[How to characterize and treat sleep complaints in bipolar disorders?] / Comment caractériser et traiter les plaintes de sommeil dans les troubles bipolaires ?

OBJECTIVES: Sleep complaints are very common in bipolar disorders (BD) both during acute phases (manic and depressive episodes) and remission (about 80 % of patients with remitted BD have poor sleep quality). Sleep complaints during remission are of particular importance since they are associated with more mood relapses and worse outcomes. In this context, this review discusses the characterization and treatment of sleep complaints in BD. METHODS: We examined the international scientific literature in June 2016 and performed a literature search with PubMed electronic database using the following headings: "bipolar disorder" and ("sleep" or "insomnia" or "hypersomnia" or "circadian" or "apnoea" or "apnea" or "restless legs"). RESULTS: Patients with BD suffer from sleep and circadian rhythm abnormalities during major depressive episodes (insomnia or hypersomnia, nightmares, nocturnal and/or early awakenings, non-restorative sleep) and manic episodes (insomnia, decreased need for sleep without fatigue), but also some of these abnormalities may persist during remission. These remission phases are characterized by a reduced quality and quantity of sleep, with a longer sleep duration, increased sleep latency, a lengthening of the wake time after sleep onset (WASO), a decrease of sleep efficiency, and greater variability in sleep/wake rhythms. Patients also present frequent sleep comorbidities: chronic insomnia, sleepiness, sleep phase delay syndrome, obstructive sleep apnea/hypopnea syndrome (OSAHS), and restless legs syndrome (RLS). These disorders are insufficiently diagnosed and treated whereas they are associated with mood relapses, treatment resistance, affect cognitive global functioning, reduce the quality of life, and contribute to weight gain or metabolic syndrome. Sleep and circadian rhythm abnormalities have been also associated with suicidal behaviors. Therefore, a clinical exploration with characterization of these abnormalities and disorders is essential. This exploration should be helped by questionnaires and documented on sleep diaries or even actimetric objective measures. Explorations such as ventilatory polygraphy, polysomnography or a more comprehensive assessment in a sleep laboratory may be required to complete the diagnostic assessment. Treatments obviously depend on the cause identified through assessment procedures. Treatment of chronic insomnia is primarily based on non-drug techniques (by restructuring behavior and sleep patterns), on psychotherapy (cognitive behavioral therapy for insomnia [CBT-I]; relaxation; interpersonal and social rhythm therapy [IPSRT]; etc.), and if necessary with hypnotics during less than four weeks. Specific treatments are needed in phase delay syndrome, OSAHS, or other more rare sleep disorders. CONCLUSIONS: BD are defined by several sleep and circadian rhythm abnormalities during all phases of the disorder. These abnormalities and disorders, especially during remitted phases, should be characterized and diagnosed to reduce mood relapses, treatment resistance and improve BD outcomes.

Childhood-onset narcolepsy, obesity and puberty in four consecutive children: a close temporal link.

Narcolepsy is a rare but disabling condition that causes excessive daytime sleepiness. Interestingly, weight gain is frequent in patients with narcolepsy and it has sometimes been described very early in the course of the disease. Here, we report four consecutive obese children who were referred to our sleep laboratory for excessive daytime sleepiness and suspected sleep apnoea syndrome. They underwent nocturnal polysomnography associated with multiple sleep latency tests. Narcolepsy was diagnosed in all children with a close temporal link between the onset of narcolepsy, obesity and puberty. Scientifically, the relationship between sleep, weight, growth rate and puberty onset is striking and merits further investigation. From the clinical point of view, narcolepsy must be investigated in obese sleepy children along with obstructive sleep apnoea. Indeed, it can be controlled with appropriate treatment but the proper diagnosis relies not only upon nocturnal polysomnography but involves the systematic use of multiple sleep latency tests.

Prevalence of pain in 240 non-ambulatory children with severe cerebral palsy.

BACKGROUND: Several studies have given frequencies of pain in children with cerebral palsy, but comparing the findings is difficult. We aimed to estimate the prevalence of pain in non-ambulatory children with cerebral palsy and describe their characteristics by presence or absence of pain. METHODS: Data were extracted from an ongoing longitudinal national cohort following non-ambulatory children with severe cerebral palsy aged 3 to 10years over 10years. We described and compared data for the first 240 children at inclusion by presence or absence of pain. Pain was assessed by a visual analog scale and the Douleur Enfant San Salvadour scales and by investigator interview. RESULTS: Overall, 65 children experienced pain, for a prevalence of 27.1% (95% confidence interval 22-33%). All children experiencing pain had orthopaedic pain and 45.6% had pain from another origin. The main pain sites were hips (43.4%) and feet (26.9%). Joint mobilisation was the source of pain for 58.3% of children experiencing pain, and sitting was identified as painful for 10.3%. Pain was greater with scoliosis (43.1% vs 24.1% with and without pain; P=0.006) and spasticity treatment (32.3% vs 17.2%; P=0.020). CONCLUSION: Children with cerebral palsy frequently experience pain and also early pain, mostly articular and orthopedic. The assessment of pain should be systematic because of its high prevalence. Interventions to prevent scoliosis, hip luxation, and foot deformities and to reduce spasticity, such as the use of analgesics before joint mobilization exercises, may reduce the prevalence of this pain.

Effects of bilateral subthalamic stimulation on sleep in Parkinson's disease.

OBJECTIVE: Sleep disturbances are frequently observed in Parkinson's disease (PD). Bilateral chronic subthalamic nucleus (STN) stimulation is an alternative treatment for advanced PD. Improvements in motor disturbances after STN stimulation are well documented and seem to be associated with better sleep quality, even though the objective effect on sleep structure remains unclear. We have therefore studied the sleep/wakefulness cycle before and after surgical treatment in 10 consecutive parkinsonian patients. METHODS: Subjective sleep quality and sleep recordings were evaluated one month before and three months after initiation of STN stimulation. After surgery, the recordings were performed under two conditions: with stimulation (the "on" condition) and-if patients had given their consent-in the absence of stimulation (the "off" condition). RESULTS: With STN stimulation, subjective and objective sleep qualities were improved. Total sleep time, sleep efficiency and the durations of deep slow wave sleep and paradoxical sleep increased significantly. When stimulation was absent, sleep disturbances were similar to those observed before surgery. CONCLUSION: Chronic STN stimulation is associated with a sleep improvement, which can be explained in part by the concomitant decrease in motor disturbances but also by the reduction in dosages of antiparkinsonian medication. However, we can not exclude a direct effect of STN stimulation on sleep regulatory centres.

Brief and sustained movements: differences in event-related (de)synchronization (ERD/ERS) patterns.

OBJECTIVE: (1) To determine if there are changes in event-related desynchronization/event-related synchronization (ERD/ERS) patterns when the movement is sustained? (2) To determine, from a technical point of view for ERD calculation, if it is possible to take the reference period during muscular activation? METHODS: Eight healthy subjects performed two series of brief and sustained self-paced extensions with their dominant wrist. The end of the sustained movement was externally triggered by the examinator. ERD/ERS was calculated in mu and beta bands from 13 source derivations covering motor areas, computed from 29 scalp electrodes. Movement onset and offset were determined by electromyographic activity (EMG) of wrist extensors. RESULTS: When the movement was sustained, power in the mu and beta bands returned to baseline values within 4-5 s. Movement duration had little effect, if at all, on both pre and post-movement periods. Compared to brief movement, after the onset of the prolonged movement, mu ERD just returned to baseline, without synchronization. In contrast, beta ERS was still present though earlier and much lower. CONCLUSIONS: The reference period for ERD calculation may be taken during muscular activation if its duration is long enough. Beta synchronization may occur despite a non-deactivated motor cortex, suggesting a contribution from afferent somesthetic inputs.

The motor function measure to study limitation of activity in children and adults with Charcot-Marie-Tooth disease.

OBJECTIVE: To study the applicability and responsiveness of the motor function measure (total score and sub-scores D1, D2 and D3) in patients with Charcot-Marie-Tooth disease. PATIENTS AND METHODS: Two hundred and thirty-three patients aged 4-86 years were included in the descriptive study. Scores and sub-scores were analyzed by age and by disease subtypes. Sensitivity to change (responsiveness) was estimated in patients having had at least two evaluations with at least six months between the first and the second. RESULTS: Motor function measure scores decrease with age, especially sub-scores D1 and D3. There were no significant differences between the scores according to type of Charcot-Marie-Tooth disease. The scores were significantly higher for ambulatory than for non-ambulatory patients. Significant responsiveness was demonstrated only in type 2 Charcot-Marie-Tooth disease. DISCUSSION/CONCLUSIONS: Our results suggest that, especially for D1 and D3 sub-scores, the motor function measure is a reliable and valid outcome measure that can be usefully applied in longitudinal follow-up. Studies of longer duration could demonstrate its responsiveness in other Charcot-Marie-Tooth disease subtypes.

Rehabilitation of 190 non-ambulatory children with cerebral palsy in structures of care or in liberal sector.

AIMS: To describe the rehabilitation of non-ambulatory children with cerebral palsy and to explore adjustability on their individual needs. MATERIAL AND METHOD: Data described are extracted from an on-going national cohort study, following during 10years 385 children with cerebral palsy, aged from 4 to 10, Gross Motor Function Classification System IV and V. We analysed data from the first 190 patients (mean age 6years 10months (SD 2.0), 111 boys), focusing on physiotherapy, ergotherapy, psychomotility and speech therapy in medico-social and liberal sectors. RESULTS: In medico-social sector, duration of paramedical care is significantly more important than in liberal sector (structure of care: median=4.25h/week, liberal sector: median=2.00h/week) (P<0.0001). More than 4 different types of care per week are given in medico-social sector, while in liberal sector children benefit from only 2 different types of care a week. In investigators opinion, rehabilitation in structures of care is 71.65% adapted as opposed to 18.75% in the liberal sector (P<0.001). Children level V have less time of rehabilitation than the others (P=0.0424). INTERPRETATION: Rehabilitation of children with cerebral palsy who are not able to walk, with an objective to improve quality of life, is truly multidisciplinary and suitable in medico-social sector.

Development and validation of a motor function classification in patients with neuromuscular disease: the NM-score.

OBJECTIVE: To develop a classification for neuromuscular disease patients in each of the three motor function domains (D1: standing and transfers; D2: axial and proximal function; D3: distal function). MATERIALS AND METHODS: A draft classification was developed by a study group and then improved by qualitative validation studies (according to the Delphi method) and quantitative validation studies (content validity, criterion validity and inter-rater reliability). A total of 448 patients with genetic neuromuscular diseases participated in the studies. RESULTS: On average, it took 6.3minutes to rate a patient. The inter-rater agreement was good when the classification was based on patient observation or an interview with the patient (Cohen's kappa=0.770, 0.690 and 0.642 for NM-Score D1, D2 and D3 domains, respectively). Stronger correlations (according to Spearman's coefficient) with the respective "gold standard" classifications were found for NM-Score D1 (0.86 vs. the Vignos Scale and -0.88 vs. the Motor Function Measure [MFM]-D1) and NM-Score D2 (-0.7 vs. the Brooke Scale and 0.64 vs. MFM D2) than for NM-Score D3 (0.49 vs. the Brooke scale and -0.49 vs. MFM D3). DISCUSSION/CONCLUSIONS: The NM-Score is a reliable, reproducible outcome measure with value in clinical practice and in clinical research for the description of patients and the constitution of uniform patient groups (in terms of motor function).

Tolerance and effectiveness on pain control of Pamidronate® intravenous infusions in children with neuromuscular disorders.

UNLABELLED: Osteoporosis is a common complication in children with motor impairments. They have a higher risk of fractures (20% during their lifetime) mostly at femoral level. Furthermore, these children have pain yet no clear relation has been established between osteoporosis and pain. The efficacy of bisphosphonates has been validated in adults and for children with osteogenesis imperfecta (OI). However, its use in children with motor impairments has not yet been validated. PATIENTS AND METHODS: Retrospective study on the medical charts of children presenting neurological diseases and motor impairments associated to secondary symptomatic osteoporosis. These children underwent treatment with Pamidronate(®) intravenous infusions (I.V.) in Lyon and Valence between 2002 and 2008. Data were collected on pain control, incidence and frequency of fractures and bone mass density (BMD). Data on adverse events were also collected to evaluate treatment's tolerance. RESULTS: Twelve children's charts were studied for a total of 50 Pamidronate(®) I.V. infusions. Regarding treatment's efficacy, we observed a clear decrease and even total relief of the pain with improvement reported after 98% of perfusions. Regarding BMD, there was a real improvement after the treatment (e.g., lumbar BMD measures, -46.5% before treatment and -27% after treatment). The adverse events, flu-like syndrome, muscle pain and asymptomatic hypocalcemia, were minor and quickly reversible. CONCLUSION: It seems quite essential to screen for osteoporosis-related pain in these children and treat them quickly to avoid a negative impact on their quality of life. Treatment with I.V. bisphosphonates has shown its relevance, yet practical modalities still need to be defined. It would be interesting but quite difficult to implement, in light of the positive effect of this study, a prospective, randomized, controlled, double-blind vs. placebo study on a large enough sample of patients.

[Intracranial aneurysm and dysplasia of elastic tissue: pre- and postoperative problems]. / Anévrysme intracranien et dysplasie du tissu élastique: problèmes pré et post-opératoires.

From two cases of patients presenting a cerebral aneurysm associated with a dysplasia of elastic tissue, one a Marfan's syndrome, the other an anetoderma, this paper relate the post-operative, essentially cardio-vascularly and pulmonary complexities and define the elements of the pre-operative check-up.

[Neurogenic pulmonary edema, complication of meningeal hemorrhage: report of 4 cases]. / Oedème pulmonaire neurogénique, complication de l'hémorragie méningée: à propos de 4 observations.

Neurogenic pulmonary edema (NPE) observed in 4 patients admitted in Neurosurgical Intensive Care au SAH by ruptured a vascular malformation. This complication is unusual (1.9%) and has been observed in comatose patients. For 3 patients, NEP resorption was rapid, from 12 to 72 hours with a treatment by CCPV with a P.E.E.P. and with restoring the hemodynamical parameter. The drug must be discussed according to eventual deleterous side effects on cardiac output and systemic resistances. The early hemodynamical study argues for an essentially hemodynamical mechanism due to the brutal symphatic discharge created by cerebral lesions and increasing. ICP, more than a toxic lesionnal edema, as the Weidner's study shows it in ultrastructural analysis of sheep lungs.