Actimetry-Documented Persistent Periodic Limb Movements During EEG-Confirmed Deep General Anesthesia: A Case Report.

Motor activity during general anesthesia (GA) without neuromuscular blockade is often interpreted as reflecting insufficient anesthesia. Here we present the case of an octogenarian undergoing deep sclerectomy with opioid-sparing electroencephalography (EEG)-guided anesthesia. Periodic leg movements (PLM) appeared during ongoing surgery while the patient's raw EEG displayed a pattern of deep anesthesia, evidenced by burst suppression. Recognizing PLM in the context of opioid-sparing GA is of importance for anesthesiologists, as deep anesthesia is not necessarily associated with a decrease in motor activity.

A 3-year observation of excessive daytime sleepiness after subthalamic deep brain stimulation in patients with Parkinson's disease.

OBJECTIVE: Subthalamic nucleus deep brain stimulation (STN DBS) has a positive effect on sleep quality, but its effect on wake functions is controversial. This study evaluated the longitudinal changes of the quality of sleep and excessive daytime sleepiness (EDS) in Parkinson's disease (PD) patients undergoing STN DBS and identify which factors are associated with the presence of EDS before and after STN DBS. PATIENT AND METHODS: A total of 33 PD patients who underwent bilateral STN DBS between July 2011 and October 2015 were recruited. We evaluated subjective sleep quality assessed by Parkinson's Disease Sleep Scale (PDSS) and EDS using Epworth Sleepiness Scale (ESS) preoperatively and 6 months, 1 year, and 3 years postoperatively. RESULTS: There is a significant improvement in PDSS, and a noticeable change occurs immediately after the surgery. After DBS, the number of patients with persistent EDS gradually decreased, but patients with newly developed EDS were added. Baseline ESS score was highly correlated with EDS at 6 months and 1 year postoperatively, and older age of PD onset was highly associated with EDS at 1 year after DBS. At 3 years after DBS, the total PDSS score is a main contributing factor for EDS. There was no significant difference in dopamine agonist dose (agonist LED) and levodopa equivalent daily dose (LEDD) between groups with and without EDS at any time points. CONCLUSION: Bilateral STN DBS improves the subjective sleep quality, but EDS may improve or worsen. The risk factors for EDS change over time after STN DBS. Interestingly, dopaminergic medication did not affect EDS in DBS-treated PD patients.

Periodic Limb Movements During Sleep Are Not Associated With Hypertension in a Clinical Cohort of Korean Adults.

BACKGROUND: There is growing evidence of increased cardiovascular risk including hypertension in patients with periodic limb movements during sleep (PLMS). In a multiethnic cohort study, the association between prevalent hypertension and PLMS varied according to ethnicity. We evaluated whether PLMS are associated with hypertension in Koreans. METHODS: We enrolled 1,163 subjects who had polysomnography (PSG) from 2 tertiary hospitals. All subjects completed a sleep questionnaire before the PSG study. Coincidental hypertension was recorded according to past medical history. We analyzed the association between periodic limb movement index (PLMI), periodic limb movement associated with arousal index (PLMAI), and coincidental hypertension. Covariates were age, sex, body mass index (BMI), restless legs syndrome, apnea-hypopnea index (AHI), arousal index, and average oxygen saturation. RESULTS: A total of 304 subjects (26.1%) had hypertension. The proportion of subjects with hypertension in the PLMI ≥ 15 category was higher than that in the PLMI < 15 category (32.4% vs. 25.0%; P = 0.04). The proportion of subjects with hypertension in the PLMAI ≥ 1 category was 32.6%, which was higher than that in the PLMAI < 1 category (24.6%; P = 0.02). In a multivariate regression model, neither PLMI (odds ratio [OR], 1.12; 95% confidence interval [CI] 0.75-1.68) nor PLMAI (OR, 1.21; 95% CI 0.83-1.76) were associated with hypertension. Statistical significance was found between coincidental hypertension and the following variables: age, smoking history, BMI, and AHI. CONCLUSIONS: In a retrospective hospital-based study, there was no association between coincidental hypertension and PLMI/PLMAI in Koreans.

Características polisomnográficas nocturnas y otras variables relacionadas, en pacientes adultos mayores / Nocturnal polysomnbnographic characteristics and other related variables in elderly patients

Se cree que los ancianos necesitan dormir menos. Sin embargo, no es la necesidad de sueño sino la capacidad de dormir lo que disminuye con la edad, en paralelo a la mayor prevalencia de enfermedades cardiovasculares o metabólicas, o de depresión. Poco se ha descripto sobre los hallazgos polisomnográficos de esta población. En el presente estudio analizamos los hallazgos polisomnográficos en pacientes mayores de 65 años. Se realizó un estudio descriptivo a partir del análisis de una base de datos de 551 pacientes mayores de 65 años evaluados entre junio de 2013 y diciembre de 2014. Todos los sujetos se realizaron una polisomnografía (PSG) nocturna de 6 horas de duración. Las variables analizadas fueron: latencia de sueño (LS), eficacia de sueño (ES), latencia de fase REM (Lat R), % de R, índice de apneas hipopneas (IHA) y movimientos periódicos de piernas durante el sueño (PLMS). Se dividió la población en 3 grupos: G1: de 65 a 70 años; G2: 71 a 75; G3: mayor de 75 años. Se analizaron los datos de la serie general y las diferencias intergrupos. El IHA se incrementó con la edad y resultó más severo en los pacientes mayores de 75 años en relación con el grupo de menor edad. El incremento del IAH no se asoció a un incremento del índice de masa corporal ni a mayor somnolencia diurna. (AU)

It is believed that the elderly need less sleep. However, it is not the need for sleep but the ability to sleep that decreases with age, in parallel to the increasing prevalence of cardiovascular or metabolic disease, or depression. Little has been described about the polysomnographic findings of this population, hypothesizing that there are several alterations that prematurely corrected could improve the quality of life as the years go by. We analyzed the polysomnographic findings in patients over 65 years of age. A descriptive study was carried out based on the analyses of a database of 551 patients over 65 years of age evaluated between June 2013 to December 2014. All subjects underwent nocturnal PSG of 6 hours duration. The polysomnographic variables analyzed were: sleep latency (LS), sleep efficiency (ES), latency R phase (Lat R), % R, Apneas Hypoapneas Index (AHI) and Periodic Limb Movements of Sleep (PLMS). The population was divided into 3 groups: G1: from 65 to 70 years G2: 71 to 75, G3 greater than 75. AHI increased with age, being more severe in patients over 75 years of age in relation to the younger age group. The increase in AHI was not associated with an increase in Body Mass Index (BMI) or greater daytime sleepiness. (AU)

Periodic limb movements of sleep are associated with an increased prevalence of atrial fibrillation in patients with mild sleep-disordered breathing.

BACKGROUND: Growing evidence indicates that periodic limb movements of sleep (PLMS) may be related to increased risk of developing cardiovascular disease. However, the association of PLMS with atrial fibrillation (AF) is unclear, especially in patients with sleep-disordered breathing (SDB). This study sought to investigate whether PLMS were associated with increased AF prevalence, independent of established risk factors. METHODS: We performed a cross-sectional study of patients who underwent attended polysomnography at Mayo Clinic from 2011 to 2014. The association of PLMS with AF prevalence was estimated by using logistic regression models. RESULTS: 15,414 patients were studied, 76.3% of individuals with SDB defined by apnea-hypopnea index (AHI) ≥5/h, and 15.3% with a diagnosis of AF. In univariate logistic modelling, individuals with periodic limb movement index (PLMI) ≥30/h had higher odds of AF (odds ratio [OR] 1.96, 95% confidence interval [CI]1.79-2.16, p<0.001) when compared to patients with PLMI <15/h. After multivariate adjustment (for age, race, sex, history of smoking, hypertension, diabetes, coronary artery disease, heart failure, cerebrovascular disease, renal disease, iron deficiency anemia, chronic obstructive pulmonary disease, AHI, arousal index), in mild SDB patients, a PLMI ≥30/h or periodic limb movement arousal index (PLMAI) ≥5/h had significantly higher odds of AF than those with PLMI <15/h (OR 1.21, 95% CI 1.00-1.47, p=0.048) or PLMAI <1/h (OR 1.27, 95% CI 1.03-1.56, p=0.024). CONCLUSIONS: Frequent PLMS are independently associated with AF prevalence in patients with mild SDB. Further studies are needed to better understand the relationship with incident AF.

Somatic and neuropsychiatric comorbidities in pediatric restless legs syndrome: A systematic review of the literature.

Restless legs syndrome (RLS) is a relatively common neurological disorder in childhood, although it is usually overlooked due to the atypical presentation in children and associated comorbid conditions that may affect its clinical presentation. Here, we aimed to perform, for the first time, a systematic review of studies reporting the association between RLS in children and adolescents (<18 y) and somatic or neuropsychiatric conditions. We searched for peer-reviewed studies in PubMed, Ovid (including PsycINFO, Ovid MEDLINE®, and Embase), Web of Knowledge (Web of Science, Biological abstracts, BIOSIS, FSTA) through November 2015, with no language restrictions. We found 42 pertinent studies. Based on the retrieved studies, we discuss the association between RLS and a number of conditions, including growing pains, kidney disease, migraine, diabetes, epilepsy, rheumatologic disorders, cardiovascular disease, liver and gastrointestinal disorders, and neuropsychiatric disorders (e.g., attention deficit hyperactivity disorder (ADHD), depression, and conduct disorder). Our systematic review provides empirical evidence supporting the notion that RLS in children is comorbid with a number of somatic and neuropsychiatric conditions. We posit that the awareness on comorbid diseases/disorders is pivotal to improve the diagnosis and management of RLS and might suggest fruitful avenues to elucidate the pathophysiology of RLS in children.

Evaluation of Periodic Limb Movements in Sleep and Iron Status in Children With Autism.

OBJECTIVE: Recent data suggest that both disordered sleep and low serum iron occur more frequently in children with autism compared with children with typical development. Iron deficiency has been linked to specific sleep disorders. The goal of the current study was to evaluate periodic limb movements in sleep and iron status in a group of children with autism compared with typically developing children and children with nonautism developmental delay to determine if iron status correlated with polysomnographic measures of latency and continuity and periodic limb movements in sleep. METHODS: A total of 102 children (68 with autism, 18 typically developing, 16 with developmental delay) aged 2 to 7 years underwent a one-night modified polysomnography study and phlebotomy at the National Institutes of Health to measure serum markers of iron status (ferritin, iron, transferrin, percent transferrin saturation). RESULTS: No serum iron marker was associated with periodic limb movements of sleep or any other sleep parameter; this did not differ among the diagnostic groups. No significant differences among groups were observed on serum iron markers or most polysomnogram parameters: periodic limb movements in sleep, periodic limb movements index, wake after sleep onset, or sleep efficiency. Children in the autism group had significantly less total sleep time. Serum ferritin was uniformly low across groups. CONCLUSIONS: This study found no evidence that serum ferritin is associated with polysomnogram measures of latency or sleep continuity or that young children with autism are at increased risk for higher periodic limb movements index compared with typically developing and developmental delay peers.

The influence of pharyngeal and esophageal pressure measurements on the parameters of polysomnography.

Sleep-disordered breathing (SDB) is highly prevalent and accompanied by a considerable reduction in quality of life and an increase in cardiovascular morbidity and mortality. To diagnose SDB and to assess the localization of an airway obstruction, multichannel pressure measurements in the pharynx and esophagus have been used but are still under debate. Specifically, these devices are often labeled to be uncomfortable for patients and to influence the parameters of sleep recordings. The aims of the current study were to determine the tolerability of multilevel pressure measurement and to assess their impact on the parameters of polysomnography (PSG). Patients who were referred for two nights of standard PSG for diagnostic purposes were included. The device for multilevel pressure recordings was applied in addition to PSG on one of the two nights according to a randomization protocol. Tolerability of the device was assessed and the most relevant outcome measures of PSG were compared between the nights with and without the pressure sensor. All polysomnographic data were analyzed by the same trained observer who was blinded to the presence of the pressure catheter. Fifty-one patients were included in the trial. Ten of the patients tolerated insertion of the pressure catheter but complained about persisting discomfort during the night, requiring removal of the device. Forty-one patients tolerated the multilevel pressure transducer, which is equivalent to a tolerability of 80%. The results of the sleep parameters are based on the data of 31 patients. The pressure device minimally influenced the outcome data of the PSG. None of the recorded differences however were clinically relevant or statistically significant. Pressure measurements with devices of small diameter (≈2 mm) are well accepted by patients and have a tolerability of at least 80%. The impact of multilevel pressure recordings on objective sleep parameters is negligible. The study strongly supports the use of multilevel pressure recordings and disproves the most relevant objections against their use.

Effects of periodic leg movements during sleep in middle-aged subjects without sleep complaints.

Recent reports have called into question the relevance of periodic leg movements during sleep disorder (PLMSD) as a specific clinical entity. Because periodic leg movement in sleep index (PLMSI) increases with age, it has become an important exclusion criterion in research on aging. However, it is unknown if PLMSI is related to sleep quality in middle-aged subjects without sleep complaints. The sleep of 70 healthy, middle-aged subjects (age 40 to 60 years) without sleep complaints was evaluated. Subjects were divided into two groups according to their PLMSI severity: (1) 43 subjects (28 women, 15 men) were in the low PLMSI group (<5) and (2) 22 subjects (9 women, 13 men) were in the high PLMSI group (>10). A significantly higher proportion of men than women showed PLMSI greater than 5. There was no significant effect of PLMSI severity group for polysomnographic sleep parameters. PLMSI exerted a small but significant effect on subjective sleep quality, especially in middle-aged men. These results raise questions about the relevance of PLMSI as a pathological index for middle-aged subjects without sleep complaints and support the notion that an increase in PLMSI may be part of the normal process of aging associated with the loss of dopaminergic function.