared to placebo. The results support a growing body of data indicating that not all antidepressants suppress REM sleep. The results also are consistent with the interpretation of an earlier study showing that trazodone prolongs penile tumescence during sleep as a result of its alpha-adrenergic blocking properties that suppress detumescence. Nefazodone, with less alpha-adrenergic blocking activity, did not abnormally penile tumescence beyond REM sleep.

Influence of sex and age on duration and frequency of sleep apnea events.

OBJECTIVES: Differences between men and women potentially provide insight into the regulation sleep apnea events. This study, therefore, examined how apnea frequency and duration varied according to age, sex, and sleep stage in a clinical population. DESIGN: NA SETTING: NA PATIENTS: Patients were 215 women and 215 men referred to a sleep disorders center with symptoms of obstructive sleep apnea and matched for BMI. Apnea events were compared across three age groups (18-39, 40-59, and 60-88 years) in stage 2 and in REM sleep. INTERVENTIONS: NA RESULTS: In stage 2 sleep, young and middle aged women were similar averaging 15 and 13 apnea events per hour respectively. Men had significantly more events averaging 27 and 30 events per hour for the corresponding age groups. The apnea frequency doubled from middle age to older women, and the sex difference narrowed between the older males and females to a non significant difference (26 events per hour for women versus 34 events per hour for men). Apnea duration was significantly longer in men than in women. Stage 2 apnea duration increased significantly with age for men (20.1, 21.5, 23.8 s) and women (16.7, 18.3, 20.6 s) across the three age groups. This also occurred in REM sleep in for men (22.8, 26.5, 29.8 s) and women (19.3, 22.4, 26.6 s). CONCLUSIONS: Duration did not demonstrate the marked "menopausal effect" that there was for apnea frequency. Female gender and younger age conferred benefit primarily by preventing airway collapse (reduced apnea frequency) with less of an effect on apnea duration, i.e., the ability to end the apnea. Compared to stage 2 sleep, REM sleep reduced the differences between men and women in apnea frequency. One explanation may be that differences in muscle tone of the upper airway account for the sex differences in apnea frequency.

Sleep-related electrodermal activity patterns in impotent patients.

The etiology of erectile failure is not always clear despite the fact that recordings of nocturnal penile tumescence (NPT) are used to detect patients with a significant organic component to their complaint. We recorded electrodermal activity in addition to NPT in 60 impotent patients. Normally more electrodermal activity occurs in stage 2 than in stage REM sleep. Despite a similar total amount of electrodermal activity, organically impotent patients tended to have less electrodermal activity in stage 2 and more in stage REM sleep than those with normal NPT. This difference was due to a subgroup of 15 organically impotent patients with less electrodermal activity in stage 2 than in stage REM sleep. Because of this difference in the pattern of electrodermal activity in relation to sleep stages, the results suggest a central nervous system change is related to impaired erectile capability and abnormal NPT in these cases.

Effects on sleep: a double-blind study comparing trimipramine to imipramine in depressed insomniac patients.

Trimipramine, a sedating tricyclic antidepressant, and imipramine were compared on polysomnographic parameters during a 4-week double-blind trial in depressed patients with insomnia and anxiety. Trimipramine eliminated objective evidence of sleep disturbance. This was not the case with imipramine, although depression improved similarly in both groups. Subjects' sleep appeared unchanged or more disturbed at the end of the treatment with imipramine. For trimipramine, the major changes in sleep parameters occurred during the first week of drug administration and did not parallel the gradual changes seen in the measures of depression. Additionally, trimipramine did not suppress REM sleep even in a subgroup of six trimipramine patients who had short rapid-eye-movement (REM) sleep latencies during the placebo baseline period, even though their depression was alleviated. The data demonstrate that (a) antidepressants may vary in their effects on sleep, even though they have similar effects on depression; (b) REM sleep suppression does not necessarily accompany improvement in depression; and (c) reports of improved sleep by patients undergoing antidepressant therapy may not reflect improvement on objective measures of sleep. The different sleep effects suggest the possibility of different antidepressant pathways.

Eight weeks of non-nightly use of zolpidem for primary insomnia.

CONTEXT: Intermittent use (i.e., a few nights per week) of hypnotic medication is often recommended for the treatment of chronic insomnia despite an absence of efficacy and safety data using this regimen. STUDY OBJECTIVES: To evaluate the clinical efficacy and safety of intermittent pharmacotherapy for chronic insomnia. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled, parallel groups, clinical trial at six sleep research sites. PATIENTS: One hundred-sixty-three (115 women, 48 men; mean age 44.1+ SE. 0.9 years), DSM-IV-defined primary insomnia patients were randomized, 134 patients completed the study. INTERVENTIONS: Eight weeks of treatment with either zolpidem 10 mg or placebo. Patients were instructed to take medication when they felt they needed it, but at least three and no more than five times per week. MAIN OUTCOME MEASURES: Investigator and Patient Global Ratings were the primary outcome variables. Secondary measures from daily questionnaires to assess efficacy, rebound insomnia and drug taking behavior. RESULTS: The Investigator's Global Rating indicated that intermittent use of zolpidem produced a significantly better therapeutic effect and significantly reduced insomnia severity throughout the 8-week study relative to placebo. Zolpidem was found to be effective in initiating and maintaining sleep on nights taken, as compared to placebo, based upon the Patient's Global Ratings and all subjective sleep variables. No evidence of rebound insomnia was found on nights that zolpidem was not taken. The number of nights a pill was taken did not differ between groups, nor did frequency of pill taking change in either group across the duration of the study. There were no significant effects of treatment upon quality of life or neurocognitive measures. CONCLUSIONS: Zolpidem 10 mg is effective in treating insomnia when used intermittently, without evidence of discontinuation effects or increased frequency of pill taking.

Impotence and blood pressure in the flaccid penis: relationship to nocturnal penile tumescence.

Evaluations of nocturnal penile tumescence (NPT) and penile blood pressure were performed on (1) a group of nondiabetics with normal NPT, (2) a group of nondiabetics with abnormally diminished NPT, and (3) a group of diabetics with abnormally diminished NPT. The 12 subjects in each group complained of impotence. Analysis of blood pressure data taken before the NPT evaluation suggests the possibility of selective low arterial blood pressure in impotent patients who show no obvious signs of other vascular disorders.

Sleep dysfunction in patients with gastro-oesophageal reflux disease: prevalence and response to GERD therapy, a pilot study.

BACKGROUND: There is little information on the prevalence of pathological sleep disorders in patients with gastro-oesophageal reflux disease and whether pharmacological treatment of patients with gastro-oesophageal reflux disease will lead to improvement in sleep. AIMS: This pilot study determined the prevalence of sleep disorder in patients with erosive gastro-oesophageal reflux disease, correlated subjective (questionnaire) and objective (actigraphy - a watch worn on the wrist that monitors motion to help differentiate sleep from awake states) assessment of sleep dysfunction and determined whether therapeutic resolution of oesophageal symptoms was associated with an improvement in sleep. METHODS: Eighteen patients with erosive gastro-oesophageal reflux disease received esomeprazole 40 mg once daily for 8 weeks. Assessments at 0, 4 and 8 weeks included: Gastrointestinal Symptoms Rating Scale, Pittsburgh Sleep Quality Index questionnaire and ambulatory wrist actigraphy. RESULTS: Unrecognized sleep disturbance occurred in 81% of this cohort of patients with gastro-oesophageal reflux disease and erosive oesophagitis. Median reflux syndrome score (heartburn and acid regurgitation) on Gastrointestinal Symptoms Rating Scale decreased from 2 at baseline to 0 at weeks 4 and 8 (P

Tricyclic antidepressants in the treatment of insomnia.

The use of tricyclic antidepressants as opposed to hypnotics in treating insomnia is reviewed. Available data indicate that TCAs alleviate sleep disturbances related to depression (often before antidepressant effects are seen) and, in selected cases, may prove effective in disturbed sleep related to sleep apnea, fibrositis, and sleep related bruxism, as well as in adults with childhood onset insomnia or a history of hyperkinesis. However, TCAs share many of the problems reported for hypnotics, as well as having some potentially serious side effects not present with benzodiazepines. The need for determination of the etiology of sleep disorders, and specific pharmacotherapy directed toward identified causes rather than the symptom of insomnia, is stressed.

Increased deep sleep after trazodone use: a double-blind placebo-controlled study in healthy young adults.

The effects of trazodone on sleep were compared with those of placebo and the sedating tricyclic antidepressant trimipramine in a double-blind crossover study in six healthy young men. Only trazodone significantly increased deep sleep without otherwise altering the normal architecture of sleep. The alpha-adrenergic receptor-blocking property of trazodone and a relative lack of noradrenergic reuptake blocking and the lack of anticholinergic effects are hypothesized to be responsible for the effects on sleep.

Diagnosis and treatment of insomnia and depression.

Disturbed sleep is a common problem particularly among depressed patients. Diagnostic and treatment considerations are reviewed for two of the more common insomnia problems, psychophysiological insomnia and insomnia associated with depression. Studies of the actual sleep patterns of patients with these disorders reveal reliable differences that are important to understand for optimized treatment outcome. As the differentiation of sleep disorders becomes more precise and the pharmacologic armamentarium becomes greater, emphasis needs to be placed on both understanding the etiology of the sleep complaint and selecting a drug that is best matched to correct the underlying problem.

Sleep apnea in obese miniature pigs.

We postulated that three extremely obese Yucatan miniature pigs would have more sleep apnea than three nonobese Yucatan miniature pigs. Pigs were studied with the use of electroencephalograms, inductance plethysmography, oximetry, expired nasal CO2, or thermistors. All of the obese pigs, but none of the nonobese pigs, had both sleep apnea (8.5, 10.3, and 97.0 in obese pigs vs. O apnea + hypopnea/h in all nonobese pigs; P < 0.05) and oxyhemoglobin desaturation episodes during sleep [9.4 +/- 3.0 vs. 0 + 0.53 (SD) mean desaturation episodes/h in obese pigs vs. nonobese pigs, respectively; P < 0.05]. Two of the extremely obese pigs had obstructive sleep apnea, whereas the third obese pig had central sleep apnea. We conclude that sleep apnea occurs in extremely obese Yucatan minipigs and suggest that this animal can be used as a model for sleep apnea in obesity.

Antibiotic susceptibility profile of group B streptococcus acquired vertically.

OBJECTIVE: To determine the contemporary antibiotic susceptibility profile of vertically acquired group B streptococcal isolates. METHODS: Susceptibility to ampicillin, penicillin G, erythromycin, clindamycin, cefazolin, and gentamicin was assessed by two methods, minimal inhibitory concentration and disc diffusion. RESULTS: The susceptibility profiles of 119 colonizing and eight invasive strains of group B streptococcus isolated from January 1996 to September 1997 at two hospitals in Birmingham, Alabama-University of Alabama at Birmingham and Cooper Green-were studied. Minimal inhibitory concentration determinations indicated that all colonizing strains were susceptible or moderately susceptible to ampicillin and penicillin G. Resistance was noted by at least one strain to each of the other antibiotics; all were resistant to gentamicin, whereas 27 (21%) were resistant to erythromycin, five (4%) to clindamycin, and one (1%) to cefazolin. All of the eight invasive strains were susceptible or moderately susceptible to ampicillin, penicillin G, clindamycin, and cefazolin; one (13%) was resistant to erythromycin, and all were resistant to gentamicin. Disc diffusion results generally were concordant with minimal inhibitory concentration results, although by disc diffusion fewer isolates were classified as susceptible, and more as moderately susceptible, to ampicillin and penicillin G than by minimal inhibitory concentration. CONCLUSION: Universal susceptibility of group B streptococcus to members of the penicillin family supports the continued use of penicillin G or ampicillin for early onset neonatal group B streptococcal disease prevention. For patients allergic to beta-lactam agents, clindamycin (4% resistance) may be a better alternative than erythromycin (21% resistance).

Estazolam and flurazepam: a multicenter, placebo-controlled comparative study in outpatients with insomnia.

A multicenter, double-blind placebo-controlled clinical trial was designed to compare the safety and efficacy of estazolam compared with flurazepam as hypnotics. Outpatients complaining of insomnia were randomized to receive either estazolam 2 mg, flurazepam 30 mg or placebo for 7 consecutive nights. The analysis of efficacy was based on the patients' daily assessments of sleep and the investigators' global evaluations. Adverse events which were considered by the investigator to be attributable to, or of unknown relationship to the test medication were analyzed. The patient subjective questionnaire indicated that estazolam and flurazepam significantly improved all parameters (P less than .05) as compared to placebo. A marked or moderate improvement in sleep was reported by 81% (58/72), 78% (63/81) and 36% (27/76) of estazolam, flurazepam, and placebo recipients, respectively. There were no significant differences in hypnotic effect between estazolam and flurazepam. All efficacy parameters of the investigators' global evaluation improved significantly more (P less than .05) for patients receiving estazolam or flurazepam (except quality of sleep) than for those receiving placebo. The percentage of patients reporting any adverse experience was greatest for flurazepam (72%), followed by estazolam (59%), and placebo (43%). Somnolence and hypokinesia were the most commonly reported adverse events. An analysis of the global evaluation of side effects showed that flurazepam had a significantly worse side effect profile than estazolam (P less than .05) or placebo (P = .001). Estazolam and flurazepam effectively, and comparably, relieved insomnia when administered for 7 nights in adult patients complaining of insomnia. Estazolam demonstrated a more favorable side effect profile than flurazepam.

Noninvasive device to produce and maintain an erection-like state.

In 35 men with organic impotence we have tested a noninvasive device which uses a vacuum to produce an erection-like state and rubber bands to maintain this state. The subjects were first evaluated to determine the cause of their impotence and to establish that it had an organic basis. Using this device 32 of the 35 subjects achieved penile rigidity sufficient for vaginal penetration. Subjects were studied with the rubber bands constricting the base of the penis for thirty minutes. During that period, blood flow continued, but at a less than normal rate. Of 30 men followed up from eight to twenty-two months, 24 use the device regularly and report that they are satisfied. Four subjects have not yet tried to use it, and 1 no longer needs it. One man was dissatisfied because the rigidity begins to decrease after five to ten minutes of sexual activity, even though it did not change over a thirty-minute period when originally tested in the laboratory. Ecchymoses of the penis, probably due to excess vacuum, developed in 3 subjects. In 8 other men petechiae of the skin of the penis developed on one or more occasions. These ecchymoses and petechiae were painless and disappeared without treatment. No other complications occurred. The vacuum device appears to be a safe and inexpensive way for an impotent man to make the penis rigid enough to engage in sexual intercourse.