Ademir Baptista Silva

A clinical, prospective, randomized, double-blind trial comparing skin whitening complex with hydroquinone vs. placebo in the treatment of melasma.

Objectives To compare, in a double‐blind, randomized, prospective study, the clinical improvement of hyperpigmentation in 30 patients with melasma using hydroquinone or skin whitening complex topically on one side of the face vs. a placebo cream on the other. The study was performed during the period November 2000 to March 2001 at the Federal University of São Paulo, Escola Paulista de Medicina.

Sleep disorders in pregnancy

CONTEXT The precise function of sleep in animals and human beings is still unknown, and any sort of physical, social or psychological variation may change the normal sleep-wake cycle. PURPOSE This research aims is to determine the sleep disorders (SD) for each of the three trimesters of the pregnancy comparing them to the pre-pregnancy state (PG). METHOD SD were investigated in three hundred pregnant women 11- to 40-years-old through with a brief clinical interview based on directed questions. One hundred pregnant women were considered for each trimester. RESULTS The rate of pregnant women with insomnia increased by 23% in the 2nd trimester (p< 0.005); the rate for excessive daytime sleepiness (EDS) by 15% in the 1st trimester (p<0.003), 55% in the 2nd trimester (p<0.001) and by 14% in the 3rd trimester (p<0.002); the rate for mild sleepiness increased by 33% in the 2nd trimester (p<0.002) and by 48% in the 3rd trimester (p<0.001); the rate for specific awakenings increased by 63% in the 1st trimester, by 80% in the 2nd trimester and by 84% in the 3rd trimester (p<0.001). CONCLUSION SD were more frequent during pregnancy comparatively to PG state, mostly at the expenses of EDS and specific awakenings.

Jactatio capitis nocturna with persistence in adulthood: case report

Rhythmic movement disorder, also known as jactatio capitis nocturna, is an infancy and childhood sleep-related disorder characterized by repetitive movements occurring immediately prior to sleep onset and sustained into light sleep. We report a 19-year-old man with a history of headbanging and repetitive bodyrocking since infancy, occurring on a daily basis at sleep onset. He was born a premature baby but psychomotor milestones were unremarkable. Physical and neurological diagnostic workups were unremarkable. A hospital-based sleep study showed: total sleep time: 178 min; sleep efficiency index 35.8; sleep latency 65 min; REM latency 189 min. There were no respiratory events and head movements occurred at 4/min during wakefulness, stages 1 and 2 NREM sleep. No tonic or phasic electromyographic abnormalities were recorded during REM sleep. A clinical diagnosis of rhythmic movement disorder was performed on the basis of the clinical and sleep studies data. Clonazepam (0.5 mg/day) and midazolam (15 mg/day) yielded no clinical improvement. Imipramine (10 mg/day) produced good clinical outcome. In summary, we report a RMD case with atypical clinical and therapeutical features.

Cardiovascular Autonomic Neuropathy Contributes to Sleep Apnea in Young and Lean Type 1 Diabetes Mellitus Patients

Knowledge about association between sleep apnea and cardiovascular autonomic neuropathy (CAN) in type 1 diabetes mellitus (T1DM) might give some insight into the pathogenesis of this condition in these patients. In obese patients, excessive central adiposity, including a large neck circumference, can contribute to obstructive sleep apnea (OSA). Its presence in non-obese patients, however, indicates that it could be correlated with autonomic neuropathy. The aim of this study was to compare the prevalence of OSA in young and lean T1DM patients with and without CAN. We studied 20 adult, non-obese, T1DM patients who were divided into two groups according to the results of the cardiovascular autonomic reflex tests (CARTs). These two groups (9 with CAN and 11 without CAN) were compared to a control group of 22 healthy individuals, who were matched by age and BMI. A polysomnography was performed and sleep was analyzed. The CAN+ group had a significantly higher prevalence of sleep apnea compared to the other groups (67% CAN+; 23% CAN−; 4.5% controls: CAN+ vs. Control; p = 0.006 and CAN+ vs. CAN−; p = 0.02). The CAN− group had higher sleep efficiency compared to the CAN+ group, demonstrating impaired sleep architecture in diabetics with this chronic complication. In conclusion, OSA may be related to the presence of CAN in young and lean T1DM patients. It could contribute to worse the prognosis and reducing the quality of life of these patients without specific treatment of these conditions.

Quality of life of patients with obstructive sleep apnea syndrome treated with an intraoral mandibular repositioner

BACKGROUND Obstructive sleep apnea syndrome (OSAS) is a very important and prevalent disease, which is associated with a poor quality of life in many patients. Treatments for OSAS include surgery, Continuous Positive Air way Pressure, and an intraoral mandibular repositioner (IOMR), but the tendency of sleep centers is to emphasize the apnea index, neglecting quality of life as treatment outcome. OBJECTIVE To verify to what extent treatment with an IOMR improves the OSAS patients quality of life. METHOD Eleven male patients aged 34 to 63 years (mean=49) with mild to moderate OSAS were evaluated using the Calgary SAQLI questionnaire applied before and four weeks after treatment with an IOMR. The mandibular repositioners were manufactured individually for each patient with acrylic polymer and equipped with a retentive device to maintain the mandible in a forward position during sleep. RESULTS Excellent improvement in the quality of life was observed in five patients (45.5%) and excellent improvement in symptoms in 10 (90.9%). CONCLUSION The systematic use of the IOMR indicates a clear improvement in the global quality of life as well as in the symptoms of patients with OSAS.

Descargas epileptiformes periódicas lateralizadas: 1. Aspectos clínicos e eletrencefalograficos

Em periodo de dois anos, em 25 de um total de 5481 EEGs foi identificada a presenca de descargas epileptiformes periodicas lateralizadas (PLEDs) (prevalencia de 0,45%), correspondendo a 22 pacientes. O grupo era composto de 13 homens e 9 mulheres, com idade variando entre 5 meses e 85 anos. Os principais diagnosticos no grupo foram epilepsias de etiologia nao identificada e tumor do cerebro (22% cada). A localizacao mais comum das PLEDs foi temporal (54% do total), principalmente temporal media. A morfologia mais frequente das PLEDs foi onda delta trifasica (1/3 do total), seguida por onda aguda bifasica e onda aguda-onda lenta (29% cada). Embora 9 dos pacientes tenham falecido, nao foi possivel determinar o valor prognostico das PLEDs para cada patologia em particular.

Brazilian guidelines for the diagnosis of narcolepsy

This manuscript contains the conclusion of the consensus meeting on the diagnosis of narcolepsy based on the review of Medline publications between 1980-2010. Narcolepsy is a chronic disorder with age at onset between the first and second decade of life. Essential narcolepsy symptoms are cataplexy and excessive sleepiness. Cataplexy is defined as sudden, recurrent and reversible attacks of muscle weakness triggered by emotions. Accessory narcolepsy symptoms are hypnagogic hallucinations, sleep paralysis and nocturnal fragmented sleep. The clinical diagnosis according to the International Classification of Sleep Disorders is the presence of excessive sleepiness and cataplexy. A full in-lab polysomnography followed by a multiple sleep latency test is recommended for the confirmation of the diagnosis and co-morbidities. The presence of two sleep-onset REM period naps in the multiple sleep latency test is diagnostic for cataplexy-free narcolepsy. A positive HLA-DQB1*0602 with lower than 110pg/mL level of hypocretin-1 in the cerebrospinal fluid is required for the final diagnosis of cataplexy- and sleep-onset REM period -free narcolepsy.

Rapid eye movements during paradoxical sleep in patients with cerebrovascular disease

Rapid eye movements that occur during paradoxical sleep are generated from the brainstem and are modulated by cerebral hemispheres. In an attempt to establish the participation of cerebral hemispheres on rapid eye movements, we carried out a quantitative study of eye movements density in patients bearing hemispheres vascular lesions. The polysomnographic recordings of 24 patients were compared to those of 24 healthy volunteers. Density of rapid eye movements was defined as the percentage of eye movements during the respective time of paradoxical sleep. Based on the present results, we concluded that: stroke patients with hemispheric lesions displayed increased density of rapid eye movements; there was no difference on the density of rapid eye movements according to the hemispheric lesion; higher density of rapid eye movements was observed in patients with anterior hemispheric lesion.

Descargas epileptiformes periódicas lateralizadas: II. Aspectos evolutivos

A investigation was done on EEG evolution of 9 patients with PLEDs. In all patients PLEDs eventualy disappeared, in general in a short period, less than 4 daysin 5 cases. In 4 cases evolution was to slow background activity, and to posterior normalization in 2. In 3 cases evolution was to delta activity and suppression bursts, and all the 3 patients died. In the last 2 patients PLEDs were replaced by localized paroxysmal activity, which was anteriorly registered in 1. PLEDs was found in acute dysfunction of CNS, and in epileptic patients in periods of increased seizure activity. These data suggest that a critical point of alteration of the normal neuronal activity is needed for appearance and maintenance of PLEDs. No correlation could be done between the evolution of PLEDs, always to disappearance, and clinical outcome, that was variable.: A investigation was done on EEG evolution of 9 patients with PLEDs. In all patients PLEDs eventually disappeared, in general in a short period, less than 4 days in 5 cases. In 4 cases evolution was to slow background activity, and to posterior normalization in 2. In 3 cases evolution was to delta activity and suppression bursts, and all the 3 patients died. In the last 2 patients PLEDs were replaced by localized paroxysmal activity, which was anteriorly registered in 1. PLEDs was found in acute dysfunction of CNS, and in epileptic patients in periods of increased seizure activity. These data suggest that a critical point of alteration of the normal neuronal activity is needed for appearance and maintenance of PLEDs. No correlation could be done between the evolution of PLEDs, always to disappearance, and clinical outcome, that was variable.

NCPAP for the treatment of obstructive sleep apnea.

Nasal continuous positive airway pressure (NCPAP) represents a real advance in the management of obstructive sleep apnea (OSA). Our data show that except for awakenings, all sleep and respiratory parameters were significantly improved (p less than 0.05) in favor of the group treated with NCPAP. A main problem with NCPAP is the acceptance by the patient; it also may disturb the sleep, at least, on short term basis and, in a small number of patients, it does not correct the apneas. In our patients series, males responded better to NCPAP than females.