Gender differences in Epworth Sleepiness Scale revealed by paired patient-spouse scoring.

PURPOSE: Evaluation of daytime sleepiness in the clinical sleep practice is commonly performed by administering the Epworth Sleepiness Scale (ESS). Our study investigates gender differences of ESS responses in patients (PTs) with a primary complaint of nighttime sleep disruption as they relate to ESS responses obtained from PTs' spouses (Ss). METHODS: One hundred and sixty-four patient-spouse (PT-S) pairs were recruited for the study and asked to independently complete ESS questionnaires consisting of 8 sleepiness scenarios (Q1-Q8). Descriptive summaries were frequencies and percentages for categorical data, and medians and quartiles for continuous variables. Differences between PT-S pairs and different data sets were evaluated using a two-tail independent T test and Wilcoxon's Rank Sum Test. All analyses were done in SAS for Windows 9.4. RESULTS: Eighty-five male and 75 female PTs were recruited for the study. Female PTs reported significantly higher total ESS scores than male PTs (12.16 vs 9.64, p < 0.0001) and had significantly higher sleepiness for scenarios Q1, Q4, Q6, and Q8. When compared with their Ss' responses, male PTs underestimated, while female PTs overestimated their sleepiness with statistical significance observed for total ESS score as well as for all sleepiness scenarios except for Q5 ("lying down to rest in the afternoon"). African-American (AA) males reported significantly higher total ESS scores than Caucasian (C) males, while AA females reported lower total ESS scores than C females. Discrepancy between PT-S ESS scores was higher in C than in AA PTs. CONCLUSIONS: Significant gender differences were noted when PT-S ESS responses were compared. Demonstrated gender differences were further influenced by the PT's race.

The effects of daylight duration on the multiple sleep latency test (MSLT) results: A pilot study.

OBJECTIVE: MSLT results are known to be affected by multiple factors including sleep time, frequency of nighttime arousals, and medications intake. Although being the main synchronizer of sleep and wakefulness, daylight duration effects on MSLT have not been examined. Burlington, Vermont, USA experiences great variations in daylight duration, ranging from 8 h 50 min to 15 h 33 min of daylight. The aim of this study was to test the hypothesis that there would be photoperiod duration effects on MSLTs performed during short daylight (short daylight studies, SDS) vs. long daylight (long daylight studies, LDS) from 2013 to 2023 in our sleep laboratory. METHODS: We identified and analyzed 37 SDS (daylight 530-560 min) and 36 LDS (daylight 903-933 min) from our database. Groups of SDS and LDS results were compared using non-paired student T test, Chi-Square and non-parametric Mann Whitney U Test. RESULTS: Average daylight duration was 15 h 18 ± 14.6 min for LDS and 8 h 57 ± 18 min for SDS. Two groups did not differ in terms of the age, gender, BMI and race of patients studied. Mean total sleep time and sleep efficiency during PSG preceding MSLT, and MSLT mean sleep onset latency did not significantly differ for the two groups. However, SDS MSLT naps had significantly more sleep onset REM periods (SOREMP), and distribution of the number of SOREMP captured during MSLT was different for SDS and LDS groups. Differences of SDS and LDS results did not relate to sleep architecture of the overnight PSG as analysis of sleep and REM latency and relative percentages of N1, N2, REM, and N3 was not significantly different between SDS and LDS. The two groups showed difference in arousal indexes during N1 and REM sleep. CONCLUSIONS: Daylight duration may impact MSLT results and should probably be accounted for in MSLT interpretation. Attention to photoperiod could be considered in MSLT guidelines, if our results are replicated in larger samples.

Effectiveness of preventive onabotulinumtoxin A injections for migraine headaches is dependent on the circadian time of administration.

We have previously shown that quarterly preventive onabotulinumtoxin A (BTA) injections administered to diurnally active patients for chronic migraines (CM) associate with increased discomfort when performed in the morning. The purpose of this study was to further examine if the effectiveness of preventive BTA injections depends on the procedure's circadian timing. A total of 90 diurnally active patients with a medical history of CM and undergoing BTA injection therapy were enrolled in the study. One hundred and fifty-five units of BTA were administered according to the standardized PREEMPT protocol, either during the course of morning (AM) or afternoon (PM) clinic hours. Patients were asked to keep headache diaries, which were reviewed at the time of their follow-up BTA injections 3 months later. The number of headache days experienced during the first, second, and third month following BTA injection, and the number of headache days during the last 7 days prior to follow-up was collected, as was the self-rating of the effectiveness of BTA treatment. Fifty-five (61%) patients were injected during the AM clinic and 35 (39%) during the PM clinic. There was no difference in gender, race, and age variables between the AM and PM patients. The average total number of headache days during 3 months following injection was significantly higher for the AM-treated compared to the PM-treated patients (22.37 ± 18.85 vs. 10.54 ± 7.5, p =.0007). AM patients also reported a higher number of headache days during each of the 3 months following BTA injection. In contrast, PM patients reported higher effectiveness of preventive BTA treatment. The average number of headache days during the week prior to the follow up, as well as the presence of headache on the day of the follow-up was not significantly different between the AM and PM groups. Scheduling diurnally active CM patients with stable circadian sleep/wake routine for afternoon BTA injections appear to improve the effectiveness of BTA therapy as well as patients' satisfaction with the treatment.

Effect of circadian rhythm on the pain associated with preventive onabotulinumtoxinA injections for migraines.

The aim of our research was to assess if the pain and discomfort following each quarterly onabotulinumtoxinA (BTA) injection given to prevent daily headaches/migraines is circadian time-dependent so as to determine the best administration time for least discomfort and minimal follow-up pain. A total of 61 diurnally active patients with a medical history of chronic migraine headaches and undergoing preventative BTA injection therapy for the first time were enrolled in the study. Patients were randomly assigned to morning or afternoon clinics, but had the ability to choose within the assigned clinic the injection time that best fits their schedule. 155 units of BTA was administered by following the standardized PREEMPT injection protocol. Patients reported the typical time of sleep onset and wakeup time for the week prior to injections. Patients then self-reported three levels of pain in the head and neck area: prior to BTA injections, immediately after, and 24 h after BTA injections. This was carried out by marking the pain level on 100 mm visual analog pain scale. Descriptive summaries were frequencies and percentages for categorical data and medians and quartiles for continuous variables. Demographic variables of gender, race, and age were tested using Chi-Square. Groups of morning versus afternoon patients were compared using the non-parametric Wilcoxson's Rank Sum Tests and student T tests. All analysis was done in SAS for Windows Version 9.4. 38 (62%) patients were injected during morning clinic and 23 (38%) during afternoon clinic. There was no difference in gender, race, and age variables between morning and afternoon patients. 67% of the patients experienced increased pain following the initial injection. Higher pain score was more frequent following morning than afternoon injections (78% vs. 50%, p = .021). The 24 h post-injection pain level was also significantly higher in patients injected in the morning than afternoon (64% vs. 28%, p = .024). Performing BTA injections for migraine prevention during the morning was associated with significantly more treatment-related discomfort, both immediately and 24 h after injection. Scheduling diurnal active patients with stable circadian sleep/wake routine for afternoon BTA injections appears beneficial for decreasing treatment-related discomfort and potentially increase compliance to therapy.

"Computed tomography-negative" intracerebral hemorrhage: case report and implications for management.

BACKGROUND: Noncontrast computed tomographic (CT) scanning of the brain is the main imaging modality recommended for the initial emergency evaluation of acute stroke. The main role of CT in this setting is to rule out intracerebral hemorrhage, especially in subjects who are potential candidates for thrombolytic therapy. OBJECTIVES AND RESULTS: We studied a patient who had symptoms suggestive of a transient ischemic attack. Although serial CT scans showed no evidence of hemorrhage, a subacute intracerebral hemorrhage was demonstrated by magnetic resonance imaging. CONCLUSIONS: This case suggests that an alternative to CT scanning should be considered in patients with acute stroke to lower the risk of an undetected intracerebral hemorrhage, especially in patients being considered for thrombolytic or anticoagulant therapy. There is evidence in the literature of other "CT-negative" cases of intracerebral hemorrhage, as well as the availability of alternative imaging techniques such as gradient echo ("susceptibility-weighted") magnetic resonance imaging sequences, which can enhance the ability of magnetic resonance imaging to detect an acute intracerebral hemorrhage.

Characteristics of male veterans with psychogenic nonepileptic seizures.

PURPOSE: To describe male patients (pts) with psychogenic nonepileptic seizures (PNESs) followed up in a Veteran's Administration (VA) seizure clinic and to compare them with those with epileptic seizures (ESs) by using clinical, and psychosocial variables. METHODS: Adult male veterans seen between 1997 and 2000 with ESs were compared with those with PNESs with respect to clinical history (head trauma, antiepileptic drug exposure, depression, anxiety, substance abuse, seizure description), documented chronic pain, posttraumatic stress disorder (PTSD), compensation for diagnosis, neurologic examination, and test results including imaging and EEG data. RESULTS: Men with PNESs were younger and reported more frequent events, and diagnoses of chronic pain, anxiety, and PTSD were significantly greater. Neuroimaging [computed tomography (CT) or magnetic resonance imaging (MRI) of the brain] and neurologic examination were significantly more likely to be normal or nonspecific in pts with PNESs, although history of ictal urinary incontinence or service-connected compensation for diagnosis did not distinguish the groups. CONCLUSIONS: Male veterans with PNESs have characteristics similar to those reported in the literature, even though younger women have dominated previously studied populations. Compared with men with ESs, those with PNESs are more likely to have chronic pain, anxiety, and PTSD, as well as normal examinations and brain imaging.