Obstructive sleep apnea and sudden unexpected death in epilepsy in unselected patients with epilepsy: are they associated?

PURPOSE: We aimed to determine (1) the frequency of high-risk sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy who have had obstructive sleep apnea (OSA) in different stages of sleep using the revised SUDEP risk inventory (rSUDEP-7) score instrument and (2) the factors associated with high risk SUDEP in patients with epilepsy who have had OSA. METHODS: We conducted a cross-sectional study of consecutive subjects who are more than 15 years old without known sleep disorders, recruited from a single epilepsy clinic in a tertiary care facility. Participants underwent polysomnography. Scoring was performed by two blinded board-certified sleep physicians. The relationships between rSUDEP-7 scores and OSA measures were evaluated using Wilcoxon rank-sum test, chi-squared test, and quantile regression. RESULTS: Our study population consisted of 95 participants. Overall median (IQR) apnea-hypopnea index (AHI) of our populations was 2.3 (0.7,7.5) events rate per hour; 12 (75%) patients had moderate OSA and 4 (25%) patients had severe OSA. Nine patients had a rSUDEP-7 score of 5 to 7. There was no significant difference between total rSUDEP-7 score or rSUDEP-7 score of > 5 or < 5 and total AHI, supine AHI, non-supine AHI, NREM AHI, or REM AHI; similarly, (2) there was no significant difference in total rSUDEP-7 score between AHI of < 15 or > 15. CONCLUSION: Our study reveals no association between AHI score, OSA, and total rSUDEP-7 score or rSUDEP-7 score of > 5. The pathophysiology underlying SUDEP appears complex. We need further studies on SUDEP to help elucidate the cardiorespiratory mechanisms and predisposing factors.

Infrequent HIV Infection of Circulating Monocytes during Antiretroviral Therapy.

Whereas human immunodeficiency virus (HIV) persists in tissue macrophages during antiretroviral therapy (ART), the role of circulating monocytes as HIV reservoirs remains controversial. Three magnetic bead selection methods and flow cytometry cell sorting were compared for their capacity to yield pure CD14+ monocyte populations. Cell sorting by flow cytometry provided the purest population of monocytes (median CD4+ T-cell contamination, 0.06%), and the levels of CD4+ T-cell contamination were positively correlated with the levels of integrated HIV DNA in the monocyte populations. Using cell sorting by flow cytometry, we assessed longitudinally the infection of monocytes and other cell subsets in a cohort of 29 Thai HIV-infected individuals. Low levels of HIV DNA were detected in a minority of monocyte fractions obtained before and after 1 year of ART (27% and 33%, respectively), whereas HIV DNA was readily detected in CD4+ T cells from all samples. Additional samples (2 to 5 years of ART) were obtained from 5 individuals in whom monocyte infection was previously detected. Whereas CD4+ T cells were infected at high levels at all time points, monocyte infection was inconsistent and absent in at least one longitudinal sample from 4/5 individuals. Our results indicate that infection of monocytes is infrequent and highlight the importance of using flow cytometry cell sorting to minimize contamination by CD4+ T cells.IMPORTANCE The role of circulating monocytes as persistent HIV reservoirs during ART is still controversial. Several studies have reported persistent infection of monocytes in virally suppressed individuals; however, others failed to detect HIV in this subset. These discrepancies are likely explained by the diversity of the methods used to isolate monocytes and to detect HIV infection. In this study, we show that only flow cytometry cell sorting yields a highly pure population of monocytes largely devoid of CD4 contaminants. Using this approach in a longitudinal cohort of HIV-infected individuals before and during ART, we demonstrate that HIV is rarely found in monocytes from untreated and treated HIV-infected individuals. This study highlights the importance of using methods that yield highly pure populations of cells as flow cytometry cell sorting to minimize and control for CD4+ T-cell contamination.

Normalization of Soluble CD163 Levels After Institution of Antiretroviral Therapy During Acute HIV Infection Tracks with Fewer Neurological Abnormalities.

Background: Myeloid activation contributes to cognitive impairment in chronic human immunodeficiency virus (HIV) infection. We explored whether combination antiretroviral therapy (cART) initiation during acute HIV infection impacts CD163 shedding, a myeloid activation marker, and in turn, implications on the central nervous system (CNS). Methods: We measured soluble CD163 (sCD163) levels in plasma and cerebrospinal fluid (CSF) by enzyme-linked immunosorbent assay in Thais who initiated cART during acute HIV infection (Fiebig stages I-IV). Examination of CNS involvement included neuropsychological testing and analysis of brain metabolites by magnetic resonance spectroscopy. Chronic HIV-infected or uninfected Thais served as controls. Results: We examined 51 adults with acute HIV infection (Fiebig stages I-III; male sex, >90%; age, 31 years). sCD163 levels before and after cART in Fiebig stage I/II were comparable to those in uninfected controls (plasma levels, 97.9 and 93.6 ng/mL, respectively, vs 99.5 ng/mL; CSF levels, 6.7 and 6.4 ng/mL, respectively, vs 7.1 ng/mL). In Fiebig stage III, sCD163 levels were elevated before cART as compared to those in uninfected controls (plasma levels, 135 ng/mL; CSF levels, 10 ng/mL; P < .01 for both comparisons) before normalization after cART (plasma levels, 90.1 ng/mL; CSF levels, 6.5 ng/mL). Before cART, higher sCD163 levels during Fiebig stage III correlated with poor CNS measures (eg, decreased N-acetylaspartate levels), but paradoxically, during Fiebig stage I/II, this association was linked with favorable CNS outcomes (eg, higher neuropsychological test scores). After cART initiation, higher sCD163 levels during Fiebig stage III were associated with negative CNS indices (eg, worse neuropsychological test scores). Conclusion: Initiation of cART early during acute HIV infection (ie, during Fiebig stage I/II) may decrease inflammation, preventing shedding of CD163, which in turn might lower the risk of brain injury.

Global Outcomes of Epilepsy Surgery in Drug-Resistant Focal Epilepsy: A Longitudinal Survey.

Objective: Epilepsy surgery has been established for treatment of drug-resistant focal epilepsy. We aimed to determine long-term outcomes of epileptic surgery in various aspects including seizure outcome, quality of life, and psychosocial consequences after surgery. Material and Method: A single center, cross-sectional study was conducted. The patients with drug-resistant focal epilepsy who underwent epileptic surgery for at least one year were recruited. Results: Thirty-seven adult drug-resistant epilepsy patients after epileptic surgery were enrolled with an average follow-up period of 5.8 years. Twenty-three (62.2%) had temporal lobe epilepsy (TLE) and 14 (37.8%) had neocortical epilepsy. Four were (10.8%) compatible with lesional negative refractory epilepsy. Hippocampal sclerosis was the most common etiology (45.9%), followed by focal cortical dysplasia/gliosis (21.6%) and brain tumor (21.6%). The three commonest postoperative complications were any medical illnesses (18.9%), memory impairment (18.9%), and visual filed defect (13.5%). Twenty patients (54.1%) had no complications. Seizure outcomes, employment status, quality of life, depression, frank psychosis, and number of antiepileptic drug (AED) between pre- and post-surgical period (interviewing time) were compared. Engel Class I (seizure freedom) was persistently achieved in 19 (51.4%) patients. There were nine (24.3%) patients in Engel Class II, eight (21.6%) in Engel Class III, and one (2.7%) in Engel Class IV. Seizure outcome, quality of life, and self-assessment were improved after epileptic surgery at any age groups, duration of epilepsy, epileptogenic zone, and side of operation. In some subgroups, it was found that income was increased and number of AED was reduced. However, depression and frank psychosis did not change the outcome. On self-assessment, global impression of change in memory showed 27% improvement and 32.4% no change. For language and communication skills, 29.7% was improved but 21.6% was worsened. Conclusion: In this longitudinal study, epilepsy surgery showed improvement in seizure control, quality of life, and some neuropsychological aspects.

The Development of Sleep Questionnaires Thai Version (ESS, SA-SDQ, and PSQI): Linguistic Validation, Reliability Analysis and Cut-Off Level to Determine Sleep Related Problems in Thai Population.

Background: The Epworth Sleepiness Scale (ESS), Sleep Apnea Scale of Sleep Disorders Questionnaire (SA-SDQ), and Pittsburgh Sleep Quality Index (PSQI) are widely used in English speaking countries for sleep problem screening. However, there is no officially validated Thai-version of sleep questionnaires available. Objective: To provide standard Thai version of three sleep questionnaires and find cut-off level to screening sleep problems in Thai population. Material and Method: We used Mapi Research Institute Methods for translation from original language to Thai questionnaire. Then, test-retest reliability analysis was performed. Finally, we collected data from patients who underwent polysomnography in Phramongkutklao Sleep Lab Centre between June and August 2011. Cut-off value to screen population at risk for sleep-related disorder was researched. Results: The questionnaires were translated with very good inter-rater agreement. Cut-off of ESS, SA-SDQ, and PSQI suggested sleep disorders would be 9, 27, and 6.5 respectively. Conclusion: Sleep disorder questionnaires including ESS, SA-SDQ, and PSQI were translated into Thai with high validity, reliability, and accuracy.

Absence of Cerebrospinal Fluid Signs of Neuronal Injury Before and After Immediate Antiretroviral Therapy in Acute HIV Infection.

BACKGROUND: It is unknown whether neuronal injury begins during acute human immunodeficiency virus (HIV) infection, and whether immediate initiation of combination antiretroviral therapy (cART) prevents neuronal injury. METHODS: Cerebrospinal fluid (CSF) neurofilament light chain (NFL), a measure of axonal injury, was assessed before and after cART initiation in individuals starting treatment during acute or chronic HIV infection. Nonparametric statistics examined relationships between NFL and disease progression, neuroinflammation, and cognitive performance. RESULTS: Before treatment, subjects with acute infection had lower CSF NFL levels, with elevations for their age in 1 of 32 subjects with acute infection (3.1%) and 10 of 32 with chronic infection (31%) (P = .006). This persisted after cART initiation, with 1 of 25 acute (4%) and 4 of 9 chronic subjects (44%) showing elevated NFL levels (P = .01). In acute infection, pre-cART NFL levels were inversely correlated with proton magnetic resonance spectroscopic findings of N-acetylaspartate/creatine in frontal gray matter (r = -0.40; P = .03), frontal white matter (r = -0.46; P = .01), and parietal gray matter (r = -0.47; P = .01); correlations persisted after treatment in the frontal white matter (r = -0.51; P = .02) and parietal gray matter (r = -0.46; P = .04). CONCLUSIONS: CSF NFL levels are not elevated in untreated acute HIV infection or after 6 months of immediately initiated cART but are abnormal in chronic HIV infection before and after treatment. In acute HIV infection, CSF NFL levels are inversely associated with neuroimaging markers of neuronal health.

Association between brain volumes and HAND in cART-naïve HIV+ individuals from Thailand.

This study aimed to determine the effects of human immunodeficiency virus (HIV) on brain structure in HIV-infected individuals with and without HIV-associated neurocognitive disorders (HAND). Twenty-nine HIV-uninfected controls, 37 HIV+, treatment-naïve, individuals with HAND (HIV+HAND+; 16 asymptomatic neurocognitive impairment (ANI), 12 mild neurocognitive disorder (MND), and 9 HIV-associated dementia HAD), and 37 HIV+, treatment-naïve, individuals with normal cognitive function (HIV+HAND-) underwent magnetic resonance imaging (MRI) and neuropsychological assessment. The HIV-infected participants had a mean (SD) age of 35 (7) years, mean (interquartile range (IQR)) CD4 count of 221 (83-324), and mean (IQR) log10 plasma viral load of 4.81 (4.39-5.48). Six regions of interest were selected for analyses including total and subcortical gray matter, total white matter, caudate, corpus callosum, and thalamus. The HIV+/HAND+ group exhibited significantly smaller brain volumes compared to the HIV-uninfected group in subcortical gray and total gray matter; however, there were no statistically significant differences in brain volumes between the HIV+HAND+ and HIV+HAND- groups or between HIV+/HAND- and controls. CD4 count at time of combination antiretroviral therapy (cART) initiation was associated with total and subcortical gray matter volumes but not with cognitive measures. Plasma viral load correlated with neuropsychological performance but not brain volumes. The lack of significant differences in brain volumes between HIV+HAND+ and HIV+HAND- suggests that brain atrophy is not a sensitive measure of HAND in subjects without advanced immunosuppression. Alternatively, current HAND diagnostic criteria may not sufficiently distinguish patients based on MRI measures of brain volumes.

The Changes in Mean Platelet Volume after Using of Antiplatelet Drugs in Acute Ischemic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To measure the changes of mean platelet volume (MPV) after using four antiplatelet drugs in acute non-cardioembolic ischemic stroke patients and assess the association of antiplatelets and MPV and stroke outcome. MATERIAL AND METHOD: Ischemic stroke survivors with National Institute of Health Stroke Scale (NIHSS) 8 were randomly allocated intofour groups, receiving aspirin, clopidogrel, combined aspirin and dipyridamole, and cilostazol. The change of MPV NIHSS, and modified Rankin Scale (mRS) were recorded at baseline and week 4 in all studied groups. MPV was measured using the standard automated blood test for complete blood count. RESULTS: Twenty-one subjects were included in this study. They comprised of five cases in each antiplatelet group, except for aspirin, which had six subjects. Male was 57%, and hypertension was the most common risk factor (61.9%). Most of participants (76%) had small vessel disease. At 4-week, MPVwas reduced and NIHSS, mRS were improved in every studied group. Clopidogrel sign ficantly reduced NIHSS score (p = 0.003), and it produced the greatest reduction in MPV compared to others. CONCLUSION: Every type of antiplatelets included in this study reduced MPV NIHSS, and mRS in acute non-cardioembolic stroke patients. Clopidogrel improved NIHSS the most.

Behavioral and psychological symptoms of dementia.

OBJECTIVE: To identify the frequency of behavioral and psychological symptoms of dementia (BPSD) and to explore the different characteristics between subgroup and severity of dementia. MATERIAL AND METHOD: Sixty-seven patients with Alzheimer's disease, vascular dementia, and mixed dementia were recruited to our cross-sectional study. Neuropsychiatric batteries including the Mini Mental Status Examination-Thai 2002, Thai Geriatric Depression Scale, 23 items from Alzheimer's Disease co-operative Study activities of daily living inventory, Behavioralpathology in Alzheimer's disease rating scale, and Pittsburg Sleep Quality Index were tested. RESULTS: The most common behavioral and psychological symptoms of dementia (BPSD) were sleep problems (100%), paranoid/delusion (59.7%), diurnal disturbance (49.2%) and aggressiveness (46.3%). Hallucination and affective problems were more severe in AD than in VaD/mixed dementia. Sleep problems were identified more severe in mild dementia than moderate-to-severe dementia. With longer duration of having dementia, exceptfor affective problem, there was no diffemence in behavioral and psychological symptoms observed compared to the shorter dementia group. CONCLUSION: Behavioral and psychological symptoms were very common in Alzheimer disease, vascular dementia, and mixed dementia. Since these symptoms cause cognitive and functional decline, institutionalization, caregiver distress and increase direct costs ofcare, the problem must be identified and addressed.

Excessive daytime sleepiness and obstructive sleep apnea in Thai epileptic patients.

BACKGROUND: Sleepiness is a common complaint in epilepsy. Also obstructive sleep apnea (OSA) is increasingly detected and would affect the epilepsy prognosis. We aimed to determine the frequency and predictors of sleepiness and OSA in epileptic patients. MATERIAL AND METHOD: This was a cross-sectional descriptive study using Epworth Sleepiness Scale questionnaire (ESS) and Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ) to identify excessive daytime sleepiness and OSA in our consecutive epileptic patients in Neurology out-patient clinic. RESULTS: Overall 113 patients (male 55%) answered a personal survey and completed ESS and SA-SDQ. Mean age was 47 years (range 15-93). Average body mass index (BMI) was 24. Excessive daytime sleepiness (ESS 10) was demonstrated in 37%, and the prevalence of OSA diagnosed by using SA-SDQ was 20% (male 18%, female 22%). OSA were identified 68% among individuals whose BMI of more than 25, which was significant higherfi-equency than in the nomnnal BMI group (32%). The predictors of having OSA were older age and higher BMI. Epworth Sleepiness Scale score was also higher in the OSA group than in non-OSA group. CONCLUSION: Excessive daytime sleepiness was identified around one third ofour epileptic individutals. Twenty percent had met the questionnaire criteria of having OSA. Overweight was the most important and modifiable risk factor ofOSA.

Non-motor symptoms in Thai patients with Parkinson's disease studied at Phramongkutklao Hospital.

BACKGROUND: Non-motor symptoms (NMS) ofParkinson's disease (PD) have been recently recognized to be as disabling as motor symptoms in PD. However these symptoms are still under recognized causing delay in treatment and inadequate management. This study aimed to identify NMS in Thai PD patients using the NMS screening questionnaire (NMSQuest). MATERIAL AND METHOD: Patients with idiopathic Parkinson's disease visiting the neurology clinic in 2008 were enrolled. NMSQuest-Thai version (NMSQ-T) was applied to patients to identify NMS. RESULTS: Collected data from questionnaires completed by 165 probable idiopathic PD was analyzed. The demographic profiles showed mean age of 68.6 years with mean disease duration 5.4 years, and male 56.4%. Patients had Hoehn & Yahrstaging, stage-2: 43%, stage-3: 24.8%, stage-I: 24.2% and stage-4: 7.9%. The average dosage oflevodopa was 456.4 mg/d. Mean total NMSQ-T score was 9.5. Most prevalent of non-motor symptom was nocturia (64.2%). The domains which gained most positive answers were urinary domain (54.55%). Inter-domain correlations were significantly found in all, except the sexual domain. Multivariate analysis revealed the duration ofPD and stages were significantly correlated with the total score ofNMS. Only three percent denied having any non-motor symptoms. CONCLUSION: Almost all Thai PD had NMS. Urinary domain is the most prevalent in our series. Screening using NMSQ-Tto recognize NMS would be a helpful tool to improve the quality of life in Thai Parkinson 's disease.

Practice effect and normative data of an HIV-specific neuropsychological testing battery among healthy Thais.

OBJECTIVE: A longitudinal cohort study was conducted in Bangkok, Thailand between 2008 and 2013 in order to determine the practice effect of serial neuropsychological testing and establish normative data among normal (HIV-uninfected) Thai volunteers. MATERIAL AND METHOD: The authors enrolled 511 cognitively healthy individuals (HIV-uninfected, no drug abuse or other previous/current neurological or psychological conditions) to assess baseline performance on a HIV-specific neuropsychological testing battery. Ninety-nine subjects were re-assessed at 6 and 12 months to evaluate practice effects. RESULTS: The mean age of the 99 subjects completing longitudinal visits was 49.2 years and 53 were male. The authors identified improved mean raw scores on most neuropsychological tests with repeated measurements; however only change in WHO Auditory Verbal Learning Test (AVLT) scores (learning, attention, immediate and delayed recall tasks) met statistical significance, with larger differences seen between baseline and 6-month compared to 6 and 12 months follow-up. Older age correlated with poorer baseline raw score, and was a predictor of worse performance at 6 months and 12 months on several tasks. Level of education was associated with practice effects on several tests. No similar effects were observed with gender. CONCLUSION: The authors identified improved performance after repeated measurements revealing a significant practice effect on an HIV-specific neuropsychological testing battery employed in Bangkok, Thailand. Main predictors were age and educational attainment.

Expert consensus guidelines for community pharmacists in the management of diabetic peripheral neuropathy with a combination of neurotropic B vitamins.

This consensus guidance is for community pharmacists in diabetic peripheral neuropathy (DPN) management with a combination of neurotropic B vitamins. A multidisciplinary team including endocrinology, neurology, and pharmacy from Thailand discussed and aligned the practical scheme of DPN management in the community pharmacy setting, using the literature review and having face-to-face meeting. Five major statements have been endorsed as consensus recommendations for DPN care with strong acknowledgment. The aims of DPN management included reducing symptoms and the risk of complications, minimising adverse reactions from treatment regimens, and improving patients' knowledge and adherence to the treatment strategies. An initial screening process using a 7 items interview of Douleur Neuropathique 4 (DN4) questionnaire should be implemented to identify patients at risk of developing DPN. Subsequently, pharmacologic, and non-pharmacologic treatment should be employed based on patient-centered care. An interesting approach is combination of neurotropic B vitamins, which may be used as monotherapy or combination therapy to control DPN symptoms. The combined therapy potentially exhibits a synergistic effect and improves patient adherence. The consensus would be further considered in context of harmonisation of routine practice and country requirements.

Trail Making Test A improves performance characteristics of the International HIV Dementia Scale to identify symptomatic HAND.

Although HIV-associated dementia (HAD) occurs in less than 5 % of individuals with access to combination antiretroviral therapy, rates of milder forms of HIV-associated neurocognitive disorder (HAND) are much higher. We sought to define an optimal cut point for the International HIV Dementia Scale (IHDS) in Thailand for the identification of symptomatic HAND, defined as both HAD and mild neurocognitive disorder. We then sought to determine if adding a simple test from a larger neuropsychological battery could improve the performance characteristics for identifying symptomatic HAND. In this study, subjects comprising 75 seropositive adults in Bangkok, Thailand, completed neuropsychological tests and underwent a full neurological assessment. HAND diagnoses were determined by consensus conference using the 2007 Frascati criteria, blinded to the IHDS results. The optimal IHDS cut point was determined by receiver operating characteristic analysis with cross-validation. Individual neuropsychological tests were then evaluated and combined with the IHDS to test performance characteristics. The IHDS was poor at detecting symptomatic HAND at the optimized cut point of ≤ 10 (sensitivity, 53.3 %; specificity, 89.8 %). Trail Making Test A was most effective in improving performance characteristics when combined with the IHDS, with net sensitivity of 86 % and specificity of 79 %. In this setting, the IHDS performed poorly in identifying symptomatic HAND, but was substantially improved by the addition of Trail Making Test A, which typically requires less than 2 min to complete. This combination should be validated in a larger setting since it may address the critical need for HAND screening instruments in international settings.

Global NeuroAIDS roundtable.

In May 2012, the Division of AIDS Research at the National Institute of Mental Health (NIMH) organized the "Global NeuroAIDS Roundtable" in conjunction with the 11th International Symposium on Neurovirology and the 2012 Conference on HIV in the Nervous System. The meeting was held in New York, NY, USA and brought together NIMH-funded investigators who are currently working on projects related to the neurological complications of AIDS (NeuroAIDS) in Africa, Asia, Eastern Europe, and Latin America in order to provide an opportunity to share their recent findings and discuss the challenges encountered within each country. The major goals of the roundtable were to evaluate HIV-associated neurocognitive impairment and determine if it may be directly attributable to distinct HIV subtypes or clades and to discuss the future priorities for global NeuroAIDS research. At the "Global NeuroAIDS Roundtable", presentations of preliminary research indicated that HIV-associated neurocognitive impairment is prevalent in all countries examined regardless of which HIV clade is present in the region. The only clear-cut difference between HIV-1 clades was in relation to subtypes A and D in Uganda. However, a key point that emerged from the discussions was that there is an urgent need to standardize neurocognitive assessment methodologies across the globe before definitive conclusions can be drawn regarding the relationship between HIV clade diversity and neuropathogenesis. Future research directions were also discussed at the roundtable with particular emphasis on the potential of viral and host factor molecular interactions to impact the pathophysiology of HIV-associated neurocognitive disorders (HAND) from a global perspective.

Identifying obstructive sleep apnea in patients with epilepsy: A cross-sectional multicenter study.

OBJECTIVE: Several screening questionnaires for obstructive sleep apnea (OSA) have been introduced. No study has compared the performance of different questionnaire in the same patients with epilepsy. Herein, we compare the performance characteristics of four common questionnaires for assessing the probability of OSA in patients with epilepsy. METHODS: This cross-sectional multicenter study was conducted among adult epilepsy patients attending neurology and general medical clinics in Thailand. Before performing full polysomnography (PSG), all participants completed the STOP-BANG, STOP-BAG, SA-SDQ, and NoSAS questionnaires. OSA was defined by apnea/ hypopnea index (AHI) criteria of AHI: ≥ 5, ≥ 15, and ≥ 30. Discriminatory ability was assessed by area under the receiver operating characteristics (ROC) curve (AUC) and likelihood ratio. To improve discriminative ability, we created 3 ranges of the score to predict lower, middle, and higher probability of OSA as defined by each diagnostic criterion. RESULTS: A total 166 patients with epilepsy were included. OSA prevalence was 38%. Overall, NoSAS had higher AUC at all AHI criteria but not significantly higher than that of other scales. Using prediction cut-points for NoSAS of ≥ 4 and ≥ 8 to predict OSA defined by AHI ≥ 5, the likelihood ratios for the 3 ranges were 0.37, 2.22 and 9.81 respectively. CONCLUSION: Among the 4 scales, the 2-cut-point NoSAS score had the highest discriminatory ability at each AHI cutoff.

Pathogenesis of HIV in the central nervous system.

HIV can infect the brain and impair central nervous system (CNS) function. Combination antiretroviral therapy (cART) has not eradicated CNS complications. HIV-associated neurocognitive disorders (HAND) remain common despite cART, although attenuated in severity. This may result from a combination of factors including inadequate treatment of HIV reservoirs such as circulating monocytes and glia, decreased effectiveness of cART in CNS, concurrent illnesses, stimulant use, and factors associated with prescribed drugs, including antiretrovirals. This review highlights recent investigations of HIV-related CNS injury with emphasis on cART-era neuropathological mechanisms in the context of both US and international settings.

Prophylactic botulinum type A toxin complex (Dysport®) for migraine without aura.

OBJECTIVE: To evaluate the efficacy, safety, and optimum dose of a highly purified Clostridium botulinum type A toxin-hemagglutinin complex (Dysport) for migraine prophylaxis. BACKGROUND: Botulinum toxin type-A has demonstrated good efficacy in several open-label studies of patients with migraine, involving either individualized or standardized protocols, although data from placebo-controlled trials have been conflicting. METHODS: A 12-week, double-blind, randomized trial of Dysport (120 or 240 units) vs placebo was conducted in 6 centers in Thailand to evaluate the efficacy, safety, and optimum dose of botulinum toxin type-A (Dysport) for migraine prophylaxis. A total of 128 patients with migraine without aura were enrolled. The primary end point was the change in the mean number of migraine attacks per 4-week period from the pre-treatment period to 8-12 weeks post injection. Secondary efficacy measures included the change in the mean total intensity score from the pre-treatment period to 8-12 weeks, the investigator and patient global assessments of change at each visit compared with pre-treatment, and Migraine Disability Assessment and Short Form-36 scores. RESULTS: Change in number of migraine attacks from pre-treatment to weeks 8-12 was not significantly different. There was a greater improvement in total intensity score at weeks 8-12 with Dysport-240 (not significant), and interim visit data showed that this was significant at weeks 0-4 (P = .03 Dysport-240 vs placebo). The mean duration of headache during weeks 0-4 was lower with Dysport-240 (P = .04 vs placebo). Improvements in patient and investigator global assessments of change between weeks 0-4 and 8-12 were significant for the Dysport-240 group (both P < .05 vs placebo). CONCLUSIONS: Limitations in study design and assessment tools employed may have contributed to the inconclusive nature of the primary end point data. Dysport-240 showed significant benefit over placebo at some end points and further trials with more appropriate outcome measures are required to evaluate effectively this treatment.

Kleine-Levin syndrome: the first typical case in Thailand.

Kleine-Levin syndrome (KLS) is a rare disorder characterized by periodic hypersomnia, cognitive and behavioral disturbances. Other unique symptoms in KLS are megaphagia, hypersexuality and some psychiatric disturbances such as compulsion and depression. Definite diagnosis requires the elimination of other potential etiologies. We reported a typical case of KLS in a young Thai man who suffered from seven episodes of periodic hypersomnia within 1.5 years and eventually he was diagnosed with Kleine-Levin syndrome after excluding known possible neurological conditions and sleep disorders.

Prevalence of poststroke depression in Thai stroke survivors studied in Phramongkutklao Hospital.

OBJECTIVE: To study prevalence of depression in poststroke survivors in Phramongkutklao Hospital and factors associated with depression. MATERIAL AND METHOD: From 150 stroke survivors, therefor 101 patients who met inclusion criteria. These subjects were screened with Thai Geriatric Depressive Scale (TGDS) and interviewed. Demographic data that would effect depression were evaluated. RESULTS: During 9 months of studying period, 101 of 150 patients diagnosed with poststroke survivors were eligible. The prevalence of depression was 46.53%. Severity of depression were mild depression 20.79%, moderate 18.81% and severe depression 6.93%. There were no statistically significant among sex, diabetes mellitus, hypertension, smoking, hyperlipidemia, and site of stroke between depression and non-depression groups. Risk factors for severe poststroke depression were younger age, duration within one year after stroke onset and history of coronary artery disease. CONCLUSION: The prevalence of poststroke depression was 46.53%. Risk factors of severe depression were younger age, duration within one year of stroke onset and history of coronary artery disease.