Kleine-levin syndrome comorbid with obsessive compulsive disorder and personality disorder: A case report.

Background: Kleine-Levin syndrome (KLS) is a rare sleep disorder with at least two episodes of hypersomnia coincidence with at least one cognitive, eating, perceptive and disinhibited symptoms and normal inter-episodes. These symptoms are not explained by another sleep, medical, neurological, psychiatric disorders and substance or drug use. Case Presentation: Here we report a young female with personality disorder and obsessive-compulsive disorder who had KLS. Her symptoms appeared in the past 1.5 years ago, while she had an episode of hypersomnia lasting for 5 days. She had 4 attacks; each one lasted up to 2-7 days. We found that overriding KLS symptoms on underlying main psychiatric or personality disorders complicates diagnosis. All neurological examinations during episode and further investigation were in normal range. Conclusion: We suggest that taking a complete history and mental state examination in the episode and inter episode phase helps to diagnosis both KLS and comorbid psychiatric disorders.

Evaluating the Effects of Agomelatine on Polysomnography Parameters in Patients with Obstructive Sleep Apnea.

PURPOSE: Obstructive sleep apnea (OSA) is a common serious sleep disorder. Melatonin-based drugs such as agomelatine may have beneficial effects on patients with sleep disorders. This study aimed to evaluate agomelatine effects on polysomnography parameters in patients with OSA. METHODS: In this randomized, parallel, and single-blind study, seventy patients 18 years of age or older with obstructive sleep apnea who were referred to the sleep clinic were evaluated. The patients were randomly assigned into agomelatine and control groups. Patients in the agomelatine group received 50 mg agomelatine, one hour before sleep, for three consecutive nights prior to the polysomnography test, while the patients in the control group did not receive agomelatine. Sleep test parameters were compared between the two groups. RESULTS: Three parameters in the agomelatine versus control group showed significant differences. They were the median and interquartile range of the total sleep time, 397 [326.5-437.4] vs. 287.5 [184-393.1; p, 0.004] minuets, sleep efficiency percentage, 75.6 [71-87.4] vs. 65.1 [50.8-80.1; p, 0.005] and the wakening percentage, 7.5 [12.01-27.6] vs. 8.8[18.3-49; p, 0.004] agomelatine vs. control group. Other polysomnography parameters revealed no significant differences between the two groups. CONCLUSIONS: Agomelatine administration in patients with OSA may improve total sleep time, sleep efficiency percentage and the percentage of patients' awakening.

National Research Institute of Tuberculosis and Lung Disease (NRITLD) Protocol for the Treatment of Patients with COVID-19.

More than a year after the onset of the coronavirus disease pandemic in 2019, the disease remains a major global health issue. During this time, health organizations worldwide have tried to provide integrated treatment guidelines to control coronavirus disease 2019 (COVID-19) at different levels. However, due to the novel nature of the disease and the emergence of new variants, medical teams' updating medical information and drug prescribing guidelines should be given special attention. This version is an updated instruction of the National Research Institute of Tuberculosis and Lung Disease (NRITLD) in collaboration with a group of specialists from Masih Daneshvari Hospital in Tehran, Iran, which is provided to update the information of caring clinicians for the treatment and care of COVID-19 hospitalized patients.

Possibility of Applying Heart Rate Variability as a Screening Method to High-Risk Obstructive Sleep Apnea Patients.

Background: Altered heart rate variability (HRV) has been associated with a number of disorders affecting autonomic tone, including recent myocardial infarction, congestive heart failure, and diabetic neuropathy. Furthermore, obstructive sleep apnea (OSA) has been shown to be associated with characteristic disturbances in heart rhythm. In this study, using HRV frequency analysis, an attempt has been made to diagnose or possibly diagnose OSA. Materials and Methods: Using Somnologica version 3.3.1 software (Medcare-Embla), polysomnographic recordings were done. Electrocardiographic signals were digitalized with a sampling rate of 250 Hz. Using the HRV analysis report of this software, low-frequency (LF) and high- frequency (HF) information and LF to HF ratio (LF/HF) were obtained at 5-min intervals, then at cutting points 30, 35, 40, 45, and 50, which indicate the intensity of the apnea and hypopnea index (AHI), were analyzed with mean and standard deviation of HRV frequencies. Results: According to the results reported in this study, comparison of mild, moderate, and severe cases led to no significant differences, while frequency-domain analysis displayed significant LF/HF increase in more severe AHI cases. This can probably be applied in screening high-risk patients, reducing the application of PSG in high probable cases, and providing an estimate of prognosis of potentials patients for the physicians. Conclusions: In the study of frequency-domain analysis, LF/HF increases in more severe AHI cases. These can probably be applied in screening high-risk patients, reducing the application of PSG in high probable cases.

Assessment of Quality of Life and the Risk of Obstructive Sleep Apnea in Individuals with Chronic Rhinosinusitis who are Candidate for Functional Endoscopic Sinus Surgery.

BACKGROUND: Chronic rhinosinusitis is associated with changes in quality of life (QoL). The present study intended to evaluate the QoL and risk of obstructive sleep apnea in individuals with chronic rhinosinusitis who were candidate for functional endoscopic sinus surgery. To determine the Quality of Life and the risk of sleep apnea in cases with chronic Rhinosinusitis. MATERIALS AND METHODS: A total of 100 patients with drug-resistant chronic rhinosinusitis candidate for functional endoscopic sinus surgery referred to the ENT clinic of Masih Daneshvari Hospital, Tehran, Iran were recruited. SNOT-22 and STOP-BANG questionnaires were filled before the surgery. RESULTS: The mean SNOT-22 score was 40.44, with a standard deviation of 19.27 (ranged from 1 to 94). Also, according to the STOP-BANG questionnaire, 62% of participants were at increased risk of OSA. Based on the cut-off point of 30 for the SNOT-22 score (either larger or lower than 30), patients were categorized into two groups. Sixty-eight percent of participants were categorized in ≥ 30 SNOT-22 score. Age below 50, female gender, and those at high risk of OSA were associated with lower QoL. CONCLUSION: Most patients with chronic rhinosinusitis had a low QoL and were mostly at increased risk of OSA. Being women younger than 50 years and the presence of OSA probably are associated with lower QoL in these patients.

The effect of buprenorphine vs methadone on sleep breathing disorders.

Opioids are used widely as analgesics and can play an important role in agonist maintenance therapy for opium dependence. Despite their benefits, the negative effects on the respiratory system remain an important side effect to be considered. Ataxic breathing, obstructive sleep apnea, and most of all central sleep apnea are among these concerns. Obstructive sleep apnea leads to various metabolic, cardiovascular, cognitive, and mental side effects and may result in abrupt mortality. Buprenorphine is a semisynthetic opioid, a partial mu-opioid agonist with limited respiratory toxicity preferably used by these patients, as it is accompanied by significantly lower risk factors in the development of obstructive and central sleep apnea. In this manuscript, the case of a patient is reported who underwent methadone maintenance therapy which was shifted to buprenorphine in order to observe possible changes in sleep-related breathing disorders. The results of this study indicate a reduction in these problems through the desaturation and apnea hypopnea index of methadone substituted by buprenorphine while no change in sleepiness was observed.

Sleep Disorders and Mental Health in Menopausal Women in Tehran.

BACKGROUND: Sleep complaints are common problems in the general population and insomnia and sleep disorders place significant economic and social burdens on the community. Postmenopausal women are 2.6 to 3.5 times more likely to develop obstructive sleep apnea (OSA) compared to non-menopausal women. In this study, we evaluated sleep disorders and mental health in postmenopausal women. MATERIALS AND METHODS: This study was a descriptive cross-sectional study and the samples were selected from postmenopausal women above 50 years who had participated in a survey entitled, "Evaluation of Sleep Disorders among Adults in Tehran" in 2017. Cluster sampling method was applied with proportional allocation. A total of 4021 samples were collected, 2075 of which belonged to women. In addition, 174 out of 2075 samples were related to postmenopausal women over the age of 50. The data were analyzed using the statistical package IBM SPSS version 22.0. P-values less than 0.05 were considered significant. RESULTS: In this study, 118 (67.8%) women had insomnia for less than three months, and 23 (13.2%) women had insomnia for more than three months. The prevalence of STOPBANG parameters in this group of postmenopausal women was 37% and significantly related to Body mass index (BMI) and neck circumference at P < 0.001 and 0.006, respectively. There was no significant relationship between social dysfunction and insomnia. However, anxiety in General Health Questionnaire (GHQ) was significantly associated with insomnia, sleepiness, sadness, and irritability. CONCLUSION: Our results indicate that the impact of insomnia symptoms, OSA comorbidity and mental disorders could extend far beyond. The use of urgent health care and quality of life issues is essential for long-term mental and physical well-being; if there is no treatment in the menopause population, there will be serious mental and physical complications.

Can be compared obstructive respiratory events during drug induced sleep endoscopy (DISE) and nocturnal polysomnography.

PURPOSE: Obstructive sleep apnea (OSA) is a collapse of pharynx muscles during sleep that can cause obstruction in the upper airway. It is better to determine the site and pattern of obstruction in the upper airway with drug-induced sleep endoscopy (DISE) before surgery. OSA usually occurs in a non-rapid eye movement (NREM) sleep and sometimes it gets longer and more intense in REM; hence, the study is meant to explore whether the sleep stage and results in DISE may have any similarity with usual nocturnal polysomnography or not. MATERIALS AND METHODS: In this study, 38 patients with OSA diagnosed on the basis of polysomnography, underwent DISE. Moreover, EEG (12 channels), pulse oximetry and effort channel (respiratory inductance plethysmography) were recorded during DISE to determine the sleep stage and mean respiratory event duration (MRED). RESULTS: Thirty-eight patients were enrolled in this study. Eighty-four percent (84%) of obstructive respiratory events were observed in NREM sleep in Lab-PSG and 71% in DISE. 28.9% of patients' events occurred in the wake state in DISE. The mean respiratory event duration (MRED) values in DISE and nighttime sleep were 24.5 ± 7.5 s and 25.4 ± 7.7 s, respectively without significant difference (P value = 0.744), while the minimum values for SPO2 were 74.0 ± 17.3 and 73.6 ± 20.3, respectively (P = 0.885). CONCLUSIONS: Considering the fact that the majority of respiratory events occurred in NREM sleep stage in both PSG and DISE, DISE results can be trusted. Due to absence of REM stage in DISE, the level of the obstruction may mislead the surgeon.

An eleven-year retrospective cross-sectional study on pulmonary alveolar proteinosis.

INTRODUCTION: Pulmonary alveolar proteinosis (PAP) is a rare disease in the field of pulmonary medicine. The efficacy of whole-lung lavage (WLL) as the treatment of PAP had never been evaluated in the Iranian population. Therefore, there is a real need to investigate the characteristics of PAP and also to evaluate the efficacy of WLL in this rare disease. The study aimed to investigate demographic features, clinical presentation and treatment outcomes of the disease in Iranian PAP patients. MATERIAL AND METHODS: Data of 45 patients with definite diagnosis of PAP, who had regular follow-ups from March 2004 to March 2015 at an Iranian referral respiratory hospital, were collected. Whole-lung lavages (WLL) efficacy was assessed by comparing spirometric, arterial blood gas parameters and six-minute walk test (6MWT) results before and after all lavages. RESULTS: Mean age at diagnosis of disease was 30.33 ± 14.56 years. Four patients (8.8%) reported non-massive hemoptysis and three subjects (6.6%) had concomitant pulmonary tuberculosis. In 71.1% of cases, transbronchial lung biopsy and bronchoalveolar lavage were sufficient for diagnosis. Spirometric results and arterial blood gas parameters and 6MWD improved significantly after all the lavages. Four patients (8.8%) died because of respiratory failure. The only variable capable of predicting treatment failure was the history of hemoptysis. CONCLUSION: The study revealed sufficiency of WLL as the PAP patients' treatment. Also hemoptysis was found to be the independent factor that can predict treatment failure.

Diagnosis of Obstructive Sleep Apnea Syndrome in Adults: A Brief Review of Existing Data for Practice in Iran.

Obstructive sleep apnea (OSA) is a common disorder associated with major comorbidities. It is estimated that 5-35% of the adult population in Iran are at high risk for OSA. This review article is designed to assist sleep medicine specialists as well as general practitioners in Iran to screen for OSA. It summarizes empirical data for diagnosing OSA including history taking, physical examination, diagnostic testing, and diagnostic criteria with regards to existing sleep medicine centers and availability of diagnostic tests in Iran.

Prevalence of snoring and the risk of sleep apnea in hospital staff.

BACKGROUND: Untreated Obstructive sleep apnea syndrome (OSAS) as a common breathing sleep disorder results in impaired work performance. The economic burden of untreated OSAS accounts for billions of dollars per year. OBJECTIVE: The aim of this study was to evaluate the prevalence of snoring and the risk of OSAS in healthcare system staff. METHODS: This cross-sectional study was performed on 715 staff of Dr. Masih Daneshvari Hospital in 2012. The Berlin questionnaire was used to identify the prevalence of snoring and the risk of sleep apnea. Additional information, including demographic characteristics, night work, night sleep less than 4 hours, smoking, underlying disease, and quality of sleep were evaluated as well. The information was analyzed using SPSS 15. RESULTS: 12.6% reported snoring. 6.9% and 93.1% were categorized into the high and low risk groups for OSAS respectively. There was an association between the risk of OSAS and age group (P-value = 0.007), gender (P-value = 0.028), marital status (P-value = 0.008), educational level (P-value = 0.035), chronic disease (P-value = 0.008), night sleep less than 4 hours (P-value = 0.001), difficulty in staying asleep (P-value = 0.000) and waking up too early (P-value = 0.006). Even logistic regression analysis demonstrated the relationship between the risk of OSAS and night sleep less than 4 hours (P-value = 0.019) and difficulty in staying asleep (P-value = 0.009). CONCLUSIONS: The results showed that the risk of OSAS is significant in healthcare system staff. Hope to provide a special screening program for OSAS in a regular occupational examination.

Association between Occupational Accidents and Sleep Apnea in Hospital Staff.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a common disorder in which instability of the upper airways leads to a reduction or cessation of airflow during sleep. Sleep disorders such as OSAS increase the risk of occupational accidents and impaired work performance. Sleep deprivation during shift increases the risk of occupational accidents among health care employees. The purpose of this study was to determine the association between occupational injuries in hospital staff and the risk of sleep apnea. MATERIALS AND METHODS: This cross-sectional study was conducted on hospital staff of Masih Daneshvari Hospital in 2012. In this study, the hospital staff's (715) response to the Berlin questionnaire plus additional information including a history of an occupational accident, night shifts, less than four hours of night sleep, history of smoking, chronic disease and quality of sleep were assessed. Information obtained was analyzed using SPSS 15. RESULTS: In general, 27.6% reported a history of occupational accidents. The incidence of occupational accidents in the high-risk group for sleep apnea was significantly higher than the low-risk group (OR=2.736, CI=1.522-4.917, P=0.001). The results of logistic regression analysis also showed a statistically significant association between occupational accidents and risk of sleep apnea (OR = 2.247, CI = 1.194-4.231, P= 0.012). CONCLUSION: This study showed that the incidence of occupational accidents in the hospital employees is strongly related to the probability of OSA. Therefore, special attention should be directed to respiratory sleep disorders in order to reduce occupational injuries at hospitals.

A pilot study of polymorphism of adrenergic Beta-2 receptor and mild asthma: a clinical and pharmacogenetic study.

Glycine allele at codon 16 has previously been associated with the increase in asthma severity, bronchial hyperresponsiveness and also the increase in inhaled corticosteroid dependence. This study was designed to evaluate the genetic alleles in mild asthma. Thirty-four patients with diagnosis of mild asthma (FEV1 ≥ 80%, positive methacholine test) and body mass index (BMI ≤ 30 Kg/m(2)) were included in the study. They could only use short acting beta-2 agonists for asthma control. Smoking, infection, occupational sensitizers' exposure, gastroesophageal reflux, diabetes mellitus and heart failure were also considered as exclusion criteria. All patients were genotyped at 16(th) and 27(th) codons. Among all, 20 (58.8%) Arg/Gly, 14 (41.2%) Arg/Arg and no Gly/Gly genotype were detected at codon 16. Genotyping at codon 27 revealed 2 (5.9%) Glu/Glu, 13 (38.2%) Glu/Gln and 18 Gln/Gln (52.9%). Based on the obtained results, Arg/Gly mutation had a higher rate among the studied subjects compared to Arg/Arg polymorphism. This is a pilot study which shows a probable usefulness of genotyping for predicting of asthma severity.

The effect of polymorphisms of beta2 adrenoceptors on response to long-acting beta2 agonists in Iranian asthmatic patients.

The results of many studies suggested possible relationship between polymorphism at codons 16 and 27 and development of tolerance to beta-2 adrenoceptor agonist responses as well as disease severity in asthmatic patients. This study was designed to evaluate the effect of polymorphism of beta2 adrenoceptors on response to salmeterol and fluticasone (as inhaled Seretide).Sixty-four patients with either mild or moderate-severe asthma were evaluated in this study. A four-week therapy with Seretide was conducted in moderate-severe asthmatics. The respiratory parameters and asthma score (based on GINA guidelines) were measured before and after run in period. Blood samples were genotyped at codons 16 and 27.No significant difference was observed in genotypes neither at codon 16 nor at codon 27 between mild and moderate-severe asthma groups. However, Patients in Arg/Arg (n = 8) category showed significant improvement in asthma control parameters and lung function compared with Arg/Gly genotype (n =20).These results suggest that genotyping may be useful in some asthmatic patients in order to better tailor asthma treatment plan.

Successful surgical intervention in an unusual case of Aspergillus endocarditis with acute myeloid leukemia.

Endocarditis due to Aspergillus infection is a rare complication in patients with hematological malignancies. Here, we present a case of aspergillus endocarditis in a patient with acute myeloid leukemia (AML) successfully treated with antifungal therapy and surgical treatment. The patient was a 51 years old male, a known case of AML who was admitted to our medical center for evacuating his valvular vegetations and repairing his atrial septal defect. He underwent an open heart surgery to relinquish his thromboses and also received an antifungal regimen. The patient tolerated the procedure well and eight months after his surgery, the patient remains asymptomatic. Successful treatment of this severe case of aspergillus endocarditis justifies a multidisciplinary method to be as a safe and effective approach to manage these patients.

Venous thromboembolism in medical critically ill patients: prevalence and incidence.

The objective of this study was to determine the prevalence and incidence of venous thromboembolism among critically ill medical surgical patients. In this cross sectional and retrospective study, we observed 243 patients who were first admitted at the intensive care unit. Patients who were diagnosed with deep venous thrombosis or embolism either by clinical or paraclinical methods were enrolled. Among 243 patients of ICU ward 12 cases of them were confirmed to have thromboembolism (prevalence of 9.4%).But the incidence of venous thromboembolism after 48 hour of ICU admission was 5.2%(6 cases). Among 6 VTE cases 3 of them didn't receive any anticoagulant prophylaxis, 2 patients received LDUH 5000 unit twice a day and one patient received LMWH 60 mg daily but all developed VTE although receiving prophylaxis. We found that the prevalence of proximal lower limb DVT among medical-surgical critically ill patients remaining in the ICU for ≥3 days is about 9.4% and the incidence of that is about 5.2%. Further studies should be performed in order to assess the benefits and risks of venous thromboprophylaxis in Iranian patients.