Periodic limb movements in sleep revealed by treatment of sleep apnea with continuous positive airway pressure in the advanced chronic kidney disease population.

The chronic kidney disease (CKD) population has a high incidence of sleep disorders, including sleep apnea (SA) and periodic limb movements in sleep (PLMS). SA and PLMS often occur concurrently and may predict mortality in the end stage renal disease (ESRD) population. In this study, we investigated whether sleep fragmentation secondary to SA masks the underlying frequency or severity of PLMS in 16 patients with CKD, dialysis and not-on-dialysis patients (CKD-ND), and if successful treatment of SA with continuous positive airway pressure (CPAP) results in the increased appearance of PLMS. All subjects had polysomnography (PSG) diagnosed SA. The mean apnea-hypopnea index (AHI) at baseline and with CPAP treatment was 49.8 ± 25.6/h and 5.2 ± 9.1/h, respectively. With successful treatment of SA with CPAP, PLMS index (PLMSI) increased 237.7% from baseline of 13.8 ± 23.8/h to 32.8 ± 33.7/h with CPAP treatment (p = 0.019). Arousing PLMS index (APLMSI) also increased 191.5% from mean baseline of 8.2 ± 18.2/h to 15.7 ± 18.5/h with CPAP treatment (p = 0.026). PLMS occur during uninterrupted NREM sleep. SA may mask the underlying incidence and severity of PLMS in CKD patients by disrupting NREM sleep. PLMS more than doubled during successful treatment of SA. Therefore, despite successful treatment of SA with CPAP, sleep deprivation may persist due to clinical manifestation of underlying PLMS in patients with CKD. The actual underlying prevalence and severity of CKD-associated PLMS are likely higher than appreciated and are suppressed by SA in the CKD population.

Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city.

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.

Group psychotherapy for adolescents comorbid for substance abuse and psychiatric problems: a relational constructionist approach.

The group psychotherapy of adolescents comorbid for psychiatric and substance abuse problems is fraught with inconsistent attendance, frequent verbal and physical disruptions by the adolescents, and intense countertransference toward patients and their parents on the part of treating staff. A relational constructionist approach assists staff and patients in overcoming these obstacles and in focusing on the adolescents' search for personal meaning. Multiple group psychotherapy conducted in a combined day treatment and high school program is described and illustrated by case examples during the course of a year of treatment. These examples illustrate the importance of a relational non-hierarchical approach to adolescent patients by treating staff.

Potential novel predictors of mortality in end-stage renal disease patients with sleep disorders.

Patients with end-stage renal disease (ESRD) have an annual mortality rate exceeding 20%, although some survive many years. The ESRD population has a high incidence of sleep disorders, including sleep apnea and periodic limb movements in sleep (PLMS). Sleep disorders result in sleep deprivation, which can negatively affect immune function and cardiovascular-related outcomes, common causes of death in patients with ESRD. This study examined predictors of mortality in patients with ESRD with sleep problems. Twenty-nine consecutive patients with ESRD reporting disrupted sleep or daytime sleepiness were studied by all-night polysomnography. All patients were followed up until death, transplantation, or study termination. Among the variables studied, including such previously reported predictors as serum albumin level, urea reduction ratio, and hematocrit, only the PLMS index (PLMSI), arousing PLMSI (APLMSI), and total number of arousals per hour of sleep significantly predicted mortality. The 20-month survival rate with a PLMSI less than 20 was greater than 90% versus 50% for a PLMSI of 20 or greater (exact log-rank, P = 0.007). For the deceased versus survivor groups, mean PLMSI was 119.1 versus 19.8 (P = 0.01) and APLMSI was 48.1 versus 7.8 (P = 0.00006), with a mean survival of 10.3 versus greater than 25.5 months, respectively (P = 0.001). Median survival of patients with a PLMSI greater than 80 was only 6 months. PLMSI, APLMSI, and total arousals per hour of sleep were strongly associated with mortality in patients with ESRD with sleep disorders independent of other factors and may be novel predictors of near-term mortality.

A preliminary study of the effects of correction of anemia with recombinant human erythropoietin therapy on sleep, sleep disorders, and daytime sleepiness in hemodialysis patients (The SLEEPO study).

End-stage renal disease (ESRD) is commonly associated with complaints of disturbed sleep and sleep disorders, frequently related to periodic limb movements in sleep (PLMS) or sleep apnea that may result in daytime sleepiness and other sequelae. Improvements in quality of life, including subjective sleep quality, have been reported in ESRD patients treated with recombinant human erythropoietin (rHuEPO). We investigated the objective effects of normalizing hematocrit on sleep disorders, sleep patterns, and daytime ability to remain awake in ESRD patients. Ten hemodialysis patients with sleep complaints while on rHuEPO therapy were studied by polysomnography while moderately anemic (mean hematocrit, 32.3%) and again when hematocrit was normalized (mean hematocrit, 42.3%) by increased rHuEPO dosing. Sleep patterns and associated parameters were monitored. Delivered dialysis dose and iron storage factors were monitored. Maintenance of Wakefulness Testing (MWT) was performed to assess daytime alertness/sleepiness. All 10 subjects experienced highly statistically significant reductions in the total number of arousing PLMS (P = 0.002). Nine of 10 subjects showed reductions in both the Arousing PLMS Index (P < 0.01) and the PLMS Index (P = 0.03) when hematocrit was normalized. Measures of sleep quality showed trends to improved quality of sleep. MWT demonstrated significant improvement in the length of time patients were able to remain awake (9.7 versus 17.1 minutes; P = 0.04). RHuEPO therapy with full correction of anemia reduces PLMS, arousals from sleep, and sleep fragmentation while allowing for more restorative sleep and improved daytime alertness. These findings may explain one mechanism for the improved quality-of-life parameters reported in ESRD patients treated with rHuEPO.

A multiple group psychotherapy approach to adolescents with psychiatric and substance abuse comorbidity.

Multiple group psychotherapy was employed as the primary treatment modality in a day-treatment program as an innovative multifaceted approach to treating adolescents comorbid for psychiatric and substance abuse diagnoses. The concurrent educational program included a high school on site. The groups included Substance Abuse Group, which promoted the 12-step model; Health Group; Psychotherapy Group; Leisure Time Group; Self-Awareness Group; and Multiple Family Group. The effect of the multiple groups was to provide a variety of experiences focusing on varied aspects of normal and dysfunctional adolescent development. Together the combination of groups served to strengthen the participants' cohesiveness, communicating skills, and hopefulness.

Orbital herniation associated with noninvasive positive pressure ventilation.

A diagnosis of severe obstructive sleep apnea was made after a 52-year-old hypertensive man developed a large intracranial hemorrhage. Therapeutic noninvasive positive pressure ventilation (NPPV) for obstructive sleep apnea and hypoventilation was complicated by transient unilateral orbital herniation. As best as can be determined, this represents a new, potentially deleterious side effect of NPPV.

Air leaking through the mouth during nocturnal nasal ventilation: effect on sleep quality.

Air leaking through the mouth has been reported in kyphoscoliotic patients receiving nasal ventilation via volume-limited ventilators. This study accessed the frequency of occurrence and effect on sleep quality of air leaking through the mouth during nocturnal nasal ventilation in patients with chest wall and neuromuscular disease using pressure-limited ventilation. Overnight and daytime polysomnography was performed in six stable experienced users of nocturnal nasal noninvasive positive-pressure ventilation (NPPV) who had chronic respiratory failure due to neuromuscular disease or chest wall deformity. All patients used the BiPAP S/T-D ventilatory support system (Respironics, Inc., Murrysville, PA). Measures included sleep scoring, leak quantitation, diaphragm and submental electromyograms (EMGs), and tidal and leak volumes. All patients had air leaking through the mouth for the majority of sleep. Sleep quality was diminished because of poor sleep efficiency and reduced percentages of slow-wave and rapid eye movement (REM) sleep. Air leaking through the mouth was associated with frequent arousals during stages 1 and 2 and REM sleep that contributed to sleep fragmentation, but arousals were infrequent during slow-wave sleep. Despite prevalent leaking, oxygenation was well maintained in all but one patient. Patients used a-combination of passive and active mechanisms to control air leaking. Although nasal ventilation improves nocturnal hypoventilation and symptoms in patients with restrictive thoracic disorders, air leaking through the mouth is very common during use. The leaking is associated with frequent arousals during lighter stages of sleep that interfere with progression to deeper stages, compromising sleep quality. Portable pressure-limited ventilators compensate for leaks, maintaining ventilation and oxygenation, but further studies are needed to determine which interfaces and ventilator techniques best control air leaking and optimize sleep quality.

Spindle cell hemangioendothelioma: a case presentation and literature review of a rare lower extremity tumor.

The authors present a rare soft tissue mass of the lower extremity that has been presented in the podiatric literature only once. Spindle cell hemangioendothelioma was first identified 9 years ago, and approximately 45 cases have been documented in the literature. This lesion presents as a slow growing and often painless lesion of the extremities, with low malignant potential and high local recurrence. This patient was treated with surgical excision after a mass, which had been present for more than 10 years, began enlarging and became painful. A review of the literature and the case presentation will be given.

Nocturia. A rarely recognized symptom of sleep apnea and other occult sleep disorders.

BACKGROUND: Nocturia, awakening from sleep to urinate, is a common symptom in a variety of medical disorders and in the elderly. Awakening from sleep as a result of nocturia is thought to be secondary to a sensation of urinary urgency resulting from an overextended bladder. Nocturia-related awakenings cause significant sleep disruption and fatigue in elderly patients and are correlated with an increased number of falls at night. Sleep disorders such as sleep apnea are also common in the elderly and are frequently the source of awakenings from sleep. The high incidence of both nocturia and sleep disorders in the elderly and other groups of patients suggests that sleep disorders may be the source of some awakenings from sleep usually attributed by patients to nocturia. Nocturia secondary to sleep disorders would be causatively different from nocturia secondary to pressure to urinate in common medical disorders and would require different diagnostic procedures and treatment. OBJECTIVE: To determine the frequency of nocturia as a symptom of primary sleep disorders. METHODS: Eighty consecutive patients, 27 women and 53 men with a mean (+/-SD) age of 58.7+/-14.1 years, undergoing polysomnography (sleep study or PSG) for the evaluation of a suspected sleep disorder and who met the sole criteria of awakening from sleep at least once and urinating voluntarily. Each patient had either a standard PSG recording or a PSG with administration of nasal continuous positive airway pressure. Immediately after each episode of nocturia during the PSG, patients were questioned about the reason they believed they had awakened. The PSG record immediately before awakening from sleep was then reviewed for potential causes of awakening. Patients were also asked on final morning awakening to fill in a questionnaire regarding their awakenings during the prior night. Patient reports were compared with the PSG to determine the accuracy of subjective reports. RESULTS: Patients awakened from sleep and voluntarily urinated a mean (+/- of 1.5+/-0.75 times per night for a total of 121 awakenings for the group. The majority (79.3%) of these awakenings from sleep were found to be directly secondary to sleep apnea, snoring or periodic leg movements in sleep. Patients correctly identified the source of their awakening from sleep on only five(4.9%) occasions and only once was sleep apnea correctly cited by a patient as a source of awakening during the night. CONCLUSION: Most awakenings from sleep attributed by our patients to pressure to urinate were instead a result of sleep disorders, particularly sleep apnea. The fact that patients do urinate once awake likely contributed to faulty post hoc reasoning and might have limited further inquiry by patients and their physicians in clinical settings into the actual sources of awakening from sleep. Even in those patients with well-known medical reasons for noctruria, Sleep disorders were still found to be the source of almost all awakenings from sleep. Patients were extremely poor judges of the reasons they awoke from sleep. The diagnosis of a sleep disorder should be seriously considered whenever a patient reports frequent awakenings from sleep to urinate.

Transient ischemic attacks and minor stroke during sleep. Relationship to obstructive sleep apnea syndrome.

BACKGROUND: It is reported that 13% to 44% of all cerebrovascular accidents (CVAs) occur during sleep. In addition to other well-known risk factors, snoring, sleep apnea, obesity, and daytime sleepiness have been shown to significantly increase the risk of stroke. We describe two cases that support the statistical relationship between snoring, sleep apnea, and CVA during sleep. CASE DESCRIPTIONS: In the first case, motor aphasia was noted in a 64-year-old, 5-ft, 1-in, 218-lb woman when she awakened from sleep at approximately 4 AM. This completely resolved within 3 hours. During her subsequent hospitalization she was found to have severe obstructive sleep apnea that responded well to treatment with nasal continuous positive airway pressure. There has been no recurrence of symptoms in this patient. The second patient was a 59-year-old, 5-ft, 6-in, 260-lb woman who presented to the Sleep Disorders Center with signs and symptoms of severe sleep apnea. In addition, she had awakened from sleep approximately 6 months earlier with numbness and weakness on her right side. Although these symptoms had greatly improved, she continued to complain about residual weakness that was worse on awakening from sleep. Sleep studies confirmed severe obstructive sleep apnea that responded very well to treatment with nasal continuous positive airway pressure. CONCLUSIONS: Snoring and obstructive sleep apnea not only increase the statistical risk of CVA but could be the proximal trigger that precipitates these events during sleep. These two cases provide clinical support for this relationship. Successful diagnosis and treatment of obstructive sleep apnea in the patient with transient ischemic attacks and minor stroke may be an important tool for preventing recurrence.

Night terrors in an adult precipitated by sleep apnea.

Parasomnias are generally described as disorders of arousal that arise out of stage 3 and 4 nonrapid eye movement (NREM) sleep without identifiable cause. We present a case of a 35-year-old man who during nasal continuous positive airway pressure (nCPAP) treatment for severe obstructive sleep apnea experienced an intense night terror triggered by a residual obstructive apnea during rebound deep sleep. The role of rebound deep sleep was thought to be essential in creating a state of sleep with a high arousal threshold hypothesized to be important for the occurrence of parasomnias. This case supports the clinical wisdom that identifiable sources of arousal can trigger parasomnias.

Ramp abuse. A novel form of patient noncompliance to administration of nasal continuous positive airway pressure for treatment of obstructive sleep apnea.

Administration of nasal continuous positive airway pressure (NCPAP) is the treatment of choice for most patients with obstructive sleep apnea. Many patients experience side effects with NCPAP use, and the compliance rate is reported to vary between 46-89%. The ramp is a device found on many NCPAP machines that resets the pressure to 3 cm H2O and then slowly increases the pressure to the prescribed pressure over a period of up to 45 min. The ramp allows patients time to fall asleep before the higher and likely more uncomfortable prescribed pressure is administered. We present a case in which a patient's repeated remote-controlled activation of this ramping feature severely limited effective therapy even when the NCPAP mask was properly in place, the machine was on, and the patient was breathing nasally.

Portable recording in the assessment of obstructive sleep apnea. ASDA standards of practice.

The objective assessment of patients with a presumptive diagnosis of obstructive sleep apnea (OSA) has primarily used attended polysomnographic study. Recent technologic advances and issues of availability, convenience and cost have led to a rapid increase in the use of portable recording devices. However, limited scientific information has been published regarding the evaluation of the efficacy, accuracy, validity, utility, cost effectiveness and limitations of this portable equipment. Attaining a clear assessment of the role of portable devices is complicated by the multiplicity of recording systems and the variability of clinical settings in which they have been analyzed. This paper reviews the current knowledge base regarding portable recording in the assessment of OSA, including technical considerations, validation studies, potential advantages and disadvantages, issues of safety, current clinical usage and areas most in need of further study.

Sleep disordered breathing in ESRD: acute beneficial effects of treatment with nasal continuous positive airway pressure.

Complaints about sleep and daytime alertness are common in ESRD patients. Eight consecutive ESRD patients with a sleep complaint were studied with all-night polysomnography. All were found to have significant sleep apnea with a mean apnea/hypopnea index (AHI) of 64 +/- 41.6 episodes per hour of sleep (range 7.5 to 140/hr of sleep). The majority of apneas were of the central or mixed variety causing severe fragmentation of sleep and frequent awakenings. Treatment was attempted with nasal continuous positive airway pressure (NCPAP). NCPAP was highly successful in six of the eight patients, reducing the mean AHI to normal or near normal levels (6.0 +/- 3.8/hr of sleep, P < 0.02 vs. baseline). The quality of sleep was significantly improved with statistically significant decreases in light stage 1 sleep, and nocturnal oxygenation improved with statistically significant increases in low SaO2 values. Five of six responders reported that they awoke feeling more alert and fewer times from sleep. The etiology of sleep apnea in ESRD is unknown although the frequent central apneas suggest a dysfunction of central respiratory control resulting from the effects of renal failure. Sleep-related complaints in patients with ESRD are likely to result from sleep apnea, a sleep disorder that can be diagnosed with polysomnography and treated with NCPAP.

Avoiding false positive findings in measuring nocturnal penile tumescence.

The measurement and interpretation of nocturnal penile tumescence (NPT) studies depend on appropriate measurement techniques, knowledge of the conditions during which NPT was recorded, and a lack of preconceived notions about the relationship of penile circumference to penile rigidity. This case report illustrates several of the most common problems in the measurement and interpretation of NPT that could result in a false positive finding.

Periodic leg movements in sleep following treatment of obstructive sleep apnea with nasal continuous positive airway pressure.

Periodic leg movements in sleep are shown to be a common finding in patients with OSA and may become evident or increase in severity after treatment of the OSA with NCPAP. Periodic leg movements in sleep were measured during baseline polysomnography, a NCPAP treatment trial, and a repeat NCPAP recording in 33 patients treated with NCPAP for OSA. During baseline PSG, nine patients had five or more PLMS per hour of sleep (index), while 14 patients had a PLMSI of 5 or more during the NCPAP trial and the repeat NCPAP recording. Among those patients with a PLMSI of 5 or more during repeat NCPAP studies, the PLMSI showed a significant increase from baseline to initial NCPAP (16.9 +/- 25.3 vs 39.3 +/- 29.4; p less than 0.001) and from baseline to repeat NCPAP (16.9 +/- 25.3 vs 42.9 +/- 39.8; p less than 0.05). The number of PLMS associated with electroencephalographic arousal also increased significantly from baseline to initial NCPAP (4.3 +/- 7.4 vs 9.7 +/- 8.9; p less than 0.05) and from baseline to repeat NCPAP (4.3 +/- 7.4 vs 16.5 +/- 18.6; p less than 0.05). The 14 patients with a PLMSI of 5 or more on the repeat NCPAP had significantly more stage 1 sleep and less REM sleep than 19 patients with a PLMSI of less than 5. Bilateral anterior tibialis EMG must be measured during NCPAP recordings in order to recognize sleep disruption caused by PLMS.