Case report: Diagnosis and intervention of a non-24-h sleep-wake disorder in a sighted child with a psychiatric disorder.

Circadian rhythm sleep-wake disorders (CRSWD) are sleep dysfunctions related to circadian functioning. They are characterized by symptoms of insomnia or excessive sleepiness that occur because the intrinsic circadian pacemaker is not entrained to a 24-h light/dark cycle. Affected individuals with a free-running disorder or hypernycthemeral syndrome (N24SWD) have a longer sleep-wake cycle that produces a sleep pattern that typically delays each day. The disorder is seen in 70% of blind people, and among people with healthy vision, it is a rare pathology. Among sighted cases, 80% are young men and 28% have a psychiatric disorder. The patient was a 14-year-old boy with a psychiatric pathology diagnosed with a PANDAS syndrome (pediatric autoimmune neuropsychiatric disorders associated with streptococci), a sudden acute and debilitating onset of intense anxiety and mood lability accompanied by obsessive compulsive-like issues and/or tics, in association with a streptococcal A infection that occurs immediately prior to the symptoms. As a comorbidity, he exhibited severe insomnia due to an irregular sleep pattern that strongly delayed his sleep schedule day to day. It affected his daily routines, as he was not going to school, and aggravated, furthermore, the psychiatric symptoms. He was referred for sleep consultation, where the case was explored by ambulatory circadian monitoring (ACM) using the novel system Kronowise® (Chronolab, University of Murcia) and diagnosed with a non-24-h sleep-wake disorder (N24SWD). The first treatment approach for the patient was focused on improving symptoms during the acute infection and psychiatric symptoms. Additionally, sleep pathology was treated by light therapy and melatonin. After 8 months and different trials, it was possible to establish a treatment to normalize the symptoms and fix his sleep rhythm in a normal schedule as well as to reduce anxious symptoms during the day. The association of PANDAS and N24SWD has not previously been reported in the literature.

Application of Machine Learning Methods to Ambulatory Circadian Monitoring (ACM) for Discriminating Sleep and Circadian Disorders.

The present study proposes a classification model for the differential diagnosis of primary insomnia (PI) and delayed sleep phase disorder (DSPD), applying machine learning methods to circadian parameters obtained from ambulatory circadian monitoring (ACM). Nineteen healthy controls and 242 patients (PI = 184; DSPD = 58) were selected for a retrospective and non-interventional study from an anonymized Circadian Health Database (https://kronowizard.um.es/). ACM records wrist temperature (T), motor activity (A), body position (P), and environmental light exposure (L) rhythms during a whole week. Sleep was inferred from the integrated variable TAP (from temperature, activity, and position). Non-parametric analyses of TAP and estimated sleep yielded indexes of interdaily stability (IS), intradaily variability (IV), relative amplitude (RA), and a global circadian function index (CFI). Mid-sleep and mid-wake times were estimated from the central time of TAP-L5 (five consecutive hours of lowest values) and TAP-M10 (10 consecutive hours of maximum values), respectively. The most discriminative parameters, determined by ANOVA, Chi-squared, and information gain criteria analysis, were employed to build a decision tree, using machine learning. This model differentiated between healthy controls, DSPD and three insomnia subgroups (compatible with onset, maintenance and mild insomnia), with accuracy, sensitivity, and AUC >85%. In conclusion, circadian parameters can be reliably and objectively used to discriminate and characterize different sleep and circadian disorders, such as DSPD and OI, which are commonly confounded, and between different subtypes of PI. Our findings highlight the importance of considering circadian rhythm assessment in sleep medicine.

Do elite athletes sleep well? / ¿Duermen bien los deportistas de élite?

Introducción: El objetivo del estudio fue evaluar el sueño, ritmos circadianos y estado neurocognitivo de deportistas de alto rendimiento durante el periodo habitual de entrenamiento, competiciones y estudios. Materiales y métodos: Se evaluó un equipo de 12 jugadoras (mujeres, 15-17 años) de baloncesto de alto rendimiento, concentrado en una residencia de deportistas. Se estudió el sueño mediante polisomnografía, los ritmos circadianos mediante sensores de monitorización circadiana ambulatoria, y el estado neurocognitivo mediante batería de cuestionarios. Resultados: Las deportistas duermen 6:57±0,02 h, la actividad nocturna del 201,1±33,7% se sitúa por encima de la normalidad (65-135%), la regularidad de horarios, de un 72,6±9,2% también está fuera de rango normal (75-125%). La profundidad de sueño del 85,1±2,6% (valores normales entre 85-100%) es reducida, y la temperatura periférica elevada durante el día, de 33,4±0,9 ◦C (valores normales entre 31-33 ◦C) indica somnolencia. Conclusiones: Las deportistas de nuestro estudio duermen menos horas de las necesarias, la calidad del sueño es baja debido a la fatiga muscular y a unos malos hábitos, y los horarios irregulares deterioran el sistema circadiano. Todo esto influye en su rendimiento tanto físico como mental. Es básico concienciar al colectivo con todos los estamentos implicados, de la importancia de mejorar estos hábitos de sueño para mantener el rendimiento físico óptimo

Introduction: The objective of the study was to evaluate sleep, circadian rhythms and neurocognitive status of high performance athletes during the usual period of training, competitions and studies. Materials and methods: A team of 12 high-performance basketball players (women, 15-17 years old) concentrated in a sports residence was evaluated. Sleep was studied through polysomnography, circadian rhythms using ambulatory circadian monitoring sensors, and neurocognitive status using s battery of questionnaires. Results: Athletes sleep 6:57±0.02 h, nocturnal activity of 201.1±33.7% is above normal range (65-135%), regularity of schedules, 72.6±9.2% is also out of range (75-125%). The sleep depth of 85.1±2.6% (normal values between 85 and 100%) is reduced, and the peripheral temperature during the day, of 33.4±0.9 ◦C (normal values between 31 and 33 ◦C) indicates drowsiness. Conclusions: Our sample of athletes sleep less than the necessary hours, their sleep quality is low due to muscle fatigue and poor habits, and their irregular schedule deteriorates the circadian system. All of this influences both physical and mental performance. It is essential to raise awareness of the importance of improving these sleep habits in order to maintain optimum physical performance

Ambulatory circadian monitoring (ACM) based on thermometry, motor activity and body position (TAP): a comparison with polysomnography.

An integrated variable based on the combination of wrist Temperature, motor Activity and body Position (TAP) was previously developed at our laboratory to evaluate the functioning of the circadian system and sleep-wake rhythm under ambulatory conditions. However, the reliability of TAP needed to be validated with polysomnography (PSG). 22 subjects suffering from sleep disorders were monitored for one night with a temperature sensor (iButton), an actimeter (HOBO) and exploratory PSG. Mean waveforms, sensitivity (SE), specificity (SP), agreement rates (AR) and comparisons between TAP and sleep stages were studied. The TAP variable was optimized for SE, SP and AR with respect to each individual variable (SE: 92%; SP: 78%; AR: 86%). These results improved upon estimates previously published for actigraphy. Furthermore, TAP values tended to decrease as sleep depth increased, reaching the lowest point at phase 3. Finally, TAP estimates for sleep latency (SL: 37±9 min), total sleep time (TST: 367±13 min), sleep efficiency (SE: 86.8±1.9%) and number of awakenings (NA>5 min: 3.3±.4) were not significantly different from those obtained with PSG (SL: 29±4 min; SE: 89.9±1.8%; NA>5 min: 2.3±.4), despite the heterogeneity of the sleep pathologies monitored. The TAP variable is a novel measurement for evaluating circadian system status and sleep-wake rhythms with a level of reliability better to that of actigraphy. Furthermore, it allows the evaluation of a patient's sleep-wake rhythm in his/her normal home environment, and at a much lower cost than PSG. Future studies in specific pathologies would verify the relevance of TAP in those conditions.

Correlación entre la clínica y la polisomnografía en los trastornos respiratorios del sueño infantil / Clinical and polysomnographic correlation in sleep-related breathing disorders in children

Introducción: A pesar de que la polisomnografía supone la prueba diagnóstica por excelencia de los trastornos respiratorios del sueño en niños, existe controversia sobre su indicación en todos los casos. De entre los argumentos utilizados, tanto a favor como en contra, se encuentra la falta de correlación existente entre sus valores objetivos y la sintomatología. Objetivo: Evaluar la correlación entre los datos clínicos y el índice de apnea-hipoapnea (IAH), en nuestro entorno de trabajo. Material y método: Se compara estadísticamente la clínica preoperatoria y el IAH de 170 niños con trastorno respiratorio del sueño, sometidos a polisomnografia. También se evalúa la correlación a nivel postoperatorio, con un subgrupo de 80 niños intervenidos de adenoamigdalectomía con seguimiento polisomnográfico a un año. Resultados: A nivel preoperatorio únicamente el grado de hipertrofia amigdalar mostró correlación significativa con el IAH. A nivel postoperatorio se evidencia una correlación entre el IAH y las apneas observadas: 38,1% de los niños mejoran según los padres en el grupo con persistencia polisomnográfica y el 66,7% en el grupo con resolución de la enfermedad (p=0,023). También muestra correlación el nivel de mejora del ronquido, valorado mediante escala analógica visual. La media bajó 5 puntos en el grupo persistente y 6,1 en el grupo con resolución de la enfermedad (p=0,047). Conclusión: A pesar de las limitaciones en la correlación entre la clínica y la polisomnografia, especialmente en el preoperatorio, la prueba objetiva por excelencia sigue siendo esta. Deben hacerse esfuerzos para conseguir parámetros objetivos que aporten mayor nivel de correlación (AU)

Introduction: Although polysomnography is the gold standard test for sleep-disordered breathing in children, there is controversy about its indication in all cases. Among the arguments both for and against is the lack of correlation between objective values and the symptoms. Objective: To evaluate the correlation between clinical data and apnea-hypopnoea index (AHI) in our work environment. Material and methods: We compared the preoperative clinical symptoms and AHI statistically in 170 children with sleep-disordered breathing who underwent polysomnography. We also analysed the correlation to postoperative level, with a subgroup of 80 children who underwent adenotonsillectomy with 1 year of polysomnography follow-up. Results: Before surgery, only the degree of tonsillar hypertrophy was statistically significant correlated with AHI. At post-operative follow-up, evidence of correlation between AHI and apnoea was observed: 38.1% of children improved in the group with persistence and 66.7% in the disease resolution group (P=0.023). In addition, the correlations showed the level of improvement of snoring, as assessed by visual analogue scale. The mean was 5 points lower in the persistent group and 6.1 lower in the disease resolution group (P=0.047). Conclusion: Despite the limitations in the correlation between clinical data and polysomnography, especially in preoperative results, polysomnography remains the gold standard diagnostic tool. Efforts should be made to obtain objective parameters that provide higher levels of correlation (AU)

Clinical and polysomnographic correlation in sleep-related breathing disorders in children.

INTRODUCTION: Although polysomnography is the gold standard test for sleep-disordered breathing in children, there is controversy about its indication in all cases. Among the arguments both for and against is the lack of correlation between objective values and the symptoms. OBJECTIVE: To evaluate the correlation between clinical data and apnea-hypopnoea index (AHI) in our work environment. MATERIAL AND METHODS: We compared the preoperative clinical symptoms and AHI statistically in 170 children with sleep-disordered breathing who underwent polysomnography. We also analysed the correlation to postoperative level, with a subgroup of 80 children who underwent adenotonsillectomy with 1 year of polysomnography follow-up. RESULTS: Before surgery, only the degree of tonsillar hypertrophy was statistically significant correlated with AHI. At post-operative follow-up, evidence of correlation between AHI and apnoea was observed: 38.1% of children improved in the group with persistence and 66.7% in the disease resolution group (P=.023). In addition, the correlations showed the level of improvement of snoring, as assessed by visual analogue scale. The mean was 5 points lower in the persistent group and 6.1 lower in the disease resolution group (P=.047). CONCLUSION: Despite the limitations in the correlation between clinical data and polysomnography, especially in preoperative results, polysomnography remains the gold standard diagnostic tool. Efforts should be made to obtain objective parameters that provide higher levels of correlation.

Documento de consenso del síndrome de apneas-hipopneas durante el sueño en niños (versión completa) / Consensus document on sleep apnea-hypopnea syndrome in children (full version)

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Causas de insônia nos primeiros anos de vida e repercussão nas mães: atualização: [revisão] / Causes of insomnia in the first years of life and maternal consequences: an update: [review]

OBJETIVO: Revisar a literatura sobre insônia de crianças pequenas e seus aspectos relacionados às repercussões familiares, à abordagem pediátrica e ao seu tratamento. FONTES DE DADOS: Levantamento de publicações indexadas no Medline e Lilacs entre os anos de 1998 e 2008, rastreadas com a combinação dos descritores: "sleep", "insomnia", "child", "depression", "mother-child relationship", além de teses e capítulos de livros pertinentes ao assunto. SÍNTESE DOS DADOS: A insônia da criança pequena, definida como dificuldade repetida em iniciar e/ou manter o sono, é queixa frequente na clínica pediátrica e usualmente traz repercussões nos pais relativas à privação de sono. Aos dois a três meses de idade, há condições biológicas para consolidação das horas de sono à noite; estando a conduta parental associada às dificuldades neste processo. Estudos demonstram que há associação entre insônia do bebê e depressão nas mães, e a insônia pode ser manifestação de dificuldades no desenvolvimento psíquico da criança pequena, que acontece na relação com sua mãe. CONCLUSÕES: O ritmo de sono nos bebês pode e deve estabelecer-se precocemente; os hábitos para o sono devem basear-se nas medidas de higiene do sono. A depressão nas mães, que pode contribuir para a insônia do bebê, idealmente poderia ser detectada pelo pediatra, prevenindo esse comprometimento das mães e de seus bebês.

OBJECTIVE: To review the literature on insomnia in small children, its aspects related to effects on parents, pediatric approach and treatment. DATA SOURCES: A survey of publications indexed in Medline and Lilacs between the years 1998 and 2008, searched through the combination of the descriptors "sleep", "insomnia", "child", "depression", "mother-child relationship", besides thesis and chapters of books concerning the subject. DATA SYNTHESIS: The small child insomnia, defined as repeated difficulty in initiating and/or maintaining sleep, is a common complaint in the pediatric clinic, and usually entails repercussions on parents related to sleep deprivation. At about two to three months of age, there are already biological conditions for consolidating sleep hours during the night. Parental behavior is associated to difficulties to establish this process. Studies point out that baby's insomnia and mother's depression are closely related. Probably, the insomnia is a sign of the difficulties in the small child's psychic development in the context of mother-child relationship. CONCLUSIONS: Rhythmic sleep in babies can and should be established early in life; sleep habits should be built on rules of sleep hygiene. Mother's depression, which may contribute to baby's insomnia, should ideally be detected by pediatricians, thus preventing such suffering for mothers and babies.

Insomniac children maternal sleep and mood in São Paulo and Barcelona.

OBJECTIVE: To evaluate sleep characteristics verifying for the presence of depressive symptoms in mothers of insomniac children living in São Paulo (Brazil) and Barcelona (Spain). METHOD: Forty-six mothers were evaluated, 37 from São Paulo and nine from Barcelona, their ages varying from 19 to 44, and their children; otherwise healthy but with complaints of insomnia, their age varying from three to 33 months. The mothers' sleep quality was rated by the Pittsburgh Sleep Quality Index (PSQI), and the Beck Depression Inventory (BDI). RESULTS: 91.30% of mothers reported poor sleep by PSQI standards. Regarding signs and symptoms of depression, 69.56% of all mothers in this sample showed them. Direct correlation between São Paulo mothers PSQI and BDI was found and also between the child's age and BDI. CONCLUSION: The mothers' poor sleep was related to mood changes with symptoms of depression presenting similar results in both cities.

Insomniac children maternal sleep and mood in São Paulo and Barcelona / Sono e humor de mães de crianças pequenas com insônia em São Paulo e Barcelona

OBJECTIVE: To evaluate sleep characteristics verifying for the presence of depressive symptoms in mothers of insomniac children living in São Paulo (Brazil) and Barcelona (Spain). METHOD: Forty-six mothers were evaluated, 37 from São Paulo and nine from Barcelona, their ages varying from 19 to 44, and their children; otherwise healthy but with complaints of insomnia, their age varying from three to 33 months. The mothers' sleep quality was rated by the Pittsburgh Sleep Quality Index (PSQI), and the Beck Depression Inventory (BDI). RESULTS: 91.30 percent of mothers reported poor sleep by PSQI standards. Regarding signs and symptoms of depression, 69.56 percent of all mothers in this sample showed them. Direct correlation between São Paulo mothers PSQI and BDI was found and also between the child's age and BDI. CONCLUSION: The mothers' poor sleep was related to mood changes with symptoms of depression presenting similar results in both cities.

OBJETIVO: Avaliar a presença de sintomas depressivos em mães de crianças com insônia em São Paulo e Barcelona. MÉTODO: Quarenta e seis mães foram avaliadas, 37 de São Paulo e nove de Barcelona, suas idades variaram de 19 a 44 anos, e suas crianças, saudáveis, mas com queixa de insônia tinham idades de três a 33 meses. A mãe foi avaliada pelo Índice de Qualidade de Sono de Pittsburgh (PSQI) e pelo Índice de Depressão de Beck (IDB). RESULTADOS: 91,30 por cento das mães relataram sono ruim pelo padrão do PSQI. Quanto aos sinais e sintomas de depressão, 69,56 por cento das mães da amostra total relatavam. Nas mães de São Paulo foi constatada correlação direta entre o PSQI e o IDB, bem como a idade da criança e o IBD. CONCLUSÃO: O sono ruim das mães se correlacionou com sinais e sintomas depressivos e os resultados foram semelhantes nas duas cidades.

Nocturia in Spanish patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH).

OBJECTIVE: This study aimed to assess the prevalence of nocturia and its impact on quality of life (QoL) in Spanish patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia (LUTS/BPH). RESEARCH DESIGN AND METHODS: This was a Spanish, multicentre, cross-sectional study. Outpatients aged 60 years and over with LUTS/BPH, a prostate size > or = 25 g, untreated for LUTS/BPH and responding to the International Prostate Symptom Score (I-PSS) were included. Nocturia was defined as > or = 2 nocturnal voids/night. The Spanish version of the Nocturia-specific Quality of Life (N-QoL) questionnaire assessed the impact of nocturia on QoL, with a low score indicating a poor QoL due to nocturia. RESULTS: A total of 502 patients were included; mean age 68.1 +/- 5.7 years, mean I-PSS 14.9 +/- 7.1, mean prostate size 50.9 +/- 20 g. The overall prevalence of nocturia was 83.1% (95% confidence interval [CI]: 79.8-86.4). Patients with nocturia had a lower score on the overall N-QoL questionnaire and the sleep/energy and bother/concern domains than those without nocturia (p < 0.001); 42.9% of patients with nocturia stated that they had a good-very good QoL compared to 90.6% in those without nocturia (p < 0.001). CONCLUSION: This study shows a high prevalence of nocturia in Spanish LUTS/BPH patients. Nocturia negatively impacts on the QoL of LUTS/BPH patients, which is reflected in worse sleep, reduced energy levels and increased bother and concern. Therefore adequate treatment of this symptom is necessary.