Alessandro Cicolin

Tooth loss and obstructive sleep apnoea

BackgroundComplete tooth loss (edentulism) produces anatomical changes that may impair upper airway size and function. The aim of this study was to evaluate whether edentulism favours the occurrence of obstructive sleep apnoea (OSA).MethodsPolysomnography was performed in 48 edentulous subjects on two consecutive nights, one slept with and the other without dentures. Upper airway size was assessed by cephalometry and by recording forced mid-inspiratory airflow rate (FIF50). Exhaled nitric oxide (eNO) and oral NO (oNO), were measured as markers of airway and oropharyngeal inflammation.ResultsThe apnoea/hypopnoea index (AHI) without dentures was significantly higher than with dentures (17·4 ± 3·6 versus 11·0 ± 2·3. p = 0·002), and was inversely related to FIF50 (p = 0·017) and directly related to eNO (p = 0·042). Sleeping with dentures, 23 subjects (48%) had an AHI over 5, consistent with OSA, but sleeping without dentures the number of subjects with abnormal AHI rose to 34 (71%). At cephalometry, removing dentures produced a significant decrease in retropharyngeal space (from 1·522 ± 0·33 cm to 1·27 ± 0·42 cm, p = 0·006). Both morning eNO and oNO were higher after the night slept without dentures (eNO 46·1 ± 8·2 ppb versus 33·7 ± 6·3 ppb, p = 0·035, oNO 84·6 ± 13·7 ppb versus 59·2 ± 17·4 ppb, p = 0·001).ConclusionThese findings suggest that complete tooth loss favours upper airway obstruction during sleep. This untoward effect seems to be due to decrease in retropharyngeal space and is associated with increased oral and exhaled NO concentration.

Mood and behavioural disorders following traumatic brain injury: clinical evaluation and pharmacological management

In order to investigate phamacotherapeutic responsiveness of major depression and other behavioural disturbances associated with traumatic brain injury (TBI), 20 post-TBI patients were diagnosed as being depressed by two independent neuropsychiatrist observers, out of 37 consecutive TBI subjects sent to psychiatric counselling for poor compliance during rehabilitation programmes or psychiatric/behavioural disturbances after return to society. They were subsequently divided into two subgroups, depending on time elapsed from trauma (A: within 6 months; B: at 24-36 months post-trauma) and were enrolled in an open informed pharmachological study. Rating at baseline included Glasgow Coma Score on hospital admission, length of coma, length of hospitalization, Functional Independence Measure (FIM), Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression scale (CGI). BPRS and CGI were repeated after 12 weeks of oral administration of citalopram (20 mg a day) and carbamazepine (600 mg a day). At baseline, psychiatric symptoms in group B were worse than in group A (particularly somatic overconcern, anxiety, depressed mood, psychomotor slowness, inappropriate and labile affect). At T1, the global (group A and B combined) CGI and BPRS scores showed a statistically significant improvement when compared with T0, even if group B scores remained higher than group A. The results of this study suggest that: (a) citalopram combined with carbamazepine is effective in reducing depression and behavioural disorders following TBI, and (b) these disturbances should be addressed as soon as possible during the acute rehabilitation period.

Interactions Between Anticonvulsant and Psychoactive Drugs

This review considers the relevance of pharmaco‐kinetic interactions between antiepileptic drugs (AEDs) and psychoactive drugs in the treatment of mood disorders in patients with epilepsy. The determination of plasma levels of some of these drugs (mainly the AEDs) has enabled clinicians to evaluate the kinetic modifications during the course of such combined therapies and to adjusting the dosages in cases of subtherapeutic or toxic levels. In general, phenobarbital, phenytoin, and carbamazepine stimulate the catabolic degradation of tricyclic antidepressants (TCAs), and TCAs have an inhibitory effect on the elimination of AEDs. The newer antidepressants that selectively inhibit the reuptake of serotonin (SSRIs), although in different fashions for the different substances (fluoxetine, fluvoxamine, paroxetine) may cause an increase of plasma AED levels through inhibition of the isoenzyme P450 2D6. Similarly, antipsychotics (APs) are more rapidly metabolized when AEDs are co‐administered, whereas AED metabolism is scarcely influenced by AP. Finally, plasma levels of tranquilizers are lowered by AED co‐therapy. As the concomitant administration of AED and psychoactive drugs becomes increasingly used for treatment of mood disorders in patients with or without epilepsy, therapeutic drug monitoring may be useful in designing correct and rational therapy.

Effects of levetiracetam on nocturnal sleep and daytime vigilance in healthy volunteers.

Summary:   Purpose: Individuals with epilepsy commonly report daytime sleepiness, attributed to sleep disruption (frequent arousals, awakenings, and stage shifts) induced by ictal and interictal activity or antiepileptic drugs (AEDs) or both. To study the effect of levetiracetam (LEV) on sleep, at full doses but without the interference of epilepsy, we investigated the sleep architecture and daytime vigilance in healthy adults after 3 weeks of treatment.

Taylor's focal cortical dysplasia increases the risk of sleep-related epilepsy.

Purpose:  To analyze the topography of the epileptogenic zone (EZ) and the etiologic substrate as risk factors for sleep‐related focal epilepsy.

Angiotensin-Converting Enzyme Inhibitors and Obstructive Sleep Apnea

Angiotensin-converting enzyme (ACE) inhibitors may induce cough and rhinopharyngeal inflammation. Obstructive sleep apnea (OSA) is characterized by upper airway inflammation. We describe a patient who, during enalapril treatment, developed cough, upper airway symptoms, and diurnal sleepiness, with an increased number of obstructive apnea-hypopnea episodes (apnea-hypopnea index [AHI], 25) during sleep. Her symptoms and AHI improved 1 month after enalapril was discontinued and diuretic therapy (hydrochlorothiazide-spironolactone) was initiated. Similar findings were observed in 4 other patients with OSA who had ACE inhibitor-induced cough. The mean +/- SD AHI was 33.8+/-21.0 during enalapril treatment and 20.0+/-17.0 after withdrawal of this drug (P = .04). Exhaled nitric oxide, a marker of airway inflammation, was increased during enalapril treatment (15.0 +/- 4.3 parts per billion) and decreased after discontinuation of this drug (9.0 +/- 2.6; P = .03). No significant difference in the AHI and exhaled nitric oxide was observed in 4 patients with OSA who did not experience cough, before or after withdrawal of ACE inhibitor treatment. These findings suggest that ACE inhibitor treatment may contribute to OSA by inducing upper airway inflammation.

Sleep improvement with levodopa/ carbidopa intestinal gel infusion in Parkinson disease

Sleep disorders are common in patients with advanced Parkinsons disease (PD). Nocturnal akinesia and sleep fragmentation frequently coexist with daytime sleepiness, influencing daytime functioning. Levodopa/carbidopa intestinal gel (LCIG) infusion has been shown to improve motor complications in advanced PD, and preliminary findings suggest that sleep might improve following LCIG infusion.

Comparison between Automatic and Visual Scorings of REM Sleep without Atonia for the Diagnosis of REM Sleep Behavior Disorder in Parkinson Disease

Study Objectives: To compare three different methods, two visual and one automatic, for the quantification of rapid eye movement (REM) sleep without atonia (RSWA) in the diagnosis of REM sleep behavior disorder (RBD) in Parkinsons disease (PD) patients. Methods: Sixty‐two consecutive patients with idiopathic PD underwent video‐polysomnographic recording and showed more than 5 minutes of REM sleep. The electromyogram during REM sleep was analyzed by means of two visual methods (Montréal and SINBAR) and one automatic analysis (REM Atonia Index or RAI). RBD was diagnosed according to standard criteria and a series of diagnostic accuracy measures were calculated for each method, as well as the agreement between them. Results: RBD was diagnosed in 59.7% of patients. The accuracy (85.5%), receiver operating characteristic (ROC) area (0.833) and Cohens K coefficient (0.688) obtained with RAI were similar to those of the visual parameters. Visual tonic parameters, alone or in combination with phasic activity, showed high values of accuracy (93.5‐95.2%), ROC area (0.92‐0.94), and Cohens K (0.862‐0.933). Similarly, the agreement between the two visual methods was very high, and the agreement between each visual methods and RAI was substantial. Visual phasic measures alone performed worse than all the other measures. Conclusion: The diagnostic accuracy of RSWA obtained with both visual and automatic methods was high and there was a general agreement between methods. RAI may be used as the first line method to detect RSWA in the diagnosis of RBD in PD, together with the visual inspection of video‐recorded behaviors, while the visual analysis of RSWA might be used in doubtful cases.

Increased risk of impulse control symptoms in Parkinson's disease with REM sleep behaviour disorder

Objective To assess the frequency of symptoms of impulse control disorders (ICD, namely pathological gambling, compulsive sexual behaviour, compulsive eating and compulsive shopping) and related behaviours (hobbyism, punding, walkabout and dopamine dysregulation syndrome) in patients with Parkinsons disease (PD) with and without probable rapid eye movement, sleep behaviour disorder (pRBD). Methods Two hundred and sixteen consecutive PD patients, attending two university-based movement disorders clinics, were screened for p-RBD using the RBD Single Question and the RBD Screening Questionnaire (RBDSQ). Current ICDs and related behaviours symptoms were assessed with the Questionnaire for Impulsive-Compulsive Disorders in PD (QUIP)-short form. Results PD-pRBD patients (n=106/216;49%) had a longer PD duration, a higher Hoehn & Yahr score, a greater levodopa-equivalent daily dose (LEDD), but no difference in dopamine agonist use, compared to PD-without pRBD. A higher proportion of one or more current ICDs and related behaviours symptoms was reported in PD-pRBD compared to PD-without RBD (53% vs28%; p=0.0002). In a multivariate regression analysis accounting for gender, age of onset, PD duration, PD severity, depression score and total and dopaminergic agonist-LEDD, RBD was associated to a relative risk of 1.84 for any ICD or related behaviours symptoms (p=0.01), and to a risk of 2.59 for any ICD symptoms only (p=0.001). Furthermore, PD-pRBD had a more than fourfold risk for symptoms of pathological gambling (relative risk (RR): 4.87; p=0.049) compared to PD-without pRBD. Conclusions The present study indicates that RBD is associated with an increased risk of developing symptoms of ICDs in PD. Identifying RBD in PD may help clinicians to choose the best therapeutic strategy. Trial registration AU1023 Institutional Ethics Committee.

Sexual behaviors during sleep associated with polysomnographically confirmed parasomnia overlap disorder

Parasomnia overlap disorder (POD) refers to a sleep disorder characterized by the association of REM sleep behavior disorder (RBD) with NREM sleep parasomnia in the same patient. Sexual behaviors during sleep (SBS) can include most wakeful sexual activities and are classified in the ICSD-2 as a variant of confusional arousals and sleepwalking, both NREM parasomnias. A case of SBS associated with sleepwalking and possible RBD has been previously described, but it was not confirmed by polysomnography (PSG). We report two patients with SBS associated with POD documented by PSG. In one patient (60-year-old female) SBS was video-polysomnographically demonstrated: a few minute episode of masturbation occurring during slow-wave sleep (SWS) and preceded by hypersynchronous delta pattern. During the episode, the EEG pattern showed the persistence of delta rhythms with increasing alpha activity. When awoken by technicians, the patient was not aware of her sexual behavior and did not report any dream. The other patient, a 41-year-old male with a history of sleepwalking and RBD, was legally charged with repeatedly sexually fondling a young girl during the night. The POD was documented by PSG. The parasomnia defense, including sleepsex, was accepted by the Court and the patient was acquitted. This is an unprecedented report of SBS in patients with PSG-confirmed POD and of SBS documented during video-PSG.