Seasonal variation in human illumination exposure at two different latitudes.

The authors measured ambient illumination exposure in healthy volunteers in San Diego, California (latitude 32 degrees 43' N, n = 30), and Rochester, Minnesota (latitude 44 degrees 1' N, n = 24), during each of the four quarters of the year, which were centered on the solstices and equinoxes. Subjects wore photosensors on their wrists and lapels (or foreheads while in bed) 24 h per day for an average of 5-6 days per quarter. The maximum of the two illumination readings was stored each minute. Annual average time spent per day in outdoor illumination (> or = 1000 lux) was significantly higher in San Diego than it was in Rochester (p < .04). Daily durations of illumination at or exceeding thresholds of 1, 10, 100, 1000, and 10,000 lux were highly seasonal in the sample as a whole (p < .01 at 1 lux, p < .0001 at other thresholds). Seasonal variation in outdoor illumination was far more pronounced in Rochester than it was in San Diego (interaction p < .001) but remained significant in San Diego (p < or = .03). Seasonal variation in indoor illumination was generally similar in the two cities. The median Rochester subject experienced illumination > or = 1000 lux for 2 h 23 min per day during summer and 23 min per day during winter. The corresponding times in San Diego were 2 h 10 min and 1 h 20 min. Neither age nor gender predicted illumination duration at any level. Both season and geographic location strongly influenced human illumination exposure, and behavior (choice of indoor vs. outdoor environment) was the most important mediating factor.

Wrist actigraphy in insomnia.

To assess the use of actigraphy in evaluating insomnia, 36 patients with a serious complaint of insomnia slept 3 nights each in the laboratory, where the usual polysomnograms (PSGs) were obtained as well as actigraphic assessments of their sleep. Patients also wore actigraphs for 7 days at home, were extensively interviewed and filled out psychometric tests. Based on all this information, the patients were then diagnosed according to the International Classification of Sleep Disorders. Averaged over the 3 nights for each insomniac, the mean discrepancy between actigram and PSG was 49 minutes per night. In three-fourths of the cases, actigram and PSG agreed to within 1 hour on the total amount of sleep per night. Discrepancies, however, were not random: In patients with psychophysiologic insomnia and in insomnia associated with psychiatric disease, the actigram typically overestimated sleep when compared with the PSG. In patients with sleep-state misperception, the actigram was either quite accurate or it underestimated sleep when compared with the PSG. Comparing laboratory with home sleep, one-third of all insomniacs slept better in the laboratory and two-thirds slept better at home. In addition, night-by-night variability was higher at home than in the laboratory. Based on our study, we now recommend actigraphy as an additional tool in the clinical evaluation of insomnia, but we believe that in complex cases it should be combined with 1 PSG night in the sleep disorders center.

Pergolide in the management of restless legs syndrome: an extended study.

Twenty patients with problematic restless legs syndrome (RLS) were treated with pergolide. Efficacy, dosage, side effects, and tolerance were analyzed. Fifteen patients continued treatment for a median study time of 2 years. Five patients discontinued treatment after a mean of 4.2 months. Pergolide resulted in complete or near complete control of symptoms in 45% and moderate control in 50% of patients studied. Levodopa-induced daytime augmentation resolved in all patients in whom it had been present. The mean total daily maintenance dose of pergolide was 0.23 mg. Forty percent required an additional afternoon dose. Side effects developed in 12 patients (60%) and necessitated discontinuation of treatment in five. Common side effects were nausea, dizziness, and insomnia. Daytime augmentation occurred in 27% of patients, but this was mild and usually easily controlled with a supplementary afternoon dose of pergolide. Tolerance did not develop. We conclude that pergolide is an effective second-line agent for RLS, especially following levodopa-induced daytime augmentation.

The use of danazol in the treatment of painful benign breast disease: preliminary results.

The preliminary results of a double-blind randomized cross-over trial of danazol versus placebo in patients with severe cyclical breast pain are reported. Though numbers are small at present, the results are encouraging.

Controlled trial of the antigonadotropin danazol in painful nodular benign breast disease.

In a double-blind crossover study of the effects of the antigonadotropin danazol on pain and nodularity in 28 women with cyclical mastalgia danazol was given at doses of 200 mg/day and 400 mg/day, and the responses were assessed both subjectively and objectively. Danazol caused a significant and progressive decrease in breast pain and nodularity when compared with placebo. Symptoms responded more quickly with the 400 mg/day dose of danazol than with the 200 mg dose, but the larger dose also caused greater side-effects. Danazol is a useful addition to the range of antihormones that can be used to suppress the symptoms of severe hormone-related benign breast disease.

Compliance with CPAP in elderly patients with OSA.

Background: Obstructive sleep apnea (OSA) is common in the general population and especially in the geriatric age group. Nasal continuous positive airway pressure (CPAP) is a highly effective treatment but can be difficult for some patients to use.Objective: We investigated the question if older patients were less compliant with CPAP therapy than younger patients and may not realize its benefits.Methods: We conducted a prospective, non-randomized study comparing use of CPAP in patients over age 65 with patients under age 65. One hundred and seven consecutive patients with a new diagnosis of obstructive sleep apnea were started on therapy with nasal CPAP. We obtained follow-up data on all 107 patients. Compliance with CPAP was assessed by patients subjective report of use and, in a subset of 21 patients, by objective measurement using a microchip installed in the CPAP unit that measures actual hours of use at therapeutic pressure.Results: The percentage of patients using CPAP regularly was not different in the two groups: 70% of patients in the over age 65 group used CPAP regularly vs. 72% of patients under age 65. The over 65 group used CPAP 6.5 nights per week, an average of 6.5 h of use per night. The under 65 group was not significantly different, using CPAP 6.8 nights per week, a mean of 6.7 h of use per night.Conclusion: Patients over age 65 are able to tolerate CPAP as well as patients under age 65.

Assessing sleep in psychiatric inpatients: nurse and patient reports versus wrist actigraphy.

This study was designed to evaluate the conventional techniques of assessing sleep, nursing and patient report, of inpatients on a clinical psychiatric unit. Nurses assessed sleep/wake status at hourly checks and patients completed a sleep diary. For three nights patients wore a wrist actigraph, a portable instrument which provides objective data about sleep/wake activity. The nursing and patient data obtained were compared with actigraphy data. Nursing staff evaluated sleep with satisfactory agreement (76.5% night 1 and 81.6% night 3) that improved over the first three nights of hospitalization (p < 0.03). When the nurses' report did not agree with the actigraph, they tended to overestimate sleep. Patients tended to underestimate their total sleep time and total time awake after sleep onset. Time in bed and initial sleep latency were overestimated. There was great intersubject variability, making determination of agreement impossible. This data suggest that treatment teams on psychiatric units should in general consider nursing reports of sleep more accurate than patient self-report. However, since nursing staff and patients observe different aspects of sleep, both sources of data are important to inpatient treatment teams on clinical units.

Natural history of breast pain.

258 patients with breast pain were restudied 2 to 7 years after initial assessment in a special mastalgia clinic. Pain persisted at follow-up in 65% of patients. Mastalgia was cyclical in two-thirds. Mean duration of pain in patients experiencing complete relief before follow-up examination was 6.8 years, while duration of pain persisting at follow-up ranged from 2 to 30 years. In patients who had relief or substantial improvement in pain, the improvement was spontaneous in 22% and resulted from a hormonally related event--menopause, pregnancy, or use of oral contraceptives--in the remainder. Onset of cyclical pain before the age of 20 years was followed by a prolonged course. A quarter of the patients had non-cyclical pain. There were two populations of patients in this group. One experienced relief after a mean of 3 years, and in the other pain still persisted after 2-22 years. Relief was spontaneous in one half, and rarely followed a hormonally related event. About 70% of the patients, with both cyclical and non-cyclical pain, considered that their pain had warranted active treatment. This study indicates that the type of pain and age at onset may allow some prediction of the course of the disease and may aid the choice of therapy.

Effects of 24-hr nicotine replacement on sleep and daytime activity during smoking cessation.

BACKGROUND: This study uses wrist actigrapy to assess the effects of 24-hr transdermal nicotine replacement on the sleep and daytime activity of smokers during smoking cessation. METHODS: Seventy-one subjects grouped as light (n = 23), moderate (n = 24), or heavy (n = 24) smokers were randomly assigned to placebo or 11, 22, or 44 mg/day doses of transdermal nicotine for 1 week of intensive inpatient treatment of nicotine dependence. Outpatient patch therapy continued for 7 weeks following the inpatient stay. Those initially on placebo were randomly assigned to 11 or 22 mg/day, and those initially on 44 mg/day were reduced to 22 mg/day at Week 4. RESULTS: There was a significant decrease in daytime wrist activity during patch therapy and the 1st week off patch therapy. These changes in daytime wrist activity were positively correlated with percentage of nicotine and cotinine replacement. No changes from baseline in sleep (sleep efficiency or wrist activity) were detected, nor were there differences in sleep among the four patch doses. CONCLUSIONS: Using wrist actigraphy, this study failed to show any disturbing effects of 24-hr high-dose nicotine replacement on sleep. Lower levels of nicotine replacement were associated with a decrease from baseline in daytime wrist activity.