[Diagnostic criteria for obstructive sleep apnea syndrome in adolescent]. / Critères diagnostiques des troubles respiratoires obstructifs du sommeil de l'adolescent.

The obstructive sleep apnoea syndrome (OSAS) affects 1-4% of adolescents. It represents a transitional stage between paediatric and adult OSA and is characterized by specific symptoms. BACKGROUND: The persistence of childhood OSAS during adolescence is not frequent. Risk factors are male sex, obesity and a history of tonsillectomy or adenoidectomy. Symptoms may be misleading such as tiredness and depressive disorders. In adolescence, untreated OSAS may result in neuro-behavioural and cognitive deficits, systemic inflammation, cardiovascular and metabolic disorders. The French Society of Research and Sleep Medicine organized a meeting on OSAS in adolescents. A multidisciplinary group of specialists (pulmonologists, pediatricians, ENT and maxillo-facial surgeons, dentofacial orthopedists/orthodontists, myofunctional therapists and sleep specialists) exchanged their experience, discussed publications and drew up a consensus document on the diagnosis and polysomnographic criteria for OSAS in adolescents. They proposed a practical diagnostic guideline and follow-up for these adolescents. OUTLOOK AND CONCLUSION: A good knowledge of the particularities of this pathology by the physician will lead to an early diagnosis, propose adapted multifactorial treatments and avoid the deleterious consequences of this pathology at adult age.

Melatonin (MEL) and its use in circadian rhythm sleep-wake disorders: Recommendations of the French Medical and Research Sleep Society (SFRMS).

The French society of medical research on sleep (SFRMS) appointed a group of experts to conduct a consensus conference in order to study the indications and prescription status of exogenous melatonin (MEL). Eleven sleep physicians/researchers investigated in subgroups the use of MEL in different domains of healthcare in line with their subspecialties (circadian sleep/wake rhythm disorders, psychiatric disorders, neurological disorders, pediatric and neurodevelopmental disorders). In this article we present a summary of the main conclusions of the expert group on MEL therapy in circadian sleep/wake rhythm disorders such us delayed sleep-wake disorder, non-24-hour sleep wake rhythm disorder and jet lag.

Melatonin (MEL) and its use in neurological diseases and insomnia: Recommendations of the French Medical and Research Sleep Society (SFRMS).

The French Medicine and Research Sleep Society had organized a consensus conference about sleep/wake circadian rhythms and their disorders. During this conference a subgroup of 11 sleep doctors/researchers looked specifically at the use of MEL in different pathologies. This article gives a summary of the main results of MEL therapy in some neurological diseases and insomnia approved by this consensus group. Exogenous MEL, which crosses the blood-brain barrier, has been used as a treatment in its two available forms: an immediate release form that principally shows a chronobiotic action and a long release form that mimics the physiological MEL secretion rhythm and is used to replace reduced physiological secretion. MEL secretion decreases frequently with age, mostly in elderly insomniacs and dementia patients. Results of level A studies show that MEL therapy, used as an add-on treatment, has beneficial effects in mild cognitive impairment (MCI) and Alzheimer patients with sleep disorders in improving sleep quality and in regulating the sleep/wake rhythm. MEL has to be prescribed as early as possible and for a long period, at a dose of 2 to 5 or 10 mg. It may have a beneficial effect on cognitive function in MCI but shows no effect in moderate to severe Alzheimer's disease. It should be emphasized that there are no serious side effects with MEL treatment. In these diseases, light therapy used 12 hours before melatonin treatment has a positive synergic effect. In REM sleep behavior disorder, immediate release MEL should be prescribed first as its side effect profile is much better than clonazepam shortly before bedtime. MEL has a good efficacy on clinical symptoms and PSG REM sleep without atonia episodes and is well tolerated. In Parkinson disease with sleep disorders and without REM sleep behavior disorder, MEL seems to improve subjective sleep quality but no conclusions can be drawn. There is insufficient scientific proof for using MEL as a prophylactic treatment in primary headache, migraine and cluster headache. In epileptic patients, MEL can be safely used to regulate the sleep/wake rhythm and to improve insomnia but more randomized controlled studies are necessary. In primary or no-comorbid insomnia, only a 2 mg dose of slow release MEL, 1 to 2 hours before bedtime, over a period of 3 to 12 weeks, is recommended. It decreases sleep onset latency, improves quality of sleep, morning alertness and quality of life without serious side effects and without withdrawal symptoms.

[Adolescent obstructive sleep apnoea syndrome: Characteristics and treatment]. / Syndrome d'apnées obstructives du sommeil de l'adolescent : particularités et prise en charge.

Although the prevalence of the obstructive sleep apnoea syndrome (OSAS) is high in adolescents, studies pertaining to adolescent OSAS are less numerous than childhood studies. Cases of adolescent OSAS may consist of residual OSAS after adenotonsillectomy, but most often are de novo cases. Major pathophysiological factors are weight excess or even high-grade obesity, and the association of upper airway narrowing and tonsillar hypertrophy (pharyngeal, palatal or even lingual). ENT and systematic orthodontic assessments are the main points. In case of predisposing factors such as dental, occlusal or dento-facial abnormalities, a specific orthodontic treatment can be discussed. First line treatment is surgical adenotonsillectomy; surgical reduction of the lingual tonsils is seldom required. CPAP treatment may be indicated in the case of severe comorbidities (craniofacial malformations, neuromuscular diseases…) or in obese adolescents with severe residual OSAS. Treatment of adolescent OSAS has to be comprehensive and multidisciplinary, taking into account the specific treatments of obesity and abnormal sleep/wake rhythms.

French Consensus: How to diagnose restless legs syndrome.

Correct diagnosis of restless legs syndrome (RLS) is essential to patient care and treatment. Diagnosis is most often clinical and based on diagnostic criteria: the need to move the legs accompanied to varying degrees by unpleasant sensations, predominantly during the evening and improved by movement. In rare cases, clinical examination is insufficient and a polysomnography is necessary. Once a positive diagnosis has been made, a neurological examination and an assessment of iron status are required. The severity of the RLS must be evaluated to determine whether a specific treatment is necessary. Before treatment, it is essential to ensure that a definite diagnosis of RLS has been made and the phenotype characterised. This enables a personal treatment plan and limits the risk of augmentation syndrome.

[Obstructive sleep apnea-hypopnea syndrome in children: Clinical diagnosis]. / Diagnostic clinique du syndrome d'apnées obstructives du sommeil de l'enfant.

The French Society of Research and Sleep Medicine (SFRMS) organized a meeting on obstructive sleep apnea syndrome (OSAS) in children. A multidisciplinary group of specialists (pulmonologist, ENT surgeons, pediatricians, orofacial myofunctional therapists, neurophysiologists, and sleep specialists) reached a consensus on the value of isolated or clustered clinical symptoms and of questionnaires completed by parents in the clinical diagnosis and in assessing the severity of OSAS. Are clinical history with validated questionnaires and a rigorous physical examination sufficient to suspect OSAS, to appreciate its severity, and finally to confirm the diagnosis? Usually, a sleep recording of respiratory parameters remains mandatory for the diagnosis of OSAS to be made. However, clinical symptoms are very useful for estimating the probability of the diagnosis and the severity of the disease, and therefore for classifying which children will benefit form polysomnography and for proposing an adapted follow-up after OSAS therapy. Even if they are not able to ascertain the diagnosis of OSAS in children, clinical history, questionnaires, and physical examination are very important. Finally, we propose a classification of the indications for polysomnography in children suspected of having OSAS.

[Sleep: regulation and phenomenology]. / Le sommeil : régulation et phénoménologie.

This article describes the two-process model of sleep regulation. The 24-hour sleep-wake cycle is regulated by a homeostatic process and an endogenous, 2 oscillators, circadian process, under the influence of external synchronisers. These two processes are partially independent but influence each other, as shown in the two-sleep-process auto-regulation model. A reciprocal inhibition model of two interconnected neuronal groups, "SP on" and "SP off", explains the regular recurrence of paradoxical sleep. Sleep studies have primarily depended on observation of the subject and have determined the optimal conditions for sleep (position, external conditions, sleep duration and need) and have studied the consequences of sleep deprivation or modifications of sleep schedules. Then, electrophysiological recordings permitted the classification of sleep stages according to the observed EEG patterns. The course of a night's sleep is reported on a "hypnogram". The adult subject falls asleep in non-REM sleep (N1), then sleep deepens progressively to stages N2 and N3 with the appearance of spindles and slow waves (N2). Slow waves become more numerous in stage N3. Every 90minutes REM sleep recurs, with muscle atonia and rapid eye movements. These adult sleep patterns develop progressively during the 2 first years of life as total sleep duration decreases, with the reduction of diurnal sleep and of REM sleep. Around 2 to 4 months, spindles and K complexes appear on the EEG, with the differentiation of light and deep sleep with, however, a predominance of slow wave sleep.

[Role and actions of the orphan rare diseases reference center for central hypersomnias in France]. / Quel apport des centres de référence maladies rares dans la prise en charge des hypersomnies rares?

Narcolepsy (with or without cataplexy), idiopathic hypersomnia (with or without long sleep duration) and Kleine - Levin syndrome are the main central rare hypersomnias. They may be considered models to help us to better understand the mechanisms controlling sleep and waking regulation in humans. When creating the national centers for rare hypersomnias, the aims were: 1) screening and earlier treatment of patients with hypersomnia; 2) improving patient care with guidelines, a specific patient's card, coordination of treatments between centers and professionals, and the development of new treatments; 3) encouraging research studies into the epidemiology, pathophysiology and genotype/phenotype through the creation of clinical, DNA, sera and cerebrospinal fluid banks; 4) increasing public awareness among patients and their relatives, the general public and in the mass media of rare hypersomnias; and 5) regular evaluation of our activities. These goals appear to have been achieved over the past 5 years. However, there are now financial difficulties to be faced, given the increasing demands of patients and professionals while having to stay within the same limited budgets.

A case of obstructive sleep apnea syndrome: unusual comorbidity.

INTRODUCTION: Launois-Bensaude syndrome (LBS) is a rare disease, characterized by the accumulation of fatty tissue predominantly in the neck, shoulders and thorax, whose diagnostic is clinical. OBJECTIVES: We describe a new case in a 73 year-old man. As the patient was obese, complained of snoring and was treated for hypertension, we looked for a morbid association with an obstructive sleep apnea syndrome (OSAS). METHODS: A polysomnography (PSG) and a cervical magnetic resonance imaging (MRI) were performed. RESULTS: PSG demonstrated OSAS with an apnea-hypopnea index of 43/h. Cervical MRI showed fatty infiltration resulting in airway narrowing at the pharyngeal but not at the tracheal level. Only, 3 cases of such a morbid association have already been published; in 2 of these patients was a tracheal compression. More over a metabolic syndrome was present. CONCLUSIONS: This observation draws attention to the need for seeking OSAS among patients affected by LBS, even in a moderate form, and emphasises the roles of the upper airway narrowing by the fat infiltration as well as the role of the metabolic syndrome in the genesis of OSAS.

Efficacy and compliance of mandibular repositioning device in obstructive sleep apnea syndrome under a patient-driven protocol of care.

OBJECTIVE: To assess the efficacy and compliance of a traction-based mandibular repositioning device (MRD) for treatment of moderate to severe obstructive sleep apnea syndrome (OSAS) under a patient-driven protocol in a routine outpatient care setting. METHODS: Forty patients, 10 severe and 30 moderate OSAS sufferers (apnea-hypopnea index [AHI] >30 and between 15 and 30, respectively), were enrolled by four sleep centers. Nocturnal polygraphy, quality of life, and quality of sleep questionnaires were used to measure the effect of treatment after 45 days. RESULTS: Thirty-five patients completed the study. Frequency of respiratory events, daytime sleepiness, snoring, patient assessment of sleep quality, specific short-form multipurpose health survey (SF-36) and the Pittsburgh Sleep Quality Index (PSQI) improved significantly with the MRD. Sixty percent of patients were "responders" (>50% decrease in AHI); 46% of patients were "full responders" (>50% decrease and AHI <10). Observance of treatment was high; 80% of patients wore the MRD every night. Side effects and patient complaints were minor and transitory. No serious side effects or cases of pathology aggravation were reported. CONCLUSION: Efficacy on respiratory and somnolence parameters of this innovative traction-based MRD was validated under a simple protocol of care with response rates similar to those published in the literature. This study shows consistent significant improvement by the MRD in quality of life and quality of sleep parameters across several tests. Treatment with the MRD under a simple, patient-driven protocol of care with control of efficacy by nocturnal polygraphy is appropriate in routine outpatient practice for moderate OSAS patients.

Electroencephalography (EEG) recording techniques and artefact detection in early premature babies.

Electroencephalography (EEG) recording techniques in early premature babies are not very different from those used for full-term neonates. Here, we emphasise the most important points: asepsis precautions, full knowledge of the clinical data and drug therapies, fundamental role of a well-trained technician in supervising the EEG recording and monitoring the baby. We discuss the best electrode positions, the most informative montages, and their standardisation between neurophysiological laboratories. Artefact detection constitutes an important aspect of EEG signal analysis in preterm babies of less than 30 weeks. It is obviously necessary to discriminate between meaningful information and artefacts. The complexity of the signal in neonates makes artefact detection difficult. We present some characteristic features and describe some methods for eliminating them. We underline the positive aspect of some artefacts and their clinical use. We emphasise the crucial role of the technicians.

Normal EEG of premature infants born between 24 and 30 weeks gestational age: terminology, definitions and maturation aspects.

This article presents normal EEG characteristics and their maturational pattern in premature infants of 24-30 weeks gestational age. Although the very premature infants with a normal outcome are not that numerous, their normal EEG pattern should be known, as EEG constitutes a basis for neurological prognosis. Background activity is first discontinuous but the discontinuity gradually decreases and the activity is completely continuous at 30 weeks of age, during active sleep. At the same time, interburst intervals become shorter so that the proportion of time without EEG activity decreases. Based on EEG activity and eyes movements, a rough sleep state differentiation appears as early as 25 weeks of gestational age and is complete at 30 weeks. The main EEG figures are high-voltage delta waves, whose frequency is slower and amplitude higher in younger infants. Temporal delta waves occur in sequences and are characteristic of the very premature infant; they progressively become smaller and less numerous and disappear around 27-28 weeks. In contrast, occipital delta waves remain numerous; they are of high voltage and usually bilaterally superimposed with fast rhythms. Both types of frontal delta waves that are seen in 24-27 weeks premature babies disappear with maturation. Bursts of synchronized delta waves, which are less numerous than localized delta waves, also disappear before 28 weeks of gestational age. Finally, diffuse theta bursts which are mainly recorded at 26-27 weeks, progressively focus on temporal areas with maturation. At 30 weeks, they are observed on temporal areas, mainly during slow-wave sleep.

[Electroencephalography (EEG) recording techniques and artifact detection in early premature babies]. / Technique d'enregistrement et identification d'artefacts chez le grand prématuré

EEG recording techniques in early premature babies are not very different from those used for full-term neonates. Here, we emphasise the most important points: asepsis precautions, full knowledge of the clinical data and drug therapies, the fundamental role of a well-trained technician in supervising the EEG recording and monitoring the baby. The best electrode positions, the most informative montages and their standardisation between neurophysiological laboratories, are suggested. Artifact detection constitutes an important aspect of EEG signal analysis in preterm babies of less than 30 weeks. It is obviously necessary to discriminate between meaningful information and artefacts. The complexity of the signal in neonates makes artifact detection difficult. We present some characteristic features and describe some methods for eliminating them. We underline the positive aspect of some artifacts and their clinical use. We emphasise the crucial role of the technicians.

[EEG of the very premature infant born at 24 to 30 weeks gestational age. Definitions and normal area]. / EEG normal du grand prématuré de 24 à 30 semaines d'âge gestationnel. Définitions et maturation.

This article aims at summarizing normal EEG criteria and their maturational pattern in premature infants of 24 to 30 weeks gestational age. Although very premature infants with a normal outcome are not numerous, their normal EEG patterns must be known, as EEG constitutes a basis for neurological prognosis. Background activity is first discontinuous. Discontinuity decreases thereafter with increasing age, so that some long periods of continuous activity may be observed in active sleep, around 30 weeks of age. Conversely, interburst intervals become shorter and the proportion of time without EEG activity is decreasing. Based on EEG activity and eye movements, a rough sleep-state differentiation was described as soon as 25 weeks of gestational age and is completely achieved at 30 weeks. The main EEG figures are high-voltage delta waves of higher amplitude and slower frequency in younger infants. Temporal delta waves occur in sequences, these are very characteristic of the very premature infant; thereafter, they become smaller, less numerous and eventually disappear around 27-28 weeks. In contrast, occipital delta waves remain numerous and of high voltage, are usually bilateral and superimposed with fast rhythms. The two types of frontal delta waves that are observed in 24-27 weeks prematures disappear with maturation. Bursts of synchronized delta waves are less numerous than localized delta waves and also disappear before 28 weeks of age. Finally, diffuse theta bursts are mainly recorded at 26-27 weeks GA and become more localized in temporal areas with maturation. At 30 weeks, they are observed on temporal areas, mainly during slow-wave sleep.

[Obstructif sleep apnea-hypopnea syndrome: evolution of an old concept]. / Le syndrome d'apnees-hypopnees obstructif du sommeil: evolution d'un concept ancien.

This review summarizes the well-known clinical features of the obstructive sleep apnea-hypopnea syndrome (OSAHS) and emphasizes new research on this syndrome. Though described in the seventies, the prevalence OSAHS is known mainly in the US. A dramatic increasing in prevalence has been related to the increase prevalence of obesity, raising a substantial public health problem. Discussion continues on the proper definition of the syndrome and degrees of severity. Multiple factors are involved in the pathogenesis of sleep apnea: anatomic abnormalities, mechanical factors, nervous alterations, muscular imbalance between pharyngeal constrictor and dilator muscles or part of a metabolic syndrome? Indeed, obstructive sleep apnea with and without obesity is increasingly implicated in the initiation and progression of metabolic disorders and of cardiovascular diseases (hypertension, cardiac ischemia and probably congestive heart failure, cardiac arrhythmias and strokes). An extended literature reports the neural, humoral, thrombotic, metabolic and inflammatory mechanisms linking OSAHS to endocrinology and cardiovascular diseases. Daytime sleepiness, cognitive, memory and performance deficits with their risks are also stressed. These consequences require treating this syndrome as soon as possible. Multiple interventions (medical, mechanical-nasal positive airway pressure or oral appliances, and sometimes surgical management) can be used but nasal continuous positive airway pressure is the "gold standard" treatment in severe OSAHS. More often multiple interventions are appropriate in a given patient. Finally, there is growing evidence that genetic factors influence the expression of OSAHS. Numerous genetic studies have investigated the etiology of OSAHS with the goal of improving our understanding of its pathogenesis.

[Indications of electroencephalogram in the newborn]. / Indications de l'électroencéphalogramme en période néonatale. Recommandations du groupe de neurophysiologie clinique de l'enfant.

The electroencephalogram (EEG), an easy-to-use and non invasive cerebral investigation, is a useful tool for diagnosis and early prognosis in newborn babies. In newborn full term babies manifesting abnormal clinical signs, EEG can point focal lesions or specific aetiology. EEG background activity and sleep organization have a high prognostic value. Tracings recorded over long period can detect seizures, with or without clinical manifestations, and differentiate them from paroxysmal non epileptic movements. The EEG should therefore be recorded at the beginning of the first symptoms, and if possible before any seizure treatment. When used as a neonatal prognostic tool, EEG background activity is classified as normal, abnormal (type A and type B discontinuous and hyperactive rapid tracing) or highly abnormal (inactive, paroxysmal, low voltage plus theta tracing). In such cases, the initial recording must be made between 12 and 48 h after birth, and then between 4 and 8 days of life. Severe EEG abnormalities before 12 h of life have no reliable prognostic value but may help in the choice of early neuroprotective treatment of acute cerebral hypoxia-ischemia. During presumed hypoxic-ischemic encephalopathy, unusual EEG patterns may indicate another diagnosis. In premature newborn babies (29-32 w GA) with neurological abnormalities, EEG use is the same as in term newborns. Without any neurological abnormal sign, EEG requirements depend on GA and the mother's or child's risk factors. Before 28 w GA, when looking for positive rolandic sharp waves (PRSW), EEG records are to be acquired systematically at D2-D3, D7-D8, 31-32 and 36 w GA. It is well known that numerous and persistent PRSW are related to periventricular leukomalacia (PVL) and indicate a bad prognosis. In babies born after 32 GA with clinically severe symptoms, an EEG should be performed before D7. Background activity, organization and maturation of the tracing are valuable diagnosis and prognosis indicators. These recommendations are designed (1) to get a maximum of precise informations from a limited number of tracings and (2) to standardize practices and thus facilitate comparisons and multicenter studies.