Sleep disturbances and changes in urinary 6-sulphatoxymelatonin levels in patients with breast cancer undergoing lumpectomy.

BACKGROUND: Sleep disturbances and changes in self-reported discomfort and melatonin secretion are common in the post-operative period. We aimed to study the distribution of sleep stages in the perioperative period and evaluate changes in secretion of the melatonin metabolite aMT6s and subjective parameters of sleepiness, pain, general well-being and fatigue in patients undergoing surgery for breast cancer. METHODS: Twelve patients, 30-70 years, undergoing lumpectomy were included. Polysomnography was performed the night before surgery (PREOP), the night after (PO1) and 14 days after (PO14). Recordings were scored as awake, light-sleep, slow-wave sleep and rapid-eye-movement (REM) sleep. Sleep stages were analysed as % of total sleep time (TST). Self-reported discomfort was assessed using questions about the level of fatigue, well-being, pain and sleepiness. Urinary aMT6s was measured by radioimmunoassay. RESULTS: There was significantly decreased REM sleep on PO1 (5.9% of TST) compared with PREOP (18.7% of TST) (P < 0.005). An increase in light sleep was observed on PO1 (68.4% of TST) compared with PREOP (55.0% of TST) (P < 0.05). No significant changes in TST, sleep latency, sleep period or total time awake were found. The observed sleep changes were normalised after 2 weeks. No significant changes were found in pain, well-being, fatigue or sleepiness. Night secretion of aMT6s showed a trend towards a decrease from PREOP to PO1 (P = 0.09) and normalisation on PO14 (P = 0.27 between PREOP and PO14). CONCLUSION: Patients with breast cancer undergoing lumpectomy had significantly disturbed sleep architecture the night after surgery, and these changes were normalised after 2 weeks.

Idiopathic normal-pressure hydrocephalus: evaluation and findings in a multidisciplinary memory clinic.

The diagnostic evaluation of patients with possible idiopathic normal-pressure hydrocephalus (INPH) is traditionally performed in the settings of either neurological, neurosurgical or psychiatric departments. The diagnostic procedure and findings in 71 consecutive patients referred with a clinical and radiological suspicion of INPH to our out-patient multidisciplinary memory clinic are evaluated. Primary diagnoses and potential concomitant disorders considered of secondary importance for the symptomatologies were established. Abnormal hydrodynamics, demonstrated by intraventricular pressure monitoring and infusion test were mandatory for the diagnosis of INPH. Mean age was 68 years and mean Mini-Mental State Examination (MMSE) score was 22. DSM IV criteria of dementia were fulfilled in 42%. In half of the referred patients (n=36), the suspicion of INPH was already disproved subsequently to the evaluation programme performed in the outpatient clinic. The main primary diagnosis was cerebrovascular disease (CVD) comprising 27% (n=19) of the referrals, whereas INPH was diagnosed in only 20% (n=14). Shunt improvement rate was 72%. The remaining patients were diagnosed as having one of 26 different conditions. A multiplicity of disorders mimics the INPH syndrome, with CVD being the primary differential diagnosis. Evaluating patients with possible INPH in an outpatient multidisciplinary memory clinic is an effective and rational diagnostic approach.

Nocturnal sweating and temperature in depression.

OBJECTIVE: Patients with depression may have altered thermoregulation, such as high nocturnal core temperatures, decreased daytime sweating and subjective complaints of nocturnal sweating. We sought to compare nocturnal sweating in depressed patients and non-depressed controls, and to assess the impact of REM sleep on sweat rates. METHOD: Nocturnal sweat rate, nocturnal temperature and REM sleep were measured during the night in 9 controls and 8 depressed subjects; 7 depressed patients were assessed during recovery. RESULTS: The nocturnal temperature was significantly higher in depressed patients compared to controls, and decreased significantly with recovery. The nocturnal sweat rates of depressed patients did not differ significantly from those of controls, but decreased significantly with recovery. Analyses of sweat rates before, during and after REM sleep indicated a trend for the entire sample to show a decrease in sweat rates during REM. CONCLUSION: The nocturnal sweating rates in the depressed patients suggest that impaired sweating is not the cause of the high nocturnal temperature commonly found in depressed patients.

A multidisciplinary memory clinic in a neurological setting: diagnostic evaluation of 400 consecutive patients.

This report describes the operation of a multidisciplinary university hospital memory clinic in a neurological setting, and the diagnostic evaluations in 400 consecutive patients referred for cognitive symptoms and possible dementia during a period of 27 months (1 September 1995-31 December 1997). The mean age of the patients was 63.6 years (range 19-97). On clinical and neuropsychological examination, 46% of the patients fulfilled DSM IV criteria for dementia, 5% had selective amnesia, and 14% had other selective cognitive deficits. The remaining patients had either no significant cognitive deficits (31%) or were not evaluable (4%). A wide range of disorders from the fields of neurology, psychiatry, neurosurgery and internal medicine were identified as the underlying etiologies for the cognitive symptoms. Potentially reversible conditions were observed in 26% of the patients, not including the 11% in whom no specific underlying disease was identified. Concomitant conditions or risk factors with a potential influence on cognitive functions were identified in 61% of the patients. Diagnostic evaluation of patients with mild to moderate cognitive symptoms and possible dementia is an integrated multidisciplinary task, which should focus on the identification of non-progressive and potentially reversible etiologies, co-morbidity, selective cognitive deficits, and rare or atypical neurological conditions, as well as on the early identification of common progressive dementia disorders.

A 15O-H2O PET study of meditation and the resting state of normal consciousness.

The aim of the present study was to examine whether the neural structures subserving meditation can be reproducibly measured, and, if so, whether they are different from those supporting the resting state of normal consciousness. Cerebral blood flow distribution was investigated with the 15O-H20 PET technique in nine young adults, who were highly experienced yoga teachers, during the relaxation meditation (Yoga Nidra), and during the resting state of normal consciousness. In addition, global CBF was measured in two of the subjects. Spectral EEG analysis was performed throughout the investigations. In meditation, differential activity was seen, with the noticeable exception of V1, in the posterior sensory and associative cortices known to participate in imagery tasks. In the resting state of normal consciousness (compared with meditation as a baseline), differential activity was found in dorso-lateral and orbital frontal cortex, anterior cingulate gyri, left temporal gyri, left inferior parietal lobule, striatal and thalamic regions, pons and cerebellar vermis and hemispheres, structures thought to support an executive attentional network. The mean global flow remained unchanged for both subjects throughout the investigation (39+/-5 and 38+/-4 ml/100 g/min, uncorrected for partial volume effects). It is concluded that the (H2)15O PET method may measure CBF distribution in the meditative state as well as during the resting state of normal consciousness, and that characteristic patterns of neural activity support each state. These findings enhance our understanding of the neural basis of different aspects of consciousness.

Airway dimensions and head posture in obstructive sleep apnoea.

The present cephalometric study aimed to describe the antero-posterior diameters of the pharyngeal airway in a sample of 50 male obstructive sleep apnoea (OSA) patients and a reference sample of 103 male students, and to examine the relationship between these diameters and the posture of the head and the cervical column. Subjects were recorded in the cephalometer standing with the head in its natural position (mirror position). Pharyngeal airway diameters were measured at seven levels ranging from the maxillary tuberosity to the vallecula of the epiglottis. The largest difference was observed at the level behind the soft palate where the diameter was 50 per cent narrower in the OSA sample than in the reference sample. Extension of the cranio-cervical angle and forward inclination of the cervical column were correlated with an increase in the three most caudal airway diameters in the OSA sample: at the uvula, the root of the tongue, and the epiglottis, but only to increase in the lowest diameter in the reference sample. The findings were considered to reflect a compensatory physiological postural mechanism that serves to maintain airway adequacy in OSA patients in the awake erect posture, most efficiently so at the lowest levels of the oropharyngeal airway.

Sleep after laparoscopic cholecystectomy.

The sleep pattern and oxygenation of 10 patients undergoing laparoscopic cholecystectomy were studied on the night before operation and the first night after operation. Operations were performed during general anaesthesia and postoperative analgesia was achieved without the administration of opioids. There were no significant changes in the total time awake or the number of arousals on the postoperative night compared with the night before operation. During the postoperative night, we found a decrease (P = 0.02) in slow wave sleep (SWS) with a corresponding increase in stage 2 sleep (P = 0.01). SWS was absent in four of the patients after operation, whereas in six patients it was within the normal range (5-20% of the night). The proportion of rapid eye movement (REM) sleep was not significantly changed after operation. There were no changes in arterial oxygen saturation on the postoperative compared with the preoperative night. Comparison of our results with previous studies on SWS and REM sleep disturbances after open laparotomy, suggests that the magnitude of surgery or administration of opioids, or both, may be important factors in the development of postoperative sleep disturbances.

Persistent resetting of the cerebral oxygen/glucose uptake ratio by brain activation: evidence obtained with the Kety-Schmidt technique.

Global cerebral blood flow (CBF), global cerebral metabolic rates for oxygen (CMRO2), and for glucose (CMRglc), and lactate efflux were measured during rest and during cerebral activation induced by the Wisconsin card sorting test. Measurements were performed in healthy volunteers using the Kety-Schmidt technique. Global CMRO2 was unchanged during cerebral activation, whereas global CBF and global CMRglc both increased by 12%, reducing the molar ratio of oxygen to glucose consumption from 6.0 during baseline conditions to 5.4 during activation. Data obtained in the period following cerebral activation showed that the activation-induced resetting of the relation between CMRglc and CMRO2 persisted virtually unaltered for > or = 40 min after the mental activation task was terminated. The activation-induced increase in cerebral lactate efflux measured over the same time period accounted for only a small fraction of the activation-induced excess glucose uptake. These data confirm earlier reports that brain activation can induce resetting of the cerebral oxygen/glucose consumption ratio, and indicate that the resetting persists for a long period after cerebral activation has been terminated and physiologic stress indicators returned to baseline values. Activation-induced resetting of the cerebral oxygen/glucose uptake ratio is not necessarily accounted for by increased lactate production from nonoxidative glucose metabolism.

Predictive value of Müller maneuver, cephalometry and clinical features for the outcome of uvulopalatopharyngoplasty. Evaluation of predictive factors using discriminant analysis in 30 sleep apnea patients.

The success rate of uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea is generally only 50-60%. In order to improve this, various predictive factors for the outcome of UPPP were studied, including the Müller maneuver and cephalometry. Thirty unselected consecutive patients with obstructive sleep apnea (median apnea index (AI) 26 apneas/h, range 5-78) underwent UPPP with standard tonsillectomy except in the case of small tonsils and using CO2 laser for the palatal resection. Polysomnographic control 5 months after surgery showed that 63% of all patients had obtained a reduction in AI > or = 50% including an AI < 20 after surgery. Tonsillectomy had no influence on the outcome. Further, the Müller maneuver did not predict the outcome, whereas cephalometry proved to be of good predictive value. Lowered position of the hyoid bone, increased cranio-cervical angle and shortening of the maxilla length were significantly associated with poor results of UPPP, as were overweight, narrowing of the hypopharynx, the severity of sleep apnea, and hypersomnia. However, in a discriminant analysis containing all these variables, the three cephalometric measurements together with hypersomnia were most closely associated with the outcome of UPPP. A predictive model containing these four variables could correctly classify 83% of the patients in the present study. The model had a false positive rate of 7% in predicting a successful outcome. This indicates that cephalometry is mandatory in the selection of UPPP candidates and that a predictive model containing some or all of the four variables may substantially improve the success rate.

Late postoperative nocturnal episodic hypoxaemia and associated sleep pattern.

Ten patients undergoing major abdominal surgery under general anaesthesia were monitored with a pulse oximeter, electroencephalogram, electromyogram, electrocardiogram and eye and hand movement sensors two nights before and three nights after surgery. Episodic hypoxaemic events were increased significantly after surgery (P < 0.05). Rapid eye movement (REM) sleep decreased significantly on the first night after operation (P < 0.05). Seven patients had increased amounts of REM sleep (rebound) on the second, third or both nights after operation compared with the preoperative night. Slow wave sleep was depressed significantly on the first two nights after operation (P < 0.05). REM sleep-associated hypoxaemic episodes for individual patients increased about three-fold on the second and third nights after operation compared with the night before operation (P < 0.05). We conclude that postoperative sleep pattern is disturbed severely with early depression of REM and slow wave sleep and with rebound of REM sleep on the second and third nights. Postoperative rebound of REM sleep may contribute to the development of sleep disordered breathing and nocturnal episodic hypoxaemia.

Skeletal muscle vascular responses in human limbs to isometric handgrip.

Studies of whole limb blood flow have shown that static handgrip elicits a vasodilatation in the resting forearm and vasoconstriction in the resting leg. We asked if these responses occur in the skeletal muscle vascular bed, and if so, what is the relative contribution of local metabolic versus other mechanisms to these vascular responses. Blood flow recordings were made simultaneously in the skeletal muscle of the resting arm and leg using the Xenon-washout method in ten subjects during 3 min of isometric handgrip at 30% of maximal voluntary contraction. In the arm, skeletal muscle vascular resistance (SMVR) decreased transiently at the onset of exercise followed by a return to baseline levels at the end of exercise. In the leg SMVR remained unchanged during the 1st min of handgrip, but had increased to exceed baseline levels by the end of exercise. During exercise electromyography (EMG) recordings from nonexercising limbs demonstrated a progressive 20-fold increase in activity in the arm, but remained at baseline in the leg. During EMG-signal modelled exercise performed to mimic the inadvertent muscle activity, decreases in forearm SMVR amounted to 57% of the decrease seen with controlateral handgrip. The present study would seem to indicate that vascular tone in nonexercising skeletal muscle in the arm and leg are controlled differently during the early stages of static handgrip. Metabolic vasodilation due to involuntary contraction could significantly modulate forearm skeletal muscle vascular responses, but other factors, most likely neural vasodilator mechanisms, must make major contributions. During the later stages of contralateral sustained handgrip, vascular adjustments in resting forearm skeletal muscle would seem to be the final result of reflex sympathetic vasoconstrictor drive, local metabolic vasodilator forces and possibly neurogenic vasodilator mechanisms.

A system for analysis of sleep and nocturnal activity in craniomandibular muscles.

A system was developed for continuous, full-night, polysomnographic recording of sleep using manual sleep scoring and automatic electromyographic analysis of craniomandibular muscle activity. In the sleep laboratory, data are stored on tape with hard copy on paper followed by off-line, computer-controlled digital processing. Muscle activity is described by the Amplitude Probability Distribution Function and by parameters of time and intensity. Sleep and electromyographic data are available graphically on screen, and the results are presented in tables and graphics after statistical treatment. The system was developed to provide a differentiated, detailed analysis of sleep and nocturnal muscle activity in the craniomandibular system that is suitable for comparing groups of individuals, effects of treatments, and physical load of muscles. Applications of the system are demonstrated.

Head posture in obstructive sleep apnoea.

In growing subjects, obstruction of the upper airway may lead to excessive vertical facial development. According to the soft-tissue stretching hypothesis (Solow and Kreiborg, 1977) this could be due to an increased cranio-cervical angulation triggered by the airway obstruction. The present study aimed to examine the effect of airway obstruction on cranio-cervical posture in a sample of adult patients with severe obstructive sleep apnoea (OSA). Lateral cephalometric radiographs taken in the natural head position (mirror position) were obtained from 50 male patients aged 28-70 with polysomnographic diagnosis of obstructive sleep apnoea. The Apnoea Index ranged from 21 to 98 episodes per hour with a mean of 54.6. Control samples were available from previous cephalometric studies of head posture in five samples of healthy subjects and one sample of congenitally blind subjects. The average cranio-cervical angle, NSL/OPT, was found to be extremely large (mean 104.1, SD 9.1) exceeding the average values in the control samples by 1-2 standard deviations (P < 0.001). It is suggested that the large cranio-cervical angle in OSA patients is a physiological adaptation aiming to maintain airway adequacy while the head, and thus the visual axis, is kept in its natural relationship to the true vertical. The findings thus provide evidence for the hypothesis that upper airway obstruction may trigger an increase in the cranio-cervical angulation.

Middle cerebral artery blood velocity and cerebral blood flow and O2 uptake during dynamic exercise.

Results obtained by the 133Xe clearance method with external detectors and by transcranial Doppler sonography (TCD) suggest that dynamic exercise causes an increase of global average cerebral blood flow (CBF). These data are contradicted by earlier data obtained during less-well-defined conditions. To investigate this controversy, we applied the Kety-Schmidt technique to measure the global average levels of CBF and cerebral metabolic rate of oxygen (CMRO2) during rest and dynamic exercise. Simultaneously with the determination of CBF and CMRO2, we used TCD to determine mean maximal flow velocity in the middle cerebral artery (MCA Vmean). For values of CBF and MCA Vmean a correction for an observed small drop in arterial PCO2 was carried out. Baseline values for global CBF and CMRO2 were 50.7 and 3.63 ml.100 g-1.min-1, respectively. The same values were found during dynamic exercise, whereas a 22% (P < 0.0001) increase in MCA Vmean was observed. Hence, the exercise-induced increase in MCA Vmean is not a reflection of a proportional increase in CBF.

Nocturnal variations in human lower leg subcutaneous blood flow related to sleep stages.

Nocturnal subcutaneous adipose tissue blood flow rate was measured in the lower legs of 10 normal human subjects together with systemic arterial blood pressure, heart rate, and registration of sleep stages under ambulatory conditions. The 133Xe washout technique, portable CdTe(Cl) detectors, and a portable data storage unit were used for measurement of blood flow rates. The sleep recordings were performed with a portable computerized sleep analysis system. In accordance with the results of previous studies, a hyperemic blood flow rate phase (mean increase 140%) for 100 min was observed approximately 60 min after the subjects went to bed. The moment of onset of the hyperemic phase was closely related to the moment of onset of the first episode of deep sleep (stages 3 and 4). There was a significant (P < 0.01) overrepresentation of deep sleep in the hyperemic phase compared with adjacent phases, and rapid-eye-movement sleep predominantly occurred in the latter part of the night, when the subcutaneous blood flow rate was stable. The results of the present study are in accordance with current theories of the interrelationship between the thermoregulatory and the arousal state control systems and, thus, might suggest that the nightly subcutaneous hyperemia represents a thermoregulatory effector mechanism.

Mental stress and cognitive performance do not increase overall level of cerebral O2 uptake in humans.

We measured cerebral metabolic rate of oxygen (CMRO2), cerebral blood flow (CBF), and cerebral lactate output during rest, during the execution of mental arithmetic, and during mental stress induced by physical and psychological annoyance. Measurements were performed in healthy volunteers by use of the Kety-Schmidt technique with 133Xe as the inert gas. Electroencephalographic desynchronization and highly significant increases in plasma catecholamines and heart rate verified that the test measurements were performed during conditions differing distinctly from the resting state. In accordance with an earlier study (Sokoloff et al. J. Clin. Invest. 34: 1101-1108, 1985), a minimal and nonsignificant 1% reduction of global CMRO2 during mental arithmetic was observed, signifying that this form of mental activation was unassociated with any detectable increase in overall cerebral synaptic activity. Mental stress induced a slight but highly significant (P less than 0.002) 6% reduction in global CMRO2. This finding is in contrast to results from earlier investigations and contradicts the generally accepted notion of an association between mental arousal and a diffuse upregulation of cerebral synaptic activity. During mental arithmetic and mental stress, cerebral lactate output increased by 207 and 344%, respectively, but because of large individual variations in the measured responses, the elevations reached statistical significance only during mental arithmetic.

Sleep disturbances in IDDM patients with nocturnal hypoglycemia.

Eight insulin-dependent diabetic patients were studied to evaluate sleep patterns during normoglycemia and spontaneous and insulin-induced hypoglycemia. Two channels of electroencephalogram (EEG), electromyogram and actooculogram were recorded. The signals were analyzed off-line, using a polygraphic sleep analysis system. The scoring was mainly based on the color density spectral array of the EEG. Blood glucose and growth hormone were measured serially. Asymptomatic, spontaneous nocturnal hypoglycemia occurred in 38% of the nights. Conventional sleep analysis showed a tendency toward prolongation of the two first rapid eye movement cycles on hypoglycemic nights, although it was insufficient to explain the activities seen during hypoglycemia. Blood glucose values below 2.0 mmol/l were observed in some of the patients accompanied by EEG changes with increased theta and delta activity.

Computerized apnea detection in ambulatory sleep recording with the Somnolog system.

Apnea detection from a traditional polysomnographic sleep recording is tedious and time consuming. With a new portable device, the Somnolog, it is possible to make ambulatory sleep recording and apnea detection.

Shortened reaction time during nasal CPAP treatment of obstructive sleep apnea.

In 5 patients with severe obstructive sleep apnea the effect of nasal continuous positive airway pressure (CPAP) treatment on daytime functioning was measured. During a 2-week period, when the patients were effectively treated with nasal CPAP, a shortening of the reaction time could be measured.

An epidemiological study of REM latency and psychiatric disorders.

In an epidemiological population study 87 subjects were studied with home sleep recordings. Nineteen subjects had minor psychiatric disorders: six subjects had a minor depression, six subjects had a generalized anxiety disorder, and seven subjects had a mild vegetative discomfort syndrome. Syndrome profiles of the three groups, using the AMDP system, showed a significantly higher degree of insomnia in the anxiety group than in the depressive group. The mean rapid eye movement (REM) latency in the anxiety group was significantly longer than in the other groups, including normals. The study showed a slight tendency towards a reduced REM latency in the minor depressives, but no statistical significance was obtained.