Abnormal things happening during sleep: parasomnias.

Parasomnias are characterized by abnormal experiences, dreams, movements and behavior during sleep. They may occur in the middle of the sleep during REM (rapid eye movement) or NREM (non-rapid eye movement), during falling asleep or waking up. Characteristically for REM behavior disorder is an increased muscle tone although usually REM is defined by an absence of muscle tone. For these forms aggressive dreams may lead to violating bed partners or self-injury of the sleeping person. Even killing bed partners has been described. Many of the patients develop a kind of Parkinson's disease (synucleinopathies). The rate of phenoconversion is more than 30% in 5 years and nearly 100% after 15 years. There are several recommendations regarding a safe sleeping environment. Medicinal treatment consists of either melatonin or clonazepam.

[Sleep at Altitude]. / Schlaf in der Höhe.

Advancing infrastructure of mountain regions allows not only well-prepared mountaineers, but also elderly people with pre-existing illness the stay at high altitudes. Based on the hypoxic conditions, low oxygen saturation values are reached, which cause severe hypoxemia in the tissue. Symptoms of acute mountain sickness appear even at moderate altitude, which are manifested during sleep. Patients suffering from sleep apnea are at high risk, because of the obstructive ventilation disorder in combination with less oxygen availability. Concurrently, gender differences play a decisive role. Due to the respiratory stabilizing impact of estrogen, women are faster in adapting to altitude differences. A reduction of sleep duration and extended wake phases are shown, which causes lower sleep sufficiency. With continued rise of altitude, the arousal-index increases. For individual differences concerning altitude induced problems, individual acclimatization protocols are needed. Well prepared pre-acclimatization could prevent altitude induced sleep problems, as well as the treatment of such.

Effect of weekly hiking on cardiovascular risk factors in the elderly.

BACKGROUND: Hiking is one of the most popular activities among the elderly in Alpine regions. Due to the long-lasting, moderately intensive nature of this form of physical activity, hiking is generally considered to be beneficial to health. However, it is currently unclear whether once-weekly hiking--as commonly practiced at weekends--really does yield such positive effects in elderly persons aged 60 years and over. OBJECTIVES: This study investigated the effect of a single weekly mountain hiking session on cardiovascular risk factors. MATERIALS AND METHODS: A 9-month mountain hiking program was completed by 14 male (age 65.6 ± 2.7 years) and 10 female (age 66.2 ± 4.4 years) elderly participants. The program consisted of a single weekly hiking session with the goal of achieving a 500-m altitude increase within 3 h. Before and after the 9-month program, an electrocardiogram (ECG) was performed and blood pressure, glycated hemoglobin (HbA1c), high-density (HDL) and low-density lipoprotein (LDL) measurements were made. RESULTS: The elderly participants showed a normal cardiovascular risk profile at the start of the investigation. The estimated net energy expenditure for one hiking session was approximately 521 ± 91 kcal. Over the 9-month period, no changes were found in any of the investigated parameters for the entire group. However, participants with untreated hypertension showed a reduced systolic blood pressure. CONCLUSION: The present investigation showed that moderate-intensity activity only at weekends does not improve cardiovascular risk factors in elderly persons with a relatively normal cardiovascular risk profile. Conversely, elderly persons suffering from hypertension might profit from such a practice.

Cromoglycate, reproterol, or both--what's best for exercise-induced asthma?

OBJECTIVE: International guidelines recommend short- (SABA) or long-acting b-agonists for the prevention of bronchoconstriction after exercise (EIB) in patients with exercise-induced asthma (EIA). However, other drugs are still in discussion for the prevention of EIB. We investigated the efficacy of a combination of inhaled sodium cromoglycate and the ß-mimetic drug reproterol versus inhaled reproterol alone and both versus inhaled placebo in subjects with exercise-induced asthma (EIA). METHODS: The study aimed to prove the preventive effect of a combination of 1-mg reproterol and 2-mg disodium cromoglycate (DSCG) and its single components vs. placebo, measuring the decrease of FEV1 after a standardized treadmill test in 11 patients with recorded EIA. The study medication was twice as high as those of drugs which are commercially available (e.g., Allergospasmin®, Aarane®). RESULTS: The results revealed that the combination of reproterol and DSCG was significantly effective against a decrease of FEV1 after a standardized exercise challenge test (ECT) compared to placebo. The short-acting b-agonist reproterol alone had almost the same effectiveness as the combination of reproterol and DNCG. The difference between the combination with DNCG and reproterol alone was less than 10% and insignificant (p 0.48). DNCG alone did not show a difference in the effectiveness compared to placebo. CONCLUSION: Prevention of EIA with the combination of reproterol and DSCG or with reproterol only is effective. An exclusive recommendation in favor of the combination cannot be given due to the low difference in the effectiveness versus reproterol alone. Due to the limited number of subjects and some probands showing protection under DSCG, it cannot be completely excluded that there is some preventive power of DSCG in individual cases.

Fifth metacarpal instability and its effect on hamatometacarpal arthritis patterns-a cadaver study.

Osteoarthritis (OA) of the fifth carpometacarpal joint is a rare diagnosis with most cases occurring post-traumatically. The joint's ligamentous supports have not been described extensively; however we know that the volar and intermetacarpal ligaments acts as the primary stabilizers. The major deforming forces on this joint are the extensor carpi ulnaris (ECU) dorsally and the flexor carpi ulnaris volarly, via the pisimetacarpal ligament. The aim of this study was to determine how the different joint stabilizers contribute to fifth carpometacarpal joint stability and biomechanics. We also sought to describe the OA patterns affecting the fifth carpometacarpal joint. A study was performed on 10 embalmed cadavers. The fifth carpometacarpal joint was evaluated biomechanically through ECU traction and sequential transection of the joint stabilizers. Gross macroscopic evaluation of degenerative changes in the articular surface was conducted and graded on a scale of 0-3 (with 0 representing normal cartilage with no visible lesions). Biomechanical data were available from 18 specimens (10 right; 8 left) and arthritic patterns were available from all 20 specimens (10 right; 10 left). Based on the biomechanical data, the proximal and distal intermetacarpal ligaments were found to be major contributors to stability. The volar stabilizer was a minor contributor to stability and the dorsal stabilizer was a minimal contributor to stability. OA was present in 16/20 specimens (80%) with an average arthritis grade of 1.6 on the right hand and 1.0 on the left hand. The most common site of OA was the dorso-ulnar quadrant.

Right ventricle dimensions and function in response to acute hypoxia in healthy human subjects.

AIM: Acute hypoxia produces acute vasoconstriction in the pulmonary circulation with consequences on right ventricular (RV) structure and function. Previous investigations in healthy humans have been restricted to measurements after altitude acclimatization or were interrupted by normoxia. We hypothesized that immediate changes in RV dimensions in healthy subjects in response to normobaric hypoxia differ without the aforementioned constraints. METHODS: Transthoracic echocardiography was performed in 35 young, healthy subjects exposed to 11% oxygen, as well as six controls under sham hypoxia (20.6% oxygen, single blind) first at normoxia and after 30, 60, 100, 150 min of hypoxia or normoxia respectively. A subgroup of 15 subjects continued with 3-min cycling exercise in hypoxia with subsequent evaluation followed by an assessment 1 min at rest while breathing 4 L min-1 oxygen. RESULTS: During hypoxia, there was a significant linear increase of all RV dimensions (RVD1 + 29 mm, RVD2 + 42 mm, RVD3 + 41 mm, RVOT + 13 mm, RVEDA + 18 mm, P < 0.01) in the exposure group vs. the control group. In response to hypoxia, right ventricular systolic pressure (RVSP) showed a modest increase in hypoxia at rest (+7.3 mmHg, P < 0.01) and increased further with physical effort (+11.8 mmHg, P < 0.01). After 1 min of oxygen at rest, it fell by 50% of the maximum increase. CONCLUSION: Acute changes in RV morphology occur quickly after exposure to normobaric hypoxia. The changes were out of proportion to a relatively low-estimated increase in pulmonary pressure, indicating direct effects on RV structure. The results in healthy subjects are basis for future clinically oriented interventional studies in normobaric hypoxia.

Overnight pulse oximetry for sleep-disordered breathing in adults: a review.

Pulse oximetry is a well-established tool routinely used in many settings of modern medicine to determine a patient's arterial oxygen saturation and heart rate. The decreasing size of pulse oximeters over recent years has broadened their spectrum of use. For diagnosis and treatment of sleep-disordered breathing, overnight pulse oximetry helps determine the severity of disease and is used as an economical means to detect sleep apnea. In this article, we outline the clinical utility and economical benefit of overnight pulse oximetry in sleep and breathing disorders in adults and highlight the controversies regarding its limitations as presented in published studies.

Telemedicine in the sleep laboratory: feasibility and economic advantages of polysomnograms transferred online.

The costs for polysomnography (PSG) and alternative diagnostic procedures for sleep-disordered breathing are challenging public health care systems. We wanted to determine if a telemedicine protocol with online transfer of PSGs from a remote site could be cost-effective and clinically useful while improving patient access to full PSG. Fifty-nine PSGs were performed in 54 pulmonary patients with suspected sleep-disordered breathing at a remote hospital. The data were transferred by File Transfer Protocol (FTP) via the Internet to Walter Reed Army Medical Center (WRAMC) for scoring and interpretation. The results were faxed back to the remote hospital. Clinical utility was assessed by evaluating the reasons for patient referral and the resulting diagnoses. The economic benefits were calculated by comparing direct expenses of the telemedicine protocol with costs for contracting PSGs at outside sleep laboratories. A total of 93% (55) of all PSGs were transferred successfully online. Of the 54 patients, 47 had PSGs performed for diagnosis (including three split-night studies), 8 underwent treatment titration, and 1 patient had both overnight studies. Diagnoses were obstructive sleep apnea in 43 patients, central sleep apnea in 2, and upper airway resistance syndrome in 2. The disease conditions were defined as severe in 27 patients, moderate in 12 patients, and mild in 8 patients. Each PSG cost $700 (including costs for lost transmissions) compared to $1,250 for referral to a private sleep laboratory. A savings of $550 per study was realized with the telemedicine protocol. The online transfer of PSGs from a remote site to a centralized sleep laboratory is technically feasible and clinically useful. Telemedicine offers an effective alternative for cost reduction in sleep medicine while improving patient access to specialized care in remote areas.

Training and overtraining: an overview and experimental results in endurance sports.

Overtraining can be defined as "training-competition > > recovery imbalance", that is assumed to result in glycogen deficit, catabolic > anabolic imbalance, neuroendocrine imbalance, amino acid imbalance, and autonomic imbalance. Additional non-training stress factors and monotony of training exacerbate the risk of a resulting overtraining syndrome. Short-term overtraining called overreaching which can be seen as a normal part of athletic training, must be distinguished from long-term overtraining that can lead to a state described as burnout, staleness or overtraining syndrome. Persistent performance incompetence, persistent high fatigue ratings, altered mood state, increased rate of infections, and suppressed reproductive function have been described as key findings in overtraining syndrome. An increased risk of overtraining syndrome may be expected around 3 weeks of intensified/prolonged endurance training at a high training load level. Heavy training loads may apparently be tolerated for extensive periods of time if athletes take a rest day every week and use alternating hard and easy days of training. Persistent performance incompetence and high fatigue ratings may depend on impaired or inhibited transmission of ergotropic (catabolic) signals to target organs, such as: (I) decreased neuromuscular excitability, (II) inhibition of alpha-motoneuron activity (hypothetic), (III) decreased adrenal sensitivity to ACTH (cortisol release) and increased pituitary sensitivity to GHRH (GH release) resulting in a counter-regulatory shift to a more anabolic endocrine responsibility, (IV) decreased beta-adrenoreceptor density (sensitivity to catecholamines), (V) decreased intrinsic sympathetic activity, and (VI) intracellular protective mechanisms such as increased synthesis of heat-shock proteins (HSP 70) represent a complex strategy against an overload-dependent cellular damage.

"Open-word" questions: an effective tool in gauging education of patients with COPD.

For evaluation of the success of patient education in patients suffering from chronic obstructive pulmonary disease (COPD), multiple-choice tests are commonly used. Using these tests, however, only passive knowledge can be examined. We attempted to evaluate, with the help of "open-word" questions and keywords, as used in examinations of students of arts, the active knowledge achieved by 12 patients who had been participants in one of our indepth courses of patient education. The results of this "open-word" test were compared with the results of multiple-choice tests with 91 participants. The average results of the "open-word" tests, with 36% correct answers, were remarkably worse than those of the multiple-choice tests with 80% correct answers. In our opinion, this allows the conclusion that the active knowledge attained in the patient-education courses is clearly lower than the passive knowledge achieved, and that, on the other hand, multiple-choice tests cannot be considered as the exclusive method to evaluate the success of patient education because their questions may quite often prove to be too easy.

Two weeks of buspirone protects against posthypoxic ventilatory pauses in the C57BL/6J mouse strain.

The purpose was to determine if 2 weeks of buspirone suppressed post-hypoxic breathing instability and pauses in the C57BL/6J (B6) mouse. Study groups were vehicle (saline, n=8), low-dose (1.5 mg/kg, n=8), and high-dose buspirone (5.0 mg/kg, n=8). Frequency, measured by plethysmography, was the major metric, and a pause defined by breathing cessation >2.5 times the average frequency. Mice were tested after 16 days of ip injections of vehicle or drug. On day 17, 4 mice in each group were tested after buspirone and the 5-HT(1A) receptor antagonist, 4-iodo-N-{2-[4-(methoxyphenyl)-1-piperazinyl] ethyl}-N-2-pyridinyl-benzamide (p-MPPI, 5 mg/kg). A post-hypoxic pause was present in 6/8 animals given vehicle and 1/16 animals given buspirone at either dose, but always present (8/8) with p-MPPI, regardless of buspirone dose. Post-hypoxic frequency decline was blunted by buspirone (-10% vehicle vs. -5% at both doses) and restored by p-MPPI; ventilatory stability as described by the coefficient of variation which was reduced by buspirone (p<0.04) was increased by p-MPPI (0.01). In conclusion, buspirone administration after 2 weeks acts through the 5-HT(1A) receptor to reduce post-hypoxic ventilatory instability in the B6 strain.

Effects of supervised exercise on gamma-glutamyl transferase levels in patients with isolated impaired fasting glucose and those with impaired fasting glucose plus impaired glucose tolerance.

AIM: To study the effects of a supervised exercise program on serum gamma-glutamyl transferase (GGT), glycemic control and cardiovascular risk factors in pre-diabetic patients with isolated impaired fasting glucose (IFG) and those with IFG plus impaired glucose tolerance (IGT). METHODS: Out of 60 pre-diabetic patients (30 with isolated IFG and 30 with IFG + IGT) 24 were randomly assigned to the supervised exercise program (1 h twice a week) and 36 only obtained counselling on the risk of diabetes and its prevention. Patients have been followed over a 12-month period. RESULTS: The main findings were that patients with IFG + IGT had increased GGT levels at baseline (49.2±27.4 U/L) compared to subjects with isolated IFG (28.1±21.9 U/L) (p<0.01), and that GGT levels improved only after the supervised exercise intervention within the IFG + IGT subjects ( - 17.7±19.6 U/L). Similarly, baseline triglyceride levels were also higher in IFG + IGT patients (p<0.001) and there was a decrease through exercise intervention in these patients only (p<0.05). CONCLUSION: GGT is an unspecific marker of oxidative stress and both high plasma glucose and triglycerides levels may produce oxidative stress. Thus, patients with IFG + IGT seem to have higher levels of oxidative stress than those with isolated IFG. Based on the known association between GGT levels and cardiovascular risk factors, IFG + IGT patients may be at higher risk for the development of cardiovascular diseases. The specific effect of regular exercise on GGT in pre-diabetic patients may contribute to the understanding of the preventive effects related to exercise.

Cheyne stokes breathing at high altitude: a helpful response or a troublemaker?

Sleep disorders at high altitude are common and well-known for centuries. One symptom of the complex is periodic breathing (PB). PB occurs from a disbalance of the negative feedback loop of ventilation control, and at high altitude, it is increased by a phase shift of 180 degrees between hyperventilation and hypoxia. This paper explains the mechanisms that trigger the problem and discusses whether PB may be of advantage or disadvantage for the person going to high altitude. Up to about 3,000-3,500 m, PB may be of advantage because it stabilizes oxygen saturation at a relatively high level. At higher altitudes, disadvantages predominate because frequent arousals cause total sleep deprivation and mental and physical impairment of the victim. Correct acclimatization and "defensive" altitude profiles are gold standard, which minimize PB and optimizes recreative sleep, although they cannot mask PB completely, especially at extreme altitude.

[Nasal BiPAP (bilevel positive airway pressure) respiration with controlled respiratory mode in neuromuscular diseases and severe kyphoscoliosis]. / Nasale BiPAP-(Bilevel positive Airway Pressure) Beatmung im kontrollierten Atemmodus bei neuromuskulären Erkrankungen und schwerer Kyphoskoliose.

The BiPAP-System is a useful ventilatory support for patients with severe sleep apnea and need for high inspiratory pressure. Using the BiPAP as a full ventilatory support is new due to the recent addition of a timed control modus and individual control of inspiratory time. We used the new BiPAP ST-System in one young men with Duchenne-disease, one man with heredo ataxia (Friedreich), one women with spinal muscular atrophy, one man with central sleep apnea due to brainstem infarction as well as two women and one men with severe kyphoscoliosis. All patients had a significant hypoventilation and hypoxemia at night, which was documented by polysomnography. Mechanical ventilation at night with nasal BiPAP increased the baseline oxygen saturation (SaO2) by an average of 11.9% in all seven patients. The frequency of desaturations below 90% diminished by an average of 81%. The lowest SaO2 measured increased by 28% in all seven patients combined. Rhinitis due to the dryness of the inspired air were noticed in only two patients. Two other patients needed adaptation to the customized mask. The nasal BiPAP-System using the T-mode is a useful device to support ventilation at night and thus it could replace ventilatory support by the IPPV-mode in many patients.

Monitoring high-intensity endurance training using neuromuscular excitability to recognize overtraining.

The minimal rectangular current pulse that produces a single contraction of reference muscles at different pulse durations has been recommended as a marker of the neuromuscular excitability (NME) of skeletal muscles. NME is improved in well-trained, non-fatigued endurance athletes and deteriorates after prolonged heavy exercise and high-volume overtraining. The hypothesis was tested that a deterioration in NME also indicates an early stage in the overtraining process during high-intensity endurance training. Six subjects participated for 40-60 min per day in a 6-week, 6-days-per-week, intensive, steady-state and interval training program using a cycle ergometer. Training was stopped each day on volitional exhaustion. On day 7 of each week training was of low intensity for about 30-40 min. Submaximum and maximum power output were significantly increased after 3 weeks, but there was no further improvement, rather a deterioration after week 6 compared to week 3. Even after 2 weeks of regeneration no supercompensation was evident, rather a decrease in maximum power output. NME was slightly improved after 3 weeks, but deteriorated after 6 weeks, and was again normalized after 2 weeks of regeneration. The discrepancy between normalization of NME and still-deteriorated performance ability after 2 weeks of regeneration reflects additional significant, and probably central mechanisms that explain persistent performance incompetence. Deterioration in NME may indicate an early stage in the overtraining process during high-volume as well as high-intensity endurance overtraining, but normalization does not necessarily indicate sufficient regeneration.

[Efficiency of portable sleep apnea screening instruments]. / Effizienz tragbarer Schlafapnoe-Screening-Geräte.

Diagnosis of a sleep apnoea syndrome in severely snoring patients with diurnal sleepiness is growing in importance in the consulting rooms of general practitioners, internists, ENT specialists and pneumologists. However, time and cost reasons limit the diagnostic procedures conducted by practitioners to outpatient screening. Two different systems are presently available in Germany. The MESAM system (Madaus, Freiburg) records by means of a microphone and various electrodes the oxygen saturation, heart rate, snoring and sleeping position of the patient. The Apnoe-Check System (Medanz, Starnberg) determines the nasal and oral respiratory flow by means of a mask fitted with thermistors. Evaluation is accomplished in the case of MESAM via a conventional personal computer whereas with the Apnoea Check System the apnoeas and their duration can be read off direct from a writer. The cost ratio of these systems is approximately 3:1 (MESAM:Apnoea Check). Wie compared both systems by parallel measurements on 19 female and male patients and controlled the results obtained by measurements with a CO2 infrared absorption spectrometer in our sleep lab. A total of 3201 nocturnal events were recorded via MESAM and 1488 via the Apnoe-Check System. The highest number of apneas was recorded by MESAM in a patient with severe sleep apnea syndrome, namely, 546 apnoeas in one night. The lowest number of apnea events was experienced by a healthy male with 33 apneas in a night. With the Apnoe Check the maximum of nocturnal events was 255, the minimum being 8 events in one patient. In 64.6% of all nocturnal events there was time congruence for both systems.(ABSTRACT TRUNCATED AT 250 WORDS)

[Technical differences in various CPAP and BiLevel CPAP devices]. / Technische Unterschiede der verschiedenen CPAP und BiLevel-CPAP-Geräte.

PURPOSE: Since the first presentations of CPAP by Sullivan 1983 und BiPAP by Sanders 1990 as a successful treatment in obstructive sleep apnoea syndrome, many CPAP and BiLevel-CPAP devices have been developed by several companies around the world. Although all devices work on the same principle of continuous positive airway pressure delivered through nasal or facemasks, there are, however, significant technical differences between these devices, mainly due to different size and different maximum speed of the turbines. As far as we know, the only study concerning this technical difference in the devices was conducted by Raschke in 1995, who found significant differences in the pressure stability of the devices using a very complicated measurement model on volunteers who were breathing on the different devices. We intended to study the technical differences of the devices using a more simple technique in static conditions, but with very exact measurement. METHODS: We measured pressure stability on different inspiration flows and different pressure levels of 8 CPAP's and 4 BiLevel-CPAP's under static conditions using the "Höntzsch Exact ASD-G Messrohr ms 20201-18" flow-measurement device and the "Thommen HM 18.0020.A" pressure-measurement devixe. We measured the noise emission by these devices at different frequency levels using the "Brüel and Kjer Dual Channel Real Time Frequency Analyzer", and measured the speed to reach the adjusted pressure level with the "Multimeter Phillips PM 2518X" and "Oszillograph Phillips PM3350" using the voltage change due to different working of the electric engines at different turbine speeds. We also investigated the different construction of the devices by opening them and analysing the materials used in the devices. RESULTS: The real pressure levels at an adjusted pressure of 10 mbar and at an inspiration flow of 1 Liter/sec range from 8.7 mbar to 15.6 mbar in CPAP's and from 9 mbar to 9.7 mbar in BiLevel devices. At higher inspiration flows the differences are larger, at lower flows smaller. The maximum noise emission in the 10 Hhz spectrum at a distance of 100 cm from the device at an adjusted pressure level of 10 mbar ranged from 29.6 dB to 39.9 dB in CPAP's and 30.4 dB to 42.2 dB in BiLevel-CPAP's. The time to reach an adjusted pressure level of 10 mbar after closing the airway of the device ranged from 0.26 to 0.66 sec in CPAP's and from 0.46 to 0.80 sec in BiLevel devices. CONCLUSION: There are significant technical differences in the different CPAP and BiLevel devices due to different construction of the turbines and electrical engines of these devices. This should be considered when prescribing a device for a sleep apnoea patient. Not every device is suitable for every patient, and quality differences should be considered by all persons involved in the production and prescribing process.