The short Thai version of functional outcomes of sleep questionnaire (FOSQ-10T): reliability and validity in patients with sleep-disordered breathing.

PURPOSE: The study is to evaluate reliability and validity of the short Thai version of Functional Outcome of Sleep Questionnaire (FOSQ-10T), in patients with sleep disordered breathing (SDB). METHODS: Inclusion criteria were Thai patients with SDB age ≥ 18 years old who had polysomnography results available. Exclusion criteria were patients unable to complete questionnaire for any reason, patients with a history of continuous antidepressant or alcohol use, and underlying disorders including unstable cardiovascular, pulmonary, or neurological conditions. All participants were asked to complete the FOSQ-10 T and Epworth sleepiness scales (ESS). Of these, 38 patients were required to retake FOSQ-10 T at 2-4 weeks later to assess test-retest reliability, and 19 OSA patients treated with CPAP were asked to do so at 4 weeks following therapy to assess questionnaire's responsiveness to treatment. RESULTS: There were 42 participants (24 men, 18 women), with a mean age of 48.3 years. The internal consistency of the FOSQ-10T was good, as indicated by Cronbach's alpha coefficient of 0.85. The test-retest reliability was good, as indicated by intraclass correlation coefficient of 0.77. The correlation between the FOSQ-10T and ESS scores (concurrent validity) was moderate (r = - 0.41). The scores of FOSQ-10T significantly increased after receiving adequate CPAP therapy, showing an excellent responsiveness to treatment. However, there was no significant association between FOSQ-10T scores and OSA severity measured by apnea-hypopnea index. CONCLUSIONS: The FOSQ-10T has good reliability and validity to use as a tool to assess QOL in Thai patients with SDB. It is convenient and potentially useful in both clinical and research settings.

Subjective cognitive complaints and objective cognitive impairment in patients suspected of obstructive sleep apnea who underwent polysomnography.

OBJECTIVES: Obstructive sleep apnea (OSA) is linked to cognitive impairment. We aimed to investigate subjective cognitive complaints (SCCs) and objective cognitive scores and their relation to polysomnography (PSG) parameters in patients suspected of having OSA. METHODS: A prospective cohort cross-sectional study was conducted at Siriraj Hospital. Patients suspected of OSA who were scheduled for PSG were recruited. Cognition was assessed using the Montreal Cognitive Assessment (MoCA) and Color Trails Test (CTT). The Memory Index Score (MIS) was calculated from the MoCA. Subjective cognitive complaint presence was assessed through direct questioning of patients and by employing the Cognitive Change Index rated by self or informants (CCI-I). Patients with severe dementia were excluded. RESULTS: Among 258 patients (mean age 61.46 ± 7.05 years, 51.2% female), the mean MoCA score was 23.89 ± 3.89. Based on PSG results, patients were categorized into groups as follows: those without OSA or with mild OSA (combined total of 20.1%), moderate OSA (28.3%), or severe OSA (51.6%). Cognitive Change Index rated by self and CCI-I scores correlated significantly (r = 0.238, p = 0.019) but not with the MoCA score or CTT time. Objective cognitive scores were associated with PSG parameters: total sleep time (TST), sleep onset latency, wake after sleep onset, sleep stages, mean O2 saturation, and time spent with SaO2 below 90% (all p < 0.05). Subjective cognitive scores were not associated with PSG parameters, except CCI-I with TST. Participants with objective cognitive impairment had lower education, higher body mass index, more comorbidities, and lower SCC percentage (all p < 0.05). Patients with moderate to severe OSA had a higher proportion of objective cognitive impairment (64.1%) but a lower incidence of SCC (38.3%) than patients with no OSA or mild OSA. Thirty patients with severe OSA and cognitive impairment received continuous positive airway pressure (CPAP) treatment for a mean of 12.2 months. These patients showed MoCA and MIS improvement, but no significant changes were observed in their CTT and Cognitive Change Index scores. CONCLUSIONS: Most patients with OSA had objective cognitive impairment, but SCC was less frequent in patients with more severe OSA. Several PSG parameters correlated with cognitive scores but not with subjective cognitive scores. Patients with severe OSA may benefit cognitively from CPAP treatment.

Association between hypoxic burden and common cardiometabolic diseases in patients with severe obstructive sleep apnea.

PURPOSE: To determine the possible associations between total sleep time spent with arterial oxygen saturation < 90% (T90) and comorbid cardiometabolic diseases (CMDs) in patients with severe obstructive sleep apnea (OSA). METHODS: A retrospective review of the chart was conducted in patients with severe OSA diagnosed by in-lab polysomnography (PSG) between January 2018 and December 2019 at Siriraj Hospital. The patients were divided into two groups: hypoxic (T90 ≥ 10%) and nonhypoxic (T90 < 10%). The association between common CMDs including hypertension (HT), type 2 diabetes mellitus (T2DM), and impaired fasting glucose (IFG) was investigated and compared between the two groups. RESULTS: Data were collected from 450 patients with severe OSA, 289 males/161 females with a mean age of 53.5 ± 14.2 years and an apnea-hypopnea index (AHI) of 49.6 events/h. Among these, 114 patients (25.3%) were defined as the hypoxic group (T90 ≥ 10%). When compared between the hypoxic and nonhypoxic groups, the patients in the hypoxic group were significantly younger and more obese, and had a higher proportion of male patients. The majority of patients (80%) had at least one CMD; however, the most common comorbidities significantly associated with hypoxic OSA (T90 ≥ 10%) were HT and IFG. CONCLUSION: Hypoxic burden is significantly associated with an increased prevalence of HT and IFG in patients with severe OSA. T90 may be potentially useful for predicting CMDs in these patients. However, prospective studies are still required.

Association between REM-related mild obstructive sleep apnea and common cardiometabolic diseases.

PURPOSE: To explore the association between rapid eye movement-related obstructive sleep apnea (REM-OSA) and common cardiometabolic diseases (CMDs) in patients with mild OSA. METHODS: This retrospective study was conducted by reviewing the medical records and polysomnograms (PSGs) of patients at Siriraj Hospital. The PSGs of patients diagnosed with mild OSA who had ≥ 15 min of REM sleep were included. REM-OSA was defined if the apnea-hypopnea index (AHI) in REM was ≥ 2 times that of non-REM. Common CMDs included coronary artery disease, stroke, heart failure, diabetes mellitus, and hypertension. RESULTS: The data of 518 patients with a mean age of 48.3 years, 198 males, and mean AHI of 9.8 events/h were analyzed in this study. When compared with the control group, the REM-OSA group (308 patients) were predominantly female (72%), overweight (62%), and had more severe oxygen desaturation, p-value < 0.001. CMDs were significantly more common in the REM-OSA group than in the controls [odds ratio (OR) 1.52, 95% confidence interval 1.04-2.21, p-value = 0.029]. Patients with a REM AHI of ≥ 20 events/h were significantly associated with hypertension compared to those with a REM AHI of < 20 events/h, p-value = 0.001. However, these associations were found not to be statistically significant after controlling for age, sex, BMI, and prevalent coexisting CMD (OR = 1.13, 95% CI: 0.72-1.76, p-value = 0.605). CONCLUSION: Common CMDs, particularly HT, tend to show an association with REM-OSA in patients with mild OSA, but this association did not reach statistically significant levels.

Prevalence and Risk Factors for Rapid Eye Movement-Related Obstructive Sleep Apnea in Children.

Objectives: Different pathophysiological mechanisms and the distribution of respiratory events among rapid eye movement (REM) and non-rapid eye movement (NREM) sleep modulate the effect of obstructive sleep apnea (OSA). We aimed to study the prevalence and risk factors for REM-related OSA in children. Study Design: Retrospective, cross-sectional study. Methods: We recruited 366 children with OSA confirmed by polysomnography (PSG) over a 5-year period. REM-related OSA is defined by an obstructive apnea-hypopnea index (OAHI) in the REM sleep ≥2× than during NREM sleep. Results: The prevalence of REM-related OSA in children was 50.3%. Children with REM-related OSA were more likely to be female (P = 0.042), and had lower prevalence of adenotonsillar hypertrophy (P = 0.043) compared with children with other OSA subtypes. Children with REM-related OSA slept longer in the supine position (P = 0.003), had shorter duration of NREM1 sleep (P = 0.018), lower nadir SpO2 (P = 0.005), and a higher oxygen desaturation index 3% (ODI3%) (P = 0.014), and lower arousal index (P = 0.034) compared with other OSA subtypes. Female gender and supine sleep was the independent risk factors for REM-related OSA. Conclusion: The prevalence of REM-related OSA was 50.3%. OAHIREM should be considered as an important parameter in future clinical research studies done in children with OSA.

Cognitive profiles and optimal cut-offs for routine cognitive tests in elderly individuals with Parkinson's disease, Parkinson's disease dementia, Alzheimer's disease, and normal cognition.

AIM: The cognitive impairment seen in Parkinson's disease (PD) results in patient disability and reduced quality of life. However, using cognitive screening scales specific to PD in routine clinical practice is difficult because of limited time, resources, and skills. We studied the ability of routine cognitive tests to differentiate between Parkinson's disease dementia (PDD) and PD and among the neuropsychological profiles of elderly individuals with PD, PDD, Alzheimer's disease (AD), and normal cognition. METHODS: This cross-sectional study involved 124 subjects. Subjects were 35 cognitively normal elderly and 37 elderly individuals with PD, 22 with PDD, and 30 with AD. All subjects were diagnosed by a specialist using standard criteria. Clinically relevant data and scores from the Montreal Cognitive Assessment and the Thai Mental State Examination were collected. Cognitive test scores were compared among groups. Receiver operating characteristic curves were constructed for a range of cut-off points to explore the sensitivity and specificity of the screening tools to detect PDD. RESULTS: There were 74 female subjects (59.7%), and the average age of all subjects was 75.6 years. The median score on the modified Hoehn and Yahr scale was 2.5 in subjects with PD and 4 in those with PDD (P < 0.001). The cut-offs for differentiating PDD from PD were 25 on the Thai Mental State Examination and 14 on the Montreal Cognitive Assessment. The sensitivity of the Thai Mental State Examination was 78.4%, and the specificity was 66.7% (area under the curve: 0.828). The sensitivity of the Montreal Cognitive Assessment was 81.1%, and the specificity was 75% (area under the curve: 0.876). There was a significant difference in the memory and language subdomains between AD and PDD (P < 0.05). CONCLUSIONS: The cut-offs used to differentiate PDD from PD were not the same as routine cut-offs in distinguishing AD from normal elderly. The cognitive profile deficit in PDD differed from that in AD. Interpretations of positive screenings test should take this finding into consideration.

Reliability and validity of a Thai version of the Berlin questionnaire in patients with sleep disordered breathing.

OBJECTIVE: To assess the validity and test-retest reliability of a Thai version of the Berlin Questionnaire in patients with sleep disorder breathing. MARTIAL AND METHOD: Patients who were suspected of sleep disordered breathing attending the outpatient department of Siriraj Hospital and who had undergone polysomnography were recruited and asked to complete a Thai version of the Berlin questionnaire. Each participant was asked to repeat the same questionnaire over the next 2-4 weeks for test-retest reliability. RESULTS: One hundred and thirty-two patients completed the present study. The age range of the patients was 26-72 years (mean, 48.15 ++/- .80 years). All 10 items of the Thai version of the Berlin questionnaire were moderately correlated in internal consistency (Cronbach's alpha correlation coefficient = 0.68). The test-retest reliability of the Thai version of the Berlin questionnaire was investigated in 98 patients and demonstrated a high degree of reliability in intra class correlation (ICC = 0.97). CONCLUSION: The present study reveals, for the first time, that the Thai version of the Berlin questionnaire has satisfactory validity and reliability when compared to the original English version.

Reliability and validity of the Thai version of the Pittsburgh Sleep Quality Index.

OBJECTIVE: To assess the internal consistency, test-retest reliability, and validity of the Thai version of the Pittsburgh Sleep Quality Index (Thai-PSQI), which was recently translated using a standardized method, in Thai patients with major sleep disorders. MATERIAL AND METHOD: The Thai-PSQI was developed under a standard translation protocol and administered to "bad" sleepers (i.e. patients with suspected obstructive sleep apnea [OSA], depression, or insomnia) and "good" sleepers in an academic tertiary care setting. All participants were asked to complete the same questionnaire after 2-4 weeks. RESULTS: A total of 138 participants consisting of 69 patients with OSA, 28 with major depression, 11 with primary insomnia, and 30 controls completed the questionnaire. The global scores of the Thai-PSQI revealed that it had excellent internal consistency (Cronbach's alpha = 0.837) and test-retest reliability (intraclass correlation coefficient = 0.89). An analysis of covariance demonstrated a significant difference in Thai-PSQI global score between good sleepers and bad sleepers (p < 0.001). A cut-off point of 5 out of 6 on the global score resulted in a sensitivity of 77.78% and specificity of 93.33%. CONCLUSION: The Thai-PSQI is a valid and reliable tool for screening and identifying the presence of significant sleep disturbances, and is comparable to the original English version.

Evaluation of sleep disorders in Parkinson's disease: a comparison between physician diagnosis and self-administered questionnaires.

OBJECTIVE: The objective of the present study was to compare a physician's diagnosis of sleep disorders in patients with Parkinson's disease (PD) during clinical evaluation of sleep disorders diagnosed by validated questionnaires. MATERIAL AND METHOD: Patients with PD at the Parkinson's clinic at Siriraj Hospital were included in this prospective cross-sectional study. Patients completed the Modified Parkinson's Disease Sleep Scale (MPDSS), Thai Epworth Sleepiness Scale (Thai-ESS), Scales for Outcomes in Parkinson's Disease-Sleep Scale questionnaire (SCOPA), Berlin questionnaire (Thai version), and Siriraj sleep questionnaire (SSQ). Thereafter, attending physicians diagnosed sleep disorders based on patient evaluation. RESULTS: One hundred twenty patients with PD participated in the present study. Among them, 73 (60.8%) were males, the mean age was 61.5 +/- 12.0 years, and the mean body mass index (BMI) was 22.7 +/- 3.5 kg/m2 (BMI > or = 30 kg/m2 in 1.7% of patients). The study demonstrated a prevalence of overall sleep disorders in 59.2% of patients based on physician diagnosis and 81.7% of patients based on the MPDSS questionnaire. The ESS was > 10 in 29.2% of the patients. High risk for obstructive sleep apnea was observed in 28.3% (Berlin) and 42% (MPDSS) of patients (15% by both). SSQ detected all sleep disorders in 86.7% of the population, and its results correlated with the MPDSS. CONCLUSION: Sleep disorders are common in patients with PD but remain underestimated because they are not routinely screened in clinical practice. This study demonstrates the use of validated questionnaires to efficiently detect and classify patients with PD at risk for common sleep disorders.

Home-based diagnosis of obstructive sleep apnea by polysomnography type 2: accuracy, reliability, and feasibility.

PURPOSE: Despite being used in large cohort studies, role of polysomnography (PSG) type 2 is still controversy. This study was aimed to determine its accuracy, reliability, and feasibility in diagnosis of obstructive sleep apnea (OSA) compared to gold standard. METHODS: Adult patients with stable medical conditions who complained of snoring or excessive sleepiness and lived around Bangkok were recruited from a sleep clinic. All were asked to fill questionnaires and have PSG done in laboratory (in-Lab PSG) and at home (Home PSG) on separate nights within 2-4 weeks interval. RESULTS: Eighty-six patients, 48 males and 38 females, were included. Mean of total sleep time, sleep efficiency, and stage R were significantly greater in Home PSG than in-Lab PSG (p<0.05). Apnea-hypopnea index (AHI) was slightly higher in Home PSG (25.7 versus 23.5, p=0.04), but with excellent reliability, intra-class correlation coefficients of 0.96 (95% CI; 0.93-0.97), and good agreements (κ=0.59-0.70) between both tests. The sensitivity, specificity, and accuracy of Home PSG at cut-off point of AHI≥5, were 0.97, 0.56, and 0.85, respectively, and at AHI≥15 were 0.95, 0.76, and 0.85, respectively. Sixty-four patients (74.4%) preferred home-PSG but four patients (4.7%) needed repeated tests due to significant data loss. CONCLUSIONS: This is the first report in Asia demonstrating that home-based diagnosis of OSA by PSG type 2 was feasible performing with good reliability, high accuracy, and a low failure rate. However, further studies focusing on its cost-effectiveness are required.

Functional recovery at 3 months in stroke patients not receiving thrombolytic therapy: the comparison between patients arriving earlier and later than 4.5 hours.

BACKGROUND: We aim to study the recovery of functional abilities of stroke patients who did not receive recombinant tissue plasminogen activator (rtPA) after treatment for 3 months comparing patients who arrived at a hospital within 4.5 hours and those who arrived after 4.5 hours of symptom onset. Also, we investigated the predictors of the functional recovery and the quality of life (QOL) at 3 months after stroke. MATERIAL AND METHOD: Data were collected by interviewing the stroke patients and caregivers twice on Day 1 and at 3 months after the stroke onset. We collected the demographic data, Modified Rankin Scale (mRS), Barthel Index, National Institutes of Health Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), and World Health Organization Quality of Life-Bref-Thai (WHOQOL-Bref-Thai). RESULTS: Eighty-eight and 85 patients arrived at a hospital within 4.5 and after 4.5 hours respectively. At 3 months after treatment, the recovery of stroke patients as assessed by mRS, Barthel Index, and the QOL in both groups did not differ significantly (P > .05). Approximately 80% in both groups had good QOL. Both groups of patients had a similar low stroke awareness and knowledge in terms of risk factors (P = .825) and care of stroke patients (P = .562). Four variables that significantly predicted the improvement of the mRS score at 3 months after treatment were age 60 years and younger, premorbid self-care ability, the NIHSS score of 14 or less and Day 1 mRS score. CONCLUSION: Stroke patients arriving at the hospital within and after 4.5 hours of the onset who did not receive the rtPA did not have significant differences in the functional outcomes and quality of life at 3 months. However, the eligibility for rtPA is not known before arriving at the hospital so that the necessity of seeking medical treatment as quickly as possible is still warranted. Increasing effective public awareness regarding stroke risk factors and care should be implemented.

Health-related quality of life in Thai patients with obstructive sleep disordered breathing.

OBJECTIVE: To assess the health-related quality of life (HRQOL) of Thai patients with obstructive sleep disordered breathing (OSDB) and their responses to continuous positive airway pressure (CPAP) treatment. MATERIAL AND METHOD: Thirty-eight healthy volunteers, 35 primary snorers (PS), and 108 patients with obstructive sleep apnea (OSA) diagnosed with polysomnography (PSG) were asked to fill questionnaires including Thai version of Short Form-36 (SF-36), and Epworth sleepiness scale (ESS). Thirty-two subjects with OSA who had been using CPAP adequately were asked to complete SF-36 twice, before and three months after treatment initiation. RESULTS: The role-physical and general health dimensions of SF-36 in OSA patients and PS were significantly lower than healthy volunteers (p < 0.05). Other dimensions were not significantly different among groups of subjects. Nonetheless, the scores in all dimensions of SF-36 in OSA patients were lower than those of general population of Thailand, except for mental health. There were only weak but significant correlations between physical function, role-physical, general health, vitality, and role-emotional dimensions and ESS scores (r = 0.17-0.29). Most of PSG parameters, particularly apnea-hypopnea index, did not correlate with SF-36 scores except for a weak correlation between mean oxygen saturation and role-physical, mental health, and vitality dimensions. However there was a significant improvement in all dimensions of SF-36 after three months of adequate CPAP therapy (p < 0.01). CONCLUSION: Thai patients with OSDB had poorer HRQOL compared to healthy subjects and general population at least in some dimensions, and an effective CPAP use can improve them. However there was almost no relationship between HRQOL and PSG findings.

Reliability and validity of migraine disability assessment questionnaire-Thai version (Thai-MIDAS).

OBJECTIVE: To assess the validity and test-retest reliability of a Thai translation of the Migraine Disability Assessment (MIDAS) Questionnaire in Thai patients with migraine. MATERIAL AND METHOD: Migraineurs from the Headache Clinic in Siriraj Hospital were recruited and asked to complete a 13-weeks diary and answered the Thai-MIDAS at once. Some participants were asked to provide the 2nd Thai-MIDAS in the next 2 weeks for test-retest reliability. RESULTS: Ninety-three patients had completed the 13-weeks diaries. Age range was 18-58 years with mean 37.69 +/- 9.60 years. All 5 items and the total score of Thai-MIDAS were moderately correlated with data from 13-weeks diary (Spearman's correlation coefficient = 0.32-0.62). The test-retest reliability of the total score of Thai-MIDAS in 30 patients demonstrated a highly reliable degree of intraclass correlation (ICC = 0.76, 95% CI 0.49-0.88). CONCLUSION: The present study reveals that the Thai-MIDAS has satisfactory validity and reliability in comparison with the original English MIDAS version.

Functional outcomes of sleep in Thai patients with obstructive sleep-disordered breathing.

PURPOSES: Quality of life assessment in obstructive sleep-disordered breathing (OSDB) is increasingly recognized, and the functional outcomes of sleep questionnaire (FOSQ) is a popular instrument. The objective of this study was to apply this questionnaire in Thai patients to assess its reliability, validity, and responsiveness properties. METHODS: A total of 223 subjects were recruited. The scores of FOSQ in 38 healthy volunteers and 40 primary snorers were compared with those of 108 obstructive sleep apnea (OSA) patients diagnosed by polysomnography. Seventy-two subjects answered the FOSQ twice at 2-4 weeks apart to check the test-retest reliability, and 37 patients with OSA who complied well with CPAP therapy answered them again after treatment at 3-6 months. All participants also filled the Epworth sleepiness scales (ESS) to check the concurrent validity. RESULTS: There were statistically significant differences in all FOSQ subscales including global scores between healthy volunteers (17.3 ± 2.1) and OSA patients (14.5 ± 2.9) (p < 0.001). The internal consistency of the questionnaire was excellent (Cronbach's alpha 0.95), and the test-retest reliability (intra-class correlation coefficients) was 0.70 in global scores. After adequate CPAP therapy, all FOSQ scores increased significantly (p < 0.001) There were significant correlations between all FOSQ scores except sexual relationship and ESS (r -0.48); however, these had only a weak relationship with AHI and minimal oxygen saturation. CONCLUSIONS: The FOSQ can be applied to Thai patients with OSDB with good reliability, validity, and responsiveness properties. It may be the first validated version of FOSQ in East Asian countries which is a very useful tool for future research.

MRI study of intracranial hydrodynamics and ventriculoperitoneal shunt responsiveness in patient with normal pressure hydrocephalus.

OBJECTIVE: To determine the predictor for shunt responsive cases in patient with normal pressure hydrocephalus (NPH) by means of magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow study at Siriraj hospital. MATERIAL AND METHOD: The retrospective study was performed in patients suspected NPH and underwent MRI CSF flow measurement. 2D-phase contrast technique (Achieva, 3 Tesla Philips system) was used as CSF flow analysis. The preoperative and postoperative clinical outcomes were collected and analyzed to determine predictive value of MRI CSF flow measurement in shunt responsive patients. RESULTS: Between 2006 and 2011, twenty NPH patients underwent MRI CSF flow study and were treated by ventriculoperitoneal shunt placement. Fourteen of 20 cases had improved, at least in gait score. Of these, 10 were defined as significant responsive group for overall improvement of outcome (sum of iNPHGS > or =3). The mean velocity of the CSF flow through the aqueduct of Sylvius was significant difference between shunt-responsive and non- responsive groups (p < 0.05). The peak velocity was a significant difference between gait responsive and non-responsive groups (p < 0.05). Using a mean velocity threshold 26 mm/sec to identify the significant responsive group, the sensitivity is 50%, specificity 83.3%, positive predictive value 87.5%, and accuracy 70%. In order to identify the gait responsive group by using a threshold of peak velocity 70 mm/sec, the sensitivity was 60%, specificity 83.3%, positive predictive value 81.5%, and accuracy 60%. CONCLUSION: Using available commercial software in the authors'institute, the mean velocity as well as the peak velocity was a specific value that predicted significant shunt responsiveness in NPH patients.

Progressive multifocal cerebral infarction from intravascular large B cell lymphoma presenting in a man: a case report.

INTRODUCTION: Intravascular lymphoma is rare, and may present as ischemic stroke. Diagnosis is difficult due to the non-specific presentation and lack of lymphadenopathy, thus leading to frequent instances of autopsy-proven diagnosis. To the best of our knowledge, this is the first report of progressive stroke from intravascular lymphoma diagnosed antemortem by random skin biopsy. CASE PRESENTATION: A 42-year-old Thai man presented to our hospital with progressive multifocal cerebral infarction. Despite taking aspirin (300 mg/day), his neurological symptoms worsened. During admission, he developed an unexplained fever and hypoxemia. Magnetic resonance angiography clearly showed patency of all cerebral arteries including the internal carotid and vertebrobasilar arteries. Echocardiography, an antiphospholipid antibody test, cerebrospinal fluid cytology and a bone marrow study were normal. Other laboratory test results showed an elevated lactate dehydrogenase level, nephrotic range proteinuria (3.91 g/day), hypoalbuminemia (1.9 g/dL), a very low high-density lipoprotein level (7 mg/dL) and hypertriglyceridemia (353 mg/dL). Because of suspected vasculitis, pulse methylprednisolone was given with transiently minimal improvement. A random skin biopsy from both thighs revealed intravascular large B cell lymphoma. Chemotherapy was not given due to our patient having ventilator associated pneumonia. He died 10 days after the definite diagnosis was established. CONCLUSION: One etiology of stroke is intravascular lymphoma, in which random skin biopsy can be helpful for antemortem diagnosis.

Risk of sleep-disordered breathing in Parkinson's disease.

OBJECTIVE: The objective of this study is to assess the risk of sleep-disordered breathing (SDB) in patients with Parkinson's disease (PD) in a cross-sectional survey of PD subjects and controls in a university-based movement disorders clinic. METHODS: One hundred thirty-four consecutive PD subjects and 94 control subjects without prior diagnosis of SDB were assessed. Participants were assessed with clinical history, Unified Parkinson's Disease Rating Scale, Geriatric Depression Scale, Berlin Questionnaire to classify SDB risk, Epworth Sleepiness Scale, Parkinson's Disease Sleep Scale, and SF-36 to examine quality of life. The presence of risk for SDB was assessed by the Berlin Questionnaire. RESULTS: High risk for SDB was apparent in 66 (49.3%) of the PD patients and 32 (34.8%) of the controls. After adjustment for age, gender, and body mass index (BMI), PD subjects in comparison to controls showed higher risk for SBD (odds ratio = 2.81; 95% confidence interval, 1.36-5.82). Quality of life (physical component score) was significantly diminished in PD patients at high risk for SDB. PD severity did not correlate well with SDB risk. PD patients at high risk for SDB had higher BMIs and Epworth scores. CONCLUSIONS: PD patients have features suggesting increased risk for SDB. This frequently undiagnosed sleep disorder may have a substantial impact on quality of life of PD patients.

Severe obesity is a risk factor for severe obstructive sleep apnea in obese children.

OBJECTIVE: To determine the association between degree of obesity and severity of OSA in Thai children MATERIAL AND METHOD: The present retrospective study recruited obese children aged 3 to 15 years who had habitual snoring and underwent polysomnography (PSG) between January 2009 and June 2010. Obesity was defined as percentage of ideal weight for height (%W/H) > or = 120 and was classified as mild (%W/H of 120-139), moderate (140-159), severe (160-199) and morbid (> or = 200). OSA was classified as severe (AHI > or = 10) and non-severe (AHI < 10). RESULTS: Of 73 obese children, the mean age was 9.92 +/- 3.42 years of which 60.3% were boys. The mean +/- SD of BMI was 28.38 +/- 5.99 kg/m2 and %W/H +/- SD was 162.63 +/- 26 26. Gender age, height, weight and BMI were not significantly different between severe and non-severe OSA groups. However, the %W/H of the severe OSA group (171.38% +/- 29.54%) was significantly greater than the non-severe group (157.19% +/- 22.68%) (p = 0.02). Severe to morbid obesity (OR 2.80, 95% CI 1.06-7.42; p = 0.038) and enlarged tonsils at least 3+ (OR 3.28, 95% CI 1.22-8.81; p = 0.018) were the risk factors for severe OSA. CONCLUSION: Severe to morbid obesity was a predicting factor for severe OSA. These results suggested that severely obese children with snoring should have early recognition for severe OSA, which is highly contributing to multiple sequalae.

Fatigue, tiredness, and lack of energy improve with treatment for OSA.

OBJECTIVES: Many patients with obstructive sleep apnea complain of fatigue, tiredness, or lack of energy in addition to sleepiness, or instead of sleepiness. We explored whether self-defined fatigue, tiredness, and lack of energy improve, like sleepiness, after treatment with positive airway pressure (PAP). METHODS: We conducted a prospective survey of adults referred to a University-based sleep disorders center and confirmed to have obstructive sleep apnea on polysomnography. Surveys were mailed to 1539 patients 6 months to 3 years after they were prescribed PAP for home use. RESULTS: Participants (n = 313) included 183 who reported using PAP > or = 5 hours per night, 96 who were considered inadequately treated because they had no active treatment or used PAP < 5 hours per night, and 34 treated by surgery or other means and therefore excluded from subsequent analysis. At follow-up in comparison to baseline, subjects adherent to PAP reported less fatigue, tiredness, lack of energy, and sleepiness (p < 0.05 for each). Improvement of each symptom except for lack of energy was significantly better (p < 0.05) among PAP-adherent subjects than among inadequately treated subjects. CONCLUSIONS: Patients' complaints of fatigue, tiredness, and lack of energy, like sleepiness, can improve substantially with good adherence to PAP for obstructive sleep apnea. Therefore, patients who prefer a range of common, related terms other than sleepiness to describe their problem may benefit from investigation and treatment for any underlying sleep-disordered breathing.

Iron stores, periodic leg movements, and sleepiness in obstructive sleep apnea.

STUDY OBJECTIVES: Most clinical sleep studies are performed for suspected obstructive sleep apnea (OSA), yet one-quarter to one-half show periodic leg movements (PLMs), for reasons that remain unknown. Several other disparate sleep disorders also increase the risk for PLMs. We examined the novel hypotheses that OSA as a representative sleep disorder could promote lower body iron stores, as reflected by serum ferritin levels, and, through downstream effects on dopaminergic transmission, increase PLMs and daytime sleepiness. METHODS: Subjects were recruited as they underwent laboratory-based polysomnography for suspected OSA. Serum ferritin levels were measured the next morning. Each subject completed an Epworth Sleepiness Scale and a brief questionnaire to assess for restless legs syndrome (RLS). RESULTS: The frequency of apneic events showed no association with serum ferritin levels, before or after adjustment for age, sex, body mass index, and likely RLS (each p value > 0.3). Serum ferritin levels did not predict the frequency of PLMs (p = 0.7) or Epworth scores (p = 0.8). Iron deficiency as a dichotomous variable, determined by ferritin levels less than < 50 microg/L or in combination with low transferrin saturation or mean corpuscular volume, showed similar results. In exploratory analyses, contrary to expectations, lower minimum oxygen saturation and increased sleep-stage shifts predicted increased rather than decreased ferritin levels (p = 0.03 and p = 0.02, respectively). CONCLUSIONS: Results of this study, powered to detect small to moderate effect sizes, strongly suggest that OSA does not cause lower serum ferritin levels, which, in turn, cannot explain PLMs or daytime sleepiness in these patients.