Hrayr Attarian

Systematic screening allows reduction of adverse antiepileptic drug effects: A randomized trial

Objective: To determine the effectiveness of systematic screening with a brief 19-item self-report instrument, the Adverse Events Profile (AEP), to reduce adverse effects of antiepileptic drugs (AEDs) and improve subjective health status. Methods: The authors performed a prospective randomized trial comparing the use of the AEP with usual care without the AEP. Sixty-two patients with an AEP score of ≥45 were enrolled from a consecutive group of 200 consenting adults with epilepsy. Results: The mean percent improvement in AEP scores was greater in the patient group for which clinicians received the AEP compared with the usual care group (25% vs 5%; p < 0.01). Mean change in Quality of Life in Epilepsy Inventory (QOLIE)-89 total scores was not different between groups, but for the entire sample QOLIE-89 change was greater for patients having a 15-point improvement in AEP scores than for those with a 0- to 15-point improvement or a worsened score (24 vs 12 vs 3; analysis of variance, p < 0.008). More patients in the AEP group had a >15-point improvement in QOLIE-89 score (p < 0.03). Use of the AEP was associated with a 2.8-fold increase (95% CI, 1.7 to 4.8) in AED modifications. No difference in seizure rates was observed. Conclusions: Systematic screening for antiepileptic drug side effects may increase identification of toxicity and guide medication changes to reduce adverse effects and possibly improve subjective health status.

The role of obesity in the increased prevalence of obstructive sleep apnea syndrome in patients with polycystic ovarian syndrome

OBJECTIVES To determine the prevalence of obstructive sleep apnea syndrome (OSAS) in a population of premenopausal women with polycystic ovarian syndrome (PCOS) and to study the impact of obesity on the increased prevalence of OSAS in this population. METHODS Twenty-three premenopausal women with definite PCOS, and no prior diagnosis of a sleep disorder, were recruited from gynecology clinics. An investigator interviewed them, for symptoms of excessive sleepiness, their body mass index (BMI) was calculated, and they underwent overnight polysomnography. RESULTS Sixteen of 23 (69.6%) met criteria for OSAS. Five were treated with continuous positive airway pressure. Confidence interval was 47.7-84.5%. An increased respiratory disturbance index (RDI) did not correlate with higher BMI. CONCLUSIONS OSAS is significantly more prevalent in this population than in a population of obese women. There was no correlation between obesity and severity of the OSAS. Obesity is not the cause of this increased prevalence of OSAS in a population of women with PCOS.

Circadian Rhythm Abnormalities

Purpose: This article reviews the recent advances in understanding of the fundamental properties of circadian rhythms and discusses the clinical features, diagnosis, and treatment of circadian rhythm sleep disorders (CRSDs).Recent Findings: Recent evidence strongly points to the ubiquitous influence of circadian timing in nearly all physiologic functions. Thus, in addition to the prominent sleep and wake disturbances, circadian rhythm disorders are associated with cognitive impairment, mood disturbances, and increased risk of cardiometabolic disorders. The recent availability of biomarkers of circadian timing in clinical practice has improved our ability to identify and treat these CRSDs.Summary: Circadian rhythms are endogenous rhythms with a periodicity of approximately 24 hours. These rhythms are synchronized to the physical environment by social and work schedules by various photic and nonphotic stimuli. CRSDs result from a misalignment between the timing of the circadian rhythm and the external environment (eg, jet lag and shift work) or a dysfunction of the circadian clock or its afferent and efferent pathways (eg, delayed sleep-phase, advanced sleep-phase, non–24-hour, and irregular sleep-wake rhythm disorders). The most common symptoms of these disorders are difficulties with sleep onset and/or sleep maintenance and excessive sleepiness that are associated with impaired social and occupational functioning. Effective treatment for most of the CRSDs requires a multimodal approach to accelerate circadian realignment with timed exposure to light, avoidance of bright light at inappropriate times, and adherence to scheduled sleep and wake times. In addition, pharmacologic agents are recommended for some of the CRSDs. For delayed sleep-phase, non–24-hour, and shift work disorders, timed low-dose melatonin can help advance or entrain circadian rhythms; and for shift work disorder, wake-enhancing agents such as caffeine, modafinil, and armodafinil are options for the management of excessive sleepiness.

Functional MRI reveals an interhemispheric dissociation of frontal and temporal language regions in a patient with focal epilepsy

We report the case of a patient with frontal lobe epilepsy in whom the Wada test failed to lateralize representation of language (fluent speech was observed after amobarbital injection on both the right and left side). Functional magnetic resonance imaging (fMRI) during a lexical processing task revealed an atypical organization of language represented by an interhemispheric dissociation of language regions with a right frontal dominance and a left temporal dominance. Consistent with the fMRI results, the patients ability to name pictures was not reliably impaired by electrocortical stimulation (ECS) of left frontal cortex. The findings from Wada, fMRI, and ECS were confirmed by a lack of language impairment after left frontal lobectomy for seizures. This case illustrates that fMRI can precisely map cortical language networks in epileptic patients and that fMRI may be used to help interpret laterality results provided by the Wada procedure.

Relationship between depression and intractability of seizures

Patients with epilepsy have a higher prevalence of depressive disorders than the general population, but the relationship between seizure rates and depression has not been adequately studied. We used the Beck Depression Inventory to evaluate depressive symptoms in 143 consecutive epilepsy patients from outpatient clinics. Patients who were seizure free more than 6 months were considered not intractable. Thirty-six percent were neither intractable nor depressed, 43% had intractable epilepsy and were not depressed, 10% had intractable epilepsy and were depressed, and 11% did not have intractable epilepsy and were depressed. Patients with epilepsy have a higher prevalence of depression than the general population, but the intractability of the seizure disorder does not seem to be an independent risk factor for the occurrence of depression. There is no relationship between the severity of depression and monthly seizure rate.

Depression but not seizure factors or quality of life predicts suicidality in epilepsy

The objective of this study was to determine prevalence and predictive risk factors of suicidality in a large sample of epilepsy outpatients. We prospectively examined 193 consecutive adult epilepsy outpatients for depression, including suicidal ideation. Demographic and epilepsy factors, medication toxicity and health-related quality of life were also evaluated. The prevalence of suicidal ideation within the past two weeks was 11.9%. Although medication toxicity, health-related quality of life and BDI scores were each associated with suicidal ideation in the bivariate analyses, only the BDI remained significant in the logistic regression analysis. About one-fourth of the subjects with suicidal ideation had no significant symptoms of depression. Recent thoughts of suicide are a common occurrence in the outpatient epilepsy clinic setting, but these are not predicted by gender, age, seizure factors, medication toxicity or self-perceived quality of life. Although depression is associated with suicidal ideation, about one-fourth of the suicidal subjects were euthymic or only mildly depressed.

Correlation of Severity of FDG-PET Hypometabolism and Interictal Regional Delta Slowing in Temporal Lobe Epilepsy

Summary:  Purpose: We investigated the association of severity of hypometabolism detected by positron emission tomography (PET) with [18F]fluorodeoxyglucose (FDG) and persistence of interictal EEG focal slowing in patients with refractory temporal lobe epilepsy.

Restless legs syndrome in pediatric patients with chronic kidney disease

Sleep disorders have been shown to be more prevalent in adults and children with chronic kidney disease (CKD) and on dialysis. To date, the prevalence and impact of restless legs syndrome (RLS) in various stages of CKD has not been evaluated. The object of this study was to determine the prevalence of RLS in children with CKD in different stages, and to evaluate its impact on sleep and daytime functioning. We conducted a clinic-based or telephone survey of 26 patients in varying stages of CKD to assess for RLS, sleep schedule, and daytime sleepiness. Thirty-five percent of children met criteria for RLS, the majority being in CKD stages 1–4. There were no significant differences seen in sleep schedule and daytime sleepiness between those children with or without RLS. We found that there is an increased prevalence of RLS in children with CKD compared to the general population. This suggests that children with all stages of CKD should be routinely screened for RLS symptoms.

Burden of Sleep and Fatigue in US Adults With Atopic Dermatitis.

BackgroundIntense itch associated with atopic dermatitis (AD) can negatively impact sleep. However, the nature of sleep disturbance and fatigue in AD has not been fully elucidated. ObjectivesThe aim of this study was to determine the burden of sleep disturbance and fatigue in US adults with AD. MethodsThis study used a cross-sectional, questionnaire-based survey using a nationally representative sample of 5563 adults from the 2005 to 2006 National Health and Nutrition Examination Survey. Respondents were asked about history of AD, sleep disturbance, and fatigue-related instrumental activity of daily living (IADL) impairment. ResultsThere was no significant association between having AD and having a diagnosed sleep disorder (10.44% vs 7.27%; odds ratio [OR] [95% confidence interval (CI)], 1.49 [0.84–2.64]; P = 0.23); however, respondents were more likely to report sleep disturbances to clinicians (33.38% vs 23.67%; OR [95% CI], 1.62 [1.10–2.38]; P = 0.04). In multivariate regression models controlling for sociodemographic and lifestyle factors, adults with AD had higher odds of sleep disturbances, including shorter sleep duration (adjusted OR [95% CI], 1.61 [1.16–2.25]), trouble falling asleep (adjusted OR [95% CI], 1.57 [1.10–2.24]), and early morning awakenings (adjusted OR [95% CI], 1.86 [1.24–22.78]). Those with AD also had significantly higher odds of feeling unrested and feeling too tired to perform IADLs. ConclusionsUnited States adults with AD have significantly impaired sleep and fatigue affecting IADLs, and sleep disturbances may be underdiagnosed in this population.

Treatment Options for Parasomnias

Parasomnias are undesirable physical or experiential events that occur in and around sleep. Treatments include reassurance in some cases, various forms of cognitive-behavioral therapy (CBT), and pharmacologic agents. Cognitive restructuring, imagery rehearsal, relaxation, hypnosis, desensitization, and anticipatory awakenings are some of the common CBT and nonpharmacologic interventions. Medications that are used belong to a wide variety of pharmacologic classes, such as alpha-blockers (prazosin), tricyclic antidepressants (imipramine and clomipramine), selective serotonin reuptake inhibitors, benzodiazepines (diazepam and clonazepam), anticonvulsants (topiramate and gabapentin), desmopressin acetate, and anticholinergic agents (oxybutynin and tolterodine). Data on efficacy are only available from randomized trials on CBT and prazosin for nightmares and on pharmacologic and alarm therapy for enuresis. No large-scale randomized trials are available to assess the efficacy of the other treatments, and most data come from anecdotal case reports, case series, or small open-label trials.