[Consensus statement of the Austrian Sleep Medicine Society on the management of residual excessive daytime sleepiness in obstructive sleep apnea]. / Konsensus-Statement der Österreichischen Gesellschaft für Schlafmedizin (ÖGSM/ASRA) zum Management der residualen exzessiven Tagesschläfrigkeit (rETS) bei obstruktiver Schlafapnoe: Die SPAIN-Checkliste für den klinischen Alltag.

Background: Six to ten percent of patients with obstructive sleep apnea suffer from residual excessive daytime sleepiness (rEDS) despite adequate nocturnal positive airway pressure therapy or effective alternative treatment. The differential diagnosis of rEDS is an interdisciplinary challenge in clinical practice. Objectives: Development of a clear guideline for the detection, differential diagnostic considerations, and options for the continuing treatment of rEDS in clinical practice. Methods: MeSH analysis-based research and interdisciplinary consensus among specialists in internal medicine and pneumology, neurology, as well as psychiatry and psychotherapy. Results: The SPAIN checklist for systematic differential diagnostic exploration of rEDS with the parameters: S leep behavior, P sychological causes, A namesis of medication, I nternal causes and N eurological causes. Conclusions: rEDS should be recognized as a symptom worthy of treatment. It requires an interdisciplinary assessment and the individual adaptation of the treatment to the needs of the affected person.

Functional connectivity and topology in patients with restless legs syndrome: a case-control resting-state functional magnetic resonance imaging study.

BACKGROUND AND PURPOSE: Functional connectivity studies revealed alterations within thalamic, salience, and default mode networks in restless legs syndrome patients. METHODS: Eighty-two patients with restless legs syndrome (untreated, n = 30; on dopaminergic medication, n = 42; on alpha-2-delta ligands as mono- or polytherapy combined with dopaminergic medication, n = 10), and 82 individually age- and gender-matched healthy controls were studied with resting-state functional magnetic resonance imaging. Connectivity of 12 resting-state networks was investigated with independent component analysis, and network topology was studied with graph methods among 410 brain regions. RESULTS: Patients with restless legs syndrome showed significantly higher connectivity within salience (p = 0.029), executive (p = 0.001), and cerebellar (p = 0.041) networks, as well as significantly lower (p < 0.05) cerebello-frontal communication compared to controls. In addition, they had a significantly higher (p < 0.05) clustering coefficient and local efficiency in motor and frontal regions; lower clustering coefficient in the central sulcus; and lower local efficiency in the central opercular cortex, temporal, parieto-occipital, cuneus, and occipital regions compared to controls. Untreated patients had significantly lower (p < 0.05) cerebello-parietal communication compared to healthy controls. Connectivity between the thalamus and frontal regions was significantly increased (p < 0.05) in patients on dopaminergic medication compared to untreated patients and controls. CONCLUSIONS: Networks with higher intranetwork connectivity (i.e., salience, executive, cerebellar) and lower cerebello-frontal connectivity in the restless legs syndrome patients, as well as lower cerebello-parietal connectivity in untreated patients, correspond to regions associated with attention, response inhibitory control, and processing of sensory information. Intact cerebello-parietal communication and increased thalamic connectivity to the prefrontal regions in patients on dopaminergic medication suggests a treatment effect on thalamus.

[Pilot study to investigate sleep disorders in the blind and persons with relevant visual impairment]. / Pilotstudie zur Erfassung von Schlafstörungen bei Erblindung oder relevanter Sehbeeinträchtigung.

BACKGROUND: Sleep disorders are associated with serious health problems in blind and visually impaired persons. Loss of light perception may result in a shift of sleep-wake pattern, which may lead to significant impairments in daily life--the so-called non-24-hour sleep-wake disorder. To date, epidemiologic data on non-24 only exist for the USA. This pilot study was conducted to provide first epidemiologic data for the prevalence of non-24 and other sleep disorders among blind and visually impaired persons in Germany. METHODS: Recruited were 111 blind and visually impaired subjects (36 subjects without light perception; male [m] = 56, 27-85 years, average [Mx] = 59.53, standard deviation [SD] = 14.69) and 111 sighted controls (m = 41, 27-88 years, Mx = 58.32, SD = 14.21), who answered a set of validated questionnaires referring to general health status (SF-36), sleep characteristics (PSQI), and daytime sleepiness (ESS). In addition, a questionnaire to predict non-24-hour sleep-wake disorder, which is not yet validated in German, was provided. RESULTS: The prevalence of 72.2% for the non-24-hour sleep-wake disorder in blind people is in accordance with results from the USA. In contrast, our results indicated non-24 in only 21.3% of the subjects with residual light perception. Furthermore, other sleep disorders like problems falling asleep (100% vs. 79.9%), maintaining sleep (90% vs. 88.1%), sleep-disordered breathing (19.4% vs. 32%), or sleep-related movement disorders (28.1% vs. 32.9%) were also common in the group of blind or visually impaired persons. DISCUSSION: The non-24-hour sleep-wake disorder is a frequent problem among people with no light perception, associated with problems falling asleep, maintaining sleep, and daytime sleepiness. The perception of light as an external cue for our circadian rhythm plays a key role. However, sleep disruption is not fully explained by non-24, making a detailed sleep history essential.

Rapid eye movement sleep behavior disorder: devising controlled active treatment studies for symptomatic and neuroprotective therapy--a consensus statement from the International Rapid Eye Movement Sleep Behavior Disorder Study Group.

OBJECTIVES: We aimed to provide a consensus statement by the International Rapid Eye Movement Sleep Behavior Disorder Study Group (IRBD-SG) on devising controlled active treatment studies in rapid eye movement sleep behavior disorder (RBD) and devising studies of neuroprotection against Parkinson disease (PD) and related neurodegeneration in RBD. METHODS: The consensus statement was generated during the fourth IRBD-SG symposium in Marburg, Germany in 2011. The IRBD-SG identified essential methodologic components for a randomized trial in RBD, including potential screening and diagnostic criteria, inclusion and exclusion criteria, primary and secondary outcomes for symptomatic therapy trials (particularly for melatonin and clonazepam), and potential primary and secondary outcomes for eventual trials with disease-modifying and neuroprotective agents. The latter trials are considered urgent, given the high conversion rate from idiopathic RBD (iRBD) to Parkinsonian disorders (i.e., PD, dementia with Lewy bodies [DLB], multiple system atrophy [MSA]). RESULTS: Six inclusion criteria were identified for symptomatic therapy and neuroprotective trials: (1) diagnosis of RBD needs to satisfy the International Classification of Sleep Disorders, second edition, (ICSD-2) criteria; (2) minimum frequency of RBD episodes should preferably be ⩾2 times weekly to allow for assessment of change; (3) if the PD-RBD target population is included, it should be in the early stages of PD defined as Hoehn and Yahr stages 1-3 in Off (untreated); (4) iRBD patients with soft neurologic dysfunction and with operational criteria established by the consensus of study investigators; (5) patients with mild cognitive impairment (MCI); and (6) optimally treated comorbid OSA. Twenty-four exclusion criteria were identified. The primary outcome measure for RBD treatment trials was determined to be the Clinical Global Impression (CGI) efficacy index, consisting of a four-point scale with a four-point side-effect scale. Assessment of video-polysomnographic (vPSG) changes holds promise but is costly and needs further elaboration. Secondary outcome measures include sleep diaries; sleepiness scales; PD sleep scale 2 (PDSS-2); serial motor examinations; cognitive indices; mood and anxiety indices; assessment of frequency of falls, gait impairment, and apathy; fatigue severity scale; and actigraphy and customized bed alarm systems. Consensus also was established for evaluating the clinical and vPSG aspects of RBD. End points for neuroprotective trials in RBD, taking lessons from research in PD, should be focused on the ultimate goal of determining the performance of disease-modifying agents. To date no compound with convincing evidence of disease-modifying or neuroprotective efficacy has been identified in PD. Nevertheless, iRBD patients are considered ideal candidates for neuroprotective studies. CONCLUSIONS: The IRBD-SG provides an important platform for developing multinational collaborative studies on RBD such as on environmental risk factors for iRBD, as recently reported in a peer-reviewed journal article, and on controlled active treatment studies for symptomatic and neuroprotective therapy that emerged during the 2011 consensus conference in Marburg, Germany, as described in our report.

Assessment of skin extensibility and joint hypermobility in patients with spontaneous cervical artery dissection and Ehlers-Danlos syndrome.

Ehlers-Danlos syndrome (EDS) is a hereditary connective tissue disorder. One important clinical characteristic of classical type EDS is skin hyperextensibility. Examination of clinical evidence and electron microscopic views of skin biopsies suggest that connective tissue abnormalities resembling very mild EDS are present in a sizable proportion of patients with spontaneous cervical artery dissection (sCAD). Manual assessment of skin extensibility is difficult. Therefore, non-invasive machine-aided measurement of skin extensibility was used and compared with manual assessment of skin extensibility and joint hyperextensibility. Patients with classical EDS, vascular-type EDS, sCAD and healthy patients were evaluated. Skin extensibility was measurably and palpably elevated in all patients with classical type EDS but not in sCAD patients or patients with vascular-type EDS compared to healthy control individuals. Our method is able to measure the increased skin extensibility in classical type EDS. Increased skin extensibility is not present in sCAD patients.

Connective tissue and vascular phenotype in patients with cervical artery dissection.

BACKGROUND: Clinical observations and electron microscopic investigation of skin biopsies demonstrated connective tissue abnormalities in a sizeable proportion of patients with spontaneous cervical artery dissection (sCAD), suggesting an unknown connective tissue disorder as a risk factor for sCAD. OBJECTIVE: To evaluate in a case-control setting if patients with sCAD exhibit clinical signs indicative of a connective tissue disorder or show a vascular phenotype. METHODS: We investigated 43 consecutive patients with sCAD and 43 consecutive patients of similar age with ischemic stroke of other etiology. All patients underwent standardized MRI of the head and neck. The clinical investigation contained 25 items characteristic for connective tissue diseases such as hyperextensible skin, articular hypermobility, capillary fragility, and facial stigmata. A sum score counting all positive items was calculated. Additionally, the diameter of the common carotid artery (CCA) and vertebral artery (VA) and heart valve pathologies were assessed. RESULTS: Connective tissue sum scores did not differ between the sCAD group (mean 2.37 +/- 2.1, median 2) and the control group (mean 1.95 +/- 1.9, median 2, p = 0.34). One sCAD patient had osteogenesis imperfecta (2.3%) and exhibited the highest sum score of 8. The diameter of the CCA and VA and the prevalence of heart valve pathologies did not show any significant differences between groups. CONCLUSION: The connective tissue and vascular phenotype did not differ significantly between patients with spontaneous cervical artery dissection (sCAD) and control subjects with ischemic stroke of other etiology. These findings argue against a clinically apparent connective tissue disorder underlying sCAD. The prevalence of known connective tissue diseases in sCAD patients is low.

Mild mechanical traumas are possible risk factors for cervical artery dissection.

BACKGROUND AND PURPOSE: Cervical artery dissection (CAD) is a common cause of ischemic stroke in younger aged subjects. Retrospective studies suggest cervical manipulative therapy (CMT) and preceding infections as extrinsic risk factors for CAD. In a case-control study, we assessed a questionnaire with 7 mild mechanical traumas as potential trigger factors for CAD, including CMT and recent infections. PATIENTS AND METHODS: Forty-seven consecutive patients with CAD were compared with 47 consecutive patients of similar age with ischemic stroke due to etiologies other than CAD. Patients underwent a standardized face-to-face interview. We assessed head or neck pain and recent infection <7 days before symptom onset, as well as the following mechanical trigger factors <24 h and <7 days prior to symptom onset: (1) heavy lifting, (2) sexual intercourse, (3) mild direct or (4) indirect neck trauma, (5) jerky head movements, (6) sports activity, and (7) CMT. RESULTS: We found no association between any single one of the above risk factors and CAD. CMT (CAD, n = 10; non-CAD, n = 5) and recent infections (CAD, n = 18; non-CAD, n = 10) were more frequent in the CAD group but failed to reach significance. However, the cumulative analysis of all mechanical trigger factors revealed a significant association of mechanical risk factors as a whole in CAD <24 h prior to symptom onset (p = 0.01). CONCLUSION: Mild mechanical stress, including CMT, plays a role as possible trigger factor in the pathogenesis of CAD. CMT and recent infections alone failed to reach significance during the present investigation, presumably due to the relatively small sample size of the study cohort.

Vulnerability to noise-induced hearing loss in 'middle-aged' and young adult mice: a dose-response approach in CBA, C57BL, and BALB inbred strains.

Vulnerability of the cochlea to noise-induced permanent threshold shifts (NIPTS) was examined in young adult (1-2 months) and 'middle-aged' (5-7 months) CBA/CaJ, C57BL/6J, and BALB/cJ inbred mice. For each age and strain, a dose-response paradigm was applied, whereby groups of up to 12 animals were exposed to intense broadband noise (110 dB SPL) for varying durations. Exposure durations reliably associated with <10% and >90% probability of a criterion amount of NIPTS (determined 2 weeks post-exposure) were identified, and the minimum NIPTS exposure and the slope of the dose-response relation were then derived by numerical modeling. For all three strains, young adult mice were more susceptible to NIPTS than older adults; That is, a shorter exposure was able to cause NIPTS in the younger mice. Strain comparisons revealed that C57 mice were more susceptible than CBAs in the older age group only. At both ages examined, however, BALB mice were most susceptible to NIPTS. When animals with a similar amount of NIPTS were compared, outer hair cell loss in the cochlear base was more widespread in the younger animals. BALB mice appear particularly susceptible to noise-induced outer hair cell loss throughout life. Our data suggest that the mechanism or site of noise injury differs between young adults and older adults, and may depend on genetic background. The finding that both BALB and C57 mice, which show pronounced age-related hearing loss, are also especially vulnerable to noise supports the notion that genes associated with age-related hearing loss often act by rendering the cochlea susceptible to insults.

Voicing judgements by chinchillas trained with a reward paradigm.

Experiments were performed to replicate and extend previous findings of similar categorization of voiced/voiceless consonant-vowel (CV) syllables by humans and chinchillas. A reward paradigm was applied to the question of how stimulus range affects the voice-onset-time (VOT) corresponding to the voiced/voiceless category boundary. Each of four adult chinchillas and four human subjects identified synthetic CV syllables as voiced (/ba/, /da/, /ga/) or voiceless (/pa/, /ta/, /ka/) using voiceless standards of either 80 or 120 ms. In both humans and animals, extending the VOT range from 80 to 120 ms shifted category boundaries to longer VOTs, but to a different extent across listeners. Control experiments suggested that listeners were attending to different phonetic cues in a manner that depended on the listener, rather than on species. The results are interpreted in terms of similar contextual effects and use of multiple phonetic cues to voicing in humans and animals.

Development and preliminary evaluation of an earmold sound-to-tactile aid for the hearing-impaired.

A binaural earmold sound-to-tactile aid was constructed by inserting a vibrating element into a Lucite earmold. The earmold could be vibrated at either 80 Hz (when incoming acoustic signals were below 2000 Hz), at 300 Hz (when incoming acoustic signals were above 2000 Hz), or both (when incoming acoustic signals were broadband). Subjects were fitted with one of these bimodal vibrating earmolds in each ear. Normal-hearing and hearing-impaired subjects were tested in three tasks: sound localization, environmental sound identification, and syllable rhythm and stress. The device provided some benefit to performance, although the amounts of improvement varied across tasks and subjects. Possible modifications in device design, and potential combinations of auditory and tactile input via earmold systems, are discussed.