'REM-related OSA': a forgotten diagnostic? Possible path to under-diagnosing sleep apnea. / Sindrome de apnea/hipopnea obstructiva ligado al sueño REM: un diagnostico olvidado? Posible via de infradiagnostico del sindrome de apnea/hipopnea obstructiva del sueño.

INTRODUCTION: Restrictive criteria are proposed to define the disorder 'REM-related OSA' disorder, and questions remain about its nosological transcendence and clinical management. AIM: To evaluate the criteria proposed to define 'REM-related OSA', its relationship with cardio-metabolic comorbidity, and aspects related to it diagnostic. PATIENTS AND METHODS: Retrospective observational study of clinical and polysomnographic data from outpatients. 525 patients over 18 years old who had an Apnea Hypopnea Index (AHI) = 5 (total, or partial, in REM and/or NREM) were included. RESULTS: 'Phase-dependent' subgroups were formed using a criterion based on the 'ratio = 2' and another 'strict' criterion based on a partial AHI = 5 compared to another partial AHI <5 (in REM or in NREM). In the 'strict REM-related OSA' subgroup, half of the patients showed an overall AHI < 5, with less severity in the respiratory parameters, but with lower comorbidity percentages. With the current diagnostic criteria, these patients would be excluded from the sleep apnea diagnosis. CONCLUSIONS: The application of the strict criterion to detect 'REM-related OSA' makes it possible to filter milder forms of sleep apnea associated with percentages of cardiovascular and/or metabolic comorbidity that are not significantly different from other more severe forms of sleep apnea. To avoid under-diagnosis, it would be advisable to review the sleep apnea diagnostic criteria and the indications of the reduced sleep apnea diagnostic techniques.

TITLE: Sindrome de apnea/hipopnea obstructiva ligado al sueño REM: un diagnostico olvidado? Posible via de infradiagnostico del sindrome de apnea/hipopnea obstructiva del sueño.Introduccion. Recientemente se han propugnado criterios restrictivos para definir el sindrome de apnea/hipopnea obstructiva ligado al sueño REM y persisten interrogantes sobre su trascendencia nosologica y manejo clinico. Objetivo. Evaluar los criterios definitorios de la apnea del sueño REM, su relacion con la comorbilidad cardiometabolica y los aspectos relacionados con su diagnostico. Pacientes y metodos. Estudio observacional retrospectivo sobre datos clinicos y polisomnograficos de pacientes ambulatorios. Se incluyo a 525 pacientes mayores de 18 años que tenian un indice apnea/hipopnea (IAH) por hora de sueño = 5 (total, o parcial en REM o no REM). Resultados. Se han configurado subgrupos 'dependientes de la fase' utilizando un criterio basado en la 'proporcion = 2' y otro 'estricto' basado en uno de los IAH parciales = 5 frente al otro IAH < 5 (en REM o en no REM). En el subgrupo 'apnea del sueño REM estricto', la mitad de los pacientes muestra un IAH global < 5 y menos gravedad en los parametros respiratorios, pero sin menores porcentajes de comorbilidad. Con los criterios diagnosticos actuales quedarian excluidos del diagnostico de sindrome de apnea/hipopnea obstructiva del sueño (SAHOS). Conclusiones. Aplicar un criterio estricto para detectar apnea del sueño REM permite filtrar formas muy leves de SAHOS asociadas a comorbilidad cardiometabolica en porcentajes no diferentes significativamente de otras formas mas graves. Para evitar el infradiagnostico del SAHOS seria oportuno revisar los criterios diagnosticos actuales y las indicaciones de las tecnicas reducidas.

Insomnio. Posibilidades terapéuticas de la melatonina y sus agonistas / No disponible

El insomnio crónico es un trastorno muy prevalente y su fisiopatología es multifactorial, interviniendo factores homeostáticos y de control circadiano, además de cognitivo-conductuales. Su tratamiento farmacológico tiene inconvenientes por los efectos indeseables de los fármacos utilizados (Benzodiacepinas, antidepresivos sedantes, neurolépticos atípicos). La melatonina es una alternativa, pero su eficacia es controvertida. Un handicap importante es su corta vida media, por lo que se ha propuesto el uso de compuestos de liberación prolongada (CircadinR) y agonistas melatoninérgicos (Ramelteon, Agomelatina). Ramelteon está aprobado por la FDA en USA para el tratamiento del insomnio primario y CircadinR es la única melatonina aprobada para su uso clínico en la Unión Europea como monoterapia para el tratamiento a corto plazo del insomnio primario en sujetos de 55 años o más de edad; Agomelatina está también autorizada y se comercializa como antidepresivo. Los estudios realizados hasta la fecha avalan la eficacia para reducir la latencia de inicio al sueño (en parámetros menores que los hipnosedantes) y para mejorar la alerta diurna, sin observarse síntomas de rebote o de retirada con la interrupción del tratamiento. Parecen además fármacos seguros y sin efectos adversos relevantes. Los recientes datos sobre el efecto hipotensor y modulador del metabolismo de la glucosa por parte de la melatonina abren un campo a la investigación de la posible utilidad clínica de la melatonina y sus agonistas en el insomnio asociado a enfermedades con riesgo cardiovascular(AU)

Chronic insomnia is a highly prevalent disorder. Its pathophysiology shows multiple factors: both homeostatic and circadian control factors, together with cognitive-behavioural factors, intervene. Pharmacological treatment has drawbacks due to undesirable effects of prescribed drugs (benzodiazepines, sedative antidepressants, atypical neuroleptics). Melatonin is an alternative, but its efficacy is controversial. One of main melatonin handicaps is its short average life. To solve this, use of prolonged release drugs and melatonin agonists (Ramelteon, Agomelatine) has been proposed. USA’s FDA has approved Ramelteon to treat primary insomnia, and CircadinR is the only melatonin that has been approved for clinical use in the EU as monotherapy short-term treatment of primary insomnia in patients over 55 years old. Agomelatine is also authorized and sold as an antidepressant. Studies up to date prove these drugs’ efficacy to reduce sleep onset latency (in lower parameters than hypnosedatives) and to improve daytime alertness. No rebound or withdrawal symptoms were observed after discontinuing the treatment. Moreover, they seem to be safe drugs that show no significant adverse events. Recent data on melatonin’s hypotensor and modulator effect on glucose metabolism open a new research field for the potential clinical use or melatonin and its agonists in insomnia linked with CV risk diseases(AU)

[Nocturnal sleep-related eating disorder that responds to topiramate]. / Sindrome de ingesta nocturna relacionada con el sueno con respuesta al topiramato.

INTRODUCTION: Nocturnal sleep-related eating disorder is a non-REM sleep parasomnia that is associated to other sleep disorders, especially sleepwalking. It becomes chronic, is not remitting and consists in episodes of compulsive eating during the night, which are then partially or completely forgotten by the patient. This condition must be differentiated from night-eating syndrome, which is far more common and is linked to endocrinological and psychiatric disorders, as well as to other disorders involving eating behaviour during sleeping hours. CASE REPORT: A 28-year-old male who had suffered from the clinical picture every day for 10 years; this condition consisted in nocturnal episodes of binge eating in a state of semi-sleepiness, with no remembrance of what had happened the next morning. The patient had no history of psychiatric pathologies or any other eating disorder, but he did not rest adequately at night, was overweight and had a family and personal history of other sleep disorders. Since he did not respond to other treatments, we decided to try therapy with topiramate; as a result, the episodes disappeared, tolerance was excellent and effectiveness was maintained throughout the two years' follow-up. CONCLUSIONS: In this paper we review eating disorders that occur during sleep, nocturnal sleep-related eating disorder and its therapeutic possibilities, while highlighting the usefulness of topiramate to treat this condition.

Síndrome de ingesta nocturna relacionada con el sueño con respuesta al topiramato / Nocturnal sleep-related eating disorder that responds to topiramite

El síndrome de ingesta nocturna relacionada con el sueño es una parasomnia de sueño no REM, asociadaa otros trastornos del sueño, en especial al sonambulismo, crónica, no remitente y que consiste en episodios de ingesta compulsiva de alimento durante la noche con amnesia parcial o completa del episodio. Este cuadro debe ser diferenciado del síndrome de la cena durante el sueño, que es mucho más frecuente y se asocia a trastornos endocrinos y psiquiátricos, y deotros trastornos de la conducta alimentaria durante el sueño. Caso clínico. Varón de 28 años, con un cuadro diario de, al menos, 10 años de duración, consistente en episodios nocturnos de ingesta compulsiva en un estado de semisomnolencia, con amnesia del suceso a la mañana siguiente. El paciente no tenía historia de patología psiquiátrica o de otro trastorno de la alimentación,pero sí un descanso nocturno pobre, sobrepeso y antecedentes familiares y personales de otros trastornos del sueño.No respondió a otros tratamientos, por lo que se probó el topiramato con casi total desaparición de los episodios, excelente tolerancia y mantenimiento de la eficacia durante dos años de seguimiento. Conclusiones. Revisamos en este artículo lostrastornos de la conducta alimentaria durante el sueño, el síndrome de ingesta nocturna relacionada con el sueño y sus posibilidades terapéuticas, señalando la utilidad del topiramato en este cuadro

Nocturnal sleep-related eating disorder is a non-REM sleep parasomnia that is associated to othersleep disorders, especially sleepwalking. It becomes chronic, is not remitting and consists in episodes of compulsive eating during the night, which are then partially or completely forgotten by the patient. This condition must be differentiated fromnight-eating syndrome, which is far more common and is linked to endocrinological and psychiatric disorders, as well as to other disorders involving eating behaviour during sleeping hours. Case report. A 28-year-old male who had suffered from the clinical picture every day for 10 years; this condition consisted in nocturnal episodes of binge eating in a state of semisleepiness,with no remembrance of what had happened the next morning. The patient had no history of psychiatric pathologies or any other eating disorder, but he did not rest adequately at night, was overweight and had a family and personal history of other sleep disorders. Since he did not respond to other treatments, we decided to try therapy with topiramate; as a result, the episodes disappeared, tolerance was excellent and effectiveness was maintained throughout the two years’ follow-up.Conclusions. In this paper we review eating disorders that occur during sleep, nocturnal sleep-related eating disorder and its therapeutic possibilities, while highlighting the usefulness of topiramate to treat this condition

[The vestibulocollic reflex: assessment and characteristics of vestibular-evoked myogenic potentials analysed by age groups]. / Reflejo vestibulocervical. Valoracion y caracteristicas de los potenciales vestibulares miogenicos evocados analizados por tramos de edad.

INTRODUCTION: Obtaining vestibular-evoked myogenic potentials (VEMP) by means of the vestibulocollic reflex is a readily available technique that provides an image of vestibular functioning and is useful for evaluating the pathologies that involve compromise of the anatomical pathway of the reflex. Although normal patterns do exist, responses vary at different ages. AIM: To obtain reference values of the vestibulocollic reflex according to different age groups. SUBJECTS AND METHODS: We studied 40 volunteers with no symptoms of auditory or vestibular compromise. Each ear was stimulated separately by a series of clicks (sounds lasting 0.1 s; 3 pps; intensities of 100 dB nHL and 85 dB nHL) and recordings were made in the sternocleidomastoid muscles by means of surface electrodes as patients who were lying on their backs contracted these muscles as they lifted their heads. We studied the latency of the initial p13-n23 positive-negative potential and the peak-to-peak amplitude. The existence of later n34-p44 potentials was evaluated. RESULTS: No statistically significant differences were found between genders or between the two ears. We did not find any differences between the latencies of the waves according to the intensity of the stimulus, but there is a relationship between the amplitude of the p13-n23 potential and the intensity of the stimulus. The latencies of the responses in children under 10 years of age differ from those of the other groups, but no differences were found among those over the age of 11. CONCLUSIONS: The VEMP display steady and easily identifiable latencies. We obtained different reference values for latency in children under the age of 10 and those over 11 years old. The amplitude decreases with the intensity of the stimulus.

Reflejo vestibulocervical. Valoración y características de los potenciales vestibulares miogénicos evocados analizados por tramos de edad / The vestibulocollic reflex. assessment and characteristics of vestibular-evoked myogenic potentials analysed by age groups

Introducción. La obtención de potenciales vestibulares miogénicos evocados (PVME) mediante la realización del reflejo vestibulocervical es una técnica de fácil obtención que da una imagen de la función vestibular y es útil para valorar las patologías que impliquen afectación de la vía anatómica del reflejo. Aunque existen patrones normales, a distintas edades podemos encontrar variaciones en las respuestas. Objetivo. Obtener valores de referencia por tramos de edad del reflejo vestibulocervical. Sujetos y métodos. Estudiamos a 40 voluntarios sin síntomas de afectación auditiva o vestibular. Se estimula mediante clics (sonidos de 0,1 s de duración; 3 pps; intensidades de 100 dB nHL y 85 dB nHL), cada oído por separado, y se registra en los músculos esternocleidomastoideos mediante electrodos de superficie mientras el paciente los contrae al alzar la cabeza desde el decúbito supino. Hemos estudiado la latencia del potencial positivo-negativo inicial p13-n23 y la amplitud pico-pico. Se valora la existencia de potenciales más tardíos n34-p44. Resultados. No encontramos diferencias estadísticamente significativas entre géneros ni entre ambos oídos. No observamos diferencias entre latencias de las ondas en función de la intensidad del estímulo, y existe una relación entre la amplitud del potencial p13-n23 y la intensidad del estímulo. Las latencias de las respuestas en menores de 10 años difieren del resto de grupos, pero no existen diferencias en los mayores de 11 años. Conclusiones. Los PVME muestran unas latencias estables y fácilmente identificables. Obtenemos los valores de referencia de latencia diferentes para menores de 10 años y para los mayores de 11. La amplitud decrece en función de la intensidad del estímulo

Introduction. Obtaining vestibular-evoked myogenic potentials (VEMP) by means of the vestibulocollic reflex is a readily available technique that provides an image of vestibular functioning and is useful for evaluating the pathologies that involve compromise of the anatomical pathway of the reflex. Although normal patterns do exist, responses vary at different ages. Aim. To obtain reference values of the vestibulocollic reflex according to different age groups. Subjects and methods. We studied 40 volunteers with no symptoms of auditory or vestibular compromise. Each ear was stimulated separately by a series of clicks (sounds lasting 0.1 s; 3 pps; intensities of 100 dB nHL and 85 dB nHL) and recordings were made in the sternocleidomastoid muscles by means of surface electrodes as patients who were lying on their backs contracted these muscles as they lifted their heads. We studied the latency of the initial p13-n23 positive-negative potential and the peak-to-peak amplitude. The existence of later n34-p44 potentials was evaluated. Results. No statistically significant differences were found between genders or between the two ears. We did not find any differences between the latencies of the waves according to the intensity of the stimulus, but there is a relationship between the amplitude of the p13-n23 potential and the intensity of the stimulus. The latencies of the responses in children under 10 years of age differ from those of the other groups, but no differences were found among those over the age of 11. Conclusions. The VEMP display steady and easily identifiable latencies. We obtained different reference values for latency in children under the age of 10 and those over 11 years old. The amplitude decreases with the intensity of the stimulus

La relación sueño-epilepsia / The sleep epilepsy relation

En la presente revisión se agrupan los distintos aspectos de la relación entre el sueño y la epilepsia. Se analiza el impacto del sueño en la epilepsia concretado en fenómenos como la presentación circadiana de las crisis epilépticas y distinguiendo entre epilepsias relacionadas con el sueño, con el despertar y difusas. Asimismo, se describe la influencia de los distintos elementos del sueño en la actividad epileptiforme, tanto crítica como intercrítica, y se enfatiza en el efecto facilitador del sueño NREM, del despertar y de la privación de sueño. En sentido inverso, se describe el efecto de la epilepsia en la arquitectura del sueño, tanto de las crisis y del propio síndrome epiléptico, como de los fármacos anticomiciales. Por último, se reseña la importancia de valorar la posible coexistencia de trastornos del sueño en los pacientes epilépticos y la necesidad de tratar esos trastornos para un mejor manejo y control de las crisis y del funcionamiento cognitivo de los pacientes (AU)

In this paper sleep/epilepsy interaction is analized. We review the sleep impact on epilepsy including the circadian presentation of seizures and the effects of NREM, REM and sleep deprivation on inctal and interictal epileptiform discharges. Inversely we describe the impact of individual seizures and anticonvulsant drugs on sleep structure. Finally recognition and treatment of sleep disorders coexisting in epileptic patients is important for optimizing their management and may improve seizure control and daytime alertness (AU)

Antidepresivos e insomnio: estudios en pacientes que consultan por insomnio / Antidepressants and insomnia: studies in patients who consult because of insomnia

Los inconvenientes del consumo prolongado de benzodiazepinas, hipnoticos, y de las nuevas moléculas no benzodiazepínicas, motivan la búsqueda del alternativas en el tratamiento farmacológico del insomnio. La importante comorbilidad entre el insomnio y la depresión, junto con el impacto de algunos antidepresivos en los mecanismos de neurotransmisión en la regulación del sueño, justifican su utilización en los pacientes insomnes. Hay pocos estudios controlados realizados con antidepresivos en pacientes insomnes no deprimidos y se necesita una mayor información, pero los resultados con los fármacos ensayados son positivos en general. De hecho en los últimos años se observa una tendencia a incrementar la prescripción de fármacos antidepresivos para tratar el insomnio y una retracción en el uso de los fármacos agonistas de los receptores benzodiazepínicos (AU)

The drawbacks in the prolongate consume of the BZD hypnotics and the new no-BZD molecules, cause the searching of alternatives in the pharmacological treatment of insomnia. The important comorbility between insomnia and depression, added to the impact of some antidepressants in the sleep regulation neurotransmission mechanisms, justify their use in the insomniacs patients. There are few controlated studies made with antidepressants in no-depressed insomniacs patients and it is necessary more information, but the results with the assayed drugs are in general positive. In fact, in the last years it is observed an increased tendency in the prescription of antidepressants drugs in the treatment of insomnia and a retraction in the use of the BZD-receptors antagonist drugs (AU)