Jakub Antczak

Negative influence of L-dopa on subjectively assessed sleep but not on nocturnal polysomnography in Parkinson's disease

BACKGROUND Sleep disorders are highly prevalent among patients with Parkinsons disease (PD). Chronic medication with L-dopa may be one of the factors that contributes to poor sleep quality. The aim of this study was to assess the effects of long term use of L-dopa on objective and subjective measures of sleep quality in PD patients. METHODS Twenty-seven PD patients (mean age 62.5 ± 8.6 years, mean disease duration 7.3 ± 5.9 years, 11 females) underwent nocturnal polysomnography. Their sleep was rated subjectively using the Parkinsons disease sleep scale (PDSS), and their disease severity was assessed using the unified Parkinsons disease severity scale (UPDRS) standard questionnaire. Doses of L-dopa and other medications were correlated with parameters of sleep quality. The polysomnographic recordings were compared with those from 24 age- and gender-matched normal controls. RESULTS The patients showed decreased total sleep time (TST) and sleep efficiency (SE), prolonged sleep onset and REM sleep latency and wake after sleep onset (WASO). Parts I-III of the UPDRS scores correlated with TST, SE and WASO but not with PDSS scores. L-dopa dosage and part IV of the UPDRS correlated with PDSS scores but not with polysomnographic parameters. CONCLUSIONS Higher doses of chronically administered L-dopa correlated with lower sleep quality according to the subjective measures but not according to the polysomnographic parameters, which were related to the severity of PD symptoms. The low sleep quality according to the subjective measurements may result from complications of therapy at high doses of L-dopa.

Safety of nerve conduction studies in patients with implantable cardioverter–defibrillators

OBJECTIVE A patient with an implantable cardioverter-defibrillator (ICD) may suffer from neuromuscular disorders and may need to undergo a nerve conduction study (NCS). However, a NCS may be a source of electromagnetic interference (EMI). The aim of the present study was to investigate whether the interference from NCS used in a standardised test protocol affects ICD function. METHODS Twenty patients (19 males; mean age of 59.8±9.9 years) with implantable ICDs (eight with integrated and 12 with true bipolar leads), treated with amiodarone and with symptoms suggesting neuropathy were included. NCS were conducted using repetitive stimulation with frequency of 2 Hz and single, rectangular pulses of intensity up to 100 mA. Stimulation was performed in standard sites including proximal sites in the arm. RESULTS The impulses generated NCS were not detected by the ICD, irrespective of the site, rate or stimulus intensity. CONCLUSIONS Standardised test protocol for an NCS is safe in patients with an ICD regardless of the leads type. SIGNIFICANCE Current guidelines which limitate the NCS in patients with ICD may be the subject of revision.

Frequent difficulties in the treatment of restless legs syndrome - case report and literature review

Restless legs syndrome (RLS) is one of the most common sleep disorders. The purpose of this paper is a case description of the patient suffering from RLS, concurrent with numerous clinical problems. In our patient, during long-term therapy with a dopamine agonist (ropinirole), the phenomenon of the augmentation, defined as an increase in the severity of the RLS symptoms, was observed. The quality of life of the patient was significantly deteriorated. Due to the augmentation of RLS symptoms the dopaminergic drug was gradually withdrawn, and the gabapentin as a second-line drug for the treatment of RLS was introduced. Because of the large increase of both insomnia and RLS symptoms during the reduction of ropinirole dose, clonazepam was temporarily introduced. In addition, in the neurological assessment of the distal parts of the lower limb sensory disturbances of vibration were found. The neurographic study confirmed axonal neuropathy of the sural nerves, which explained an incomplete response to dopaminergic medications. However, gabapentin treatment in the dose recommended in neuropathies was impossible due to bothersome side effects. Another important issue in the treatment of the patient were depressive symptoms and the fact that the majority of used antidepressants (mirtazapine, mianserin, tricyclic antidepressants) increase the severity of RLS. Among antidepressants recommended for the treatment of depression in patients with RLS (such as bupropion, moclobemide, reboxetine, tianeptine and agomelatine) only agomelatine exhibits promoting sleep properties. Because of the concomitant insomnia, this drug was applied in our patient.

Are there clinical and neurophysiologic predictive factors for a positive response to HF-rTMS in patients with treatment-resistant depression?

Better selection of patients with treatment-resistant depression for high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) would make the procedure more efficient. The objective of this study was to search for clinical and neurophysiologic predictors of therapeutic response with a special focus on the bipolar population. Forty patients (30 bipolar) underwent 20 daily sessions of HF-rTMS. Clinical outcome measures included the 21-item Hamilton Depression Rating Scale, the Beck Depression Inventory, the Clinical Global Impression, and the Patient Global Impression. Neurophysiologic measurements included repeated estimation of the motor threshold and cortical silent period. Improvement was obtained in all psychometric scales, with no difference between unipolar and bipolar patients. Longer duration of the illness, higher number of prior hospitalizations, and more disturbed activity were associated with a worse response to rTMS, and somatic anxiety, sleep disorders, and health worries were positive predictors. In bipolar patients, longer disease duration and therapy with mirtazapine, mianserin, trazodone, hydroxyzine, and promethazine were associated with a worse response. Sleep disturbances, higher baseline motor threshold, and longer cortical silent period predicted a better response. In this study, we found several clinical and neurophysiologic predictors of better/worse responses to the standard HF-rTMS protocol. Our preliminary data need to be reproduced.

The influence of the repetitive transcranial magnetic stimulation on sleep quality in depression

OBJECTIVES Repetitive transcranial magnetic stimulation (rTMS) improves mood in depression. In this study we investigated whether the depression-related insomnia is modulated by this therapeutic method. METHODS We examined 13 patients (mean age 50.6±13.9; 11 women) with bipolar or unipolar depression. During 20 consecutive days, excluding Saturdays and Sundays, they underwent 20 daily sessions of 10 Hz rTMS over the left dorsolateral prefrontal cortex (DLPFC). Outcome measurement included the Clinical Global Impression (CGI), the 21item Hamilton Depression Rating Scale (HDRS), the Athens Insomnia Scale (AIS) as well as sleep diary and actigraphy. RESULTS After rTMS, the CGI and HDRS total score decreased significantly. Also, the insomnia-related items of HDRS improved. The AIS showed trend towards decrease. No significant changes were present in sleep diaries and actigraphy. CONCLUSIONS The beneficial effect of rTMS on the mood in depression has been confirmed. The rest of the results suggest high frequency rTMS to the left DLPFC does not have strong effects on sleep quality in patients with depression. Additional interventions or modification of the rTMS protocol should be considered to improve insomnia in these patients.

Association of peripheral neuropathy with sleep-related breathing disorders in myotonic dystrophies

Background Myotonic dystrophy (DM) type 1 and type 2 are inherited diseases characterized by myotonia and myopathy. Additional symptoms include, among others, peripheral neuropathy and sleep-related breathing disorders (SRBDs). There is growing evidence for a complex association between DM1 and DM2, which was described in patients with diabetes mellitus and in the general population. In this study, we investigated whether there is an association between peripheral neuropathy and SRBDs also in the population of patients with DM. Methods The study included 16 patients with DM1 (mean age, 37.9±14.1 years; 20–69 years) and eight patients with DM2 (mean age, 47.6±14.1 years; 20–65 years), who underwent a sensory and motor nerve conduction study (NCS) and diagnostic screening for SRBDs. In both groups, the NCS parameters were correlated with respiratory parameters. Results In both groups, the amplitude of the ulnar sensory nerve action potential (SNAP) correlated with the mean arterial oxygen saturation (SaO2). In addition, in the DM2 group, the median SNAP correlated with the mean SaO2. In the DM1 group, the median SNAP and the distal motor latency (DML) of the ulnar nerve correlated with the apnea–hypopnea index, while the oxygen desaturation index correlated with the DML of the tibial nerve and with conduction velocity in the sural nerve. Conclusion Our results indicate a complex association between neuropathy and SRBDs in DM1 and DM2. Axonal degeneration may contribute to nocturnal hypoxemia and vice versa. Neuropathy may contribute to muscle weakness, which in turn may cause respiratory events.

Current applications and perspectives of neurologic and psychiatric disorderstherapy with repetitive transcranial magnetic stimulation

Przezczaszkowa stymulacja magnetyczna serią bodźców (repetitive transcranial magnetic stimulation, rtMs) jest modyfikacją tradycyjnej TMS. W odróżnieniu od TMS, w której pojedyncze lub podwójne bodźce pola magnetycznego używane są w celu diagnostyki funkcjonalnej układu nerwowego, rTMS stosuje serie bodźców magnetycznych w celu modyfikacji pobudliwości korowej. W zależności od częstotliwości bodźców można uzyskać wzrost lub spadek pobudliwości, określane mianem odpowiednio długotrwałej depresji i długotrwałej potencjacji. W obu przypadkach dochodzi do zmian w przekaźnictwie nerwowym, co z kolei może przełożyć się na zmianę funkcji poznawczych, motorycznych i innych. Zmiany te mogą być indukowane celem osiągnięcia pozytywnych efektów w wielu chorobach układu nerwowego. Artykuł prezentuje zasadę działania, zasady bezpieczeństwa i zastosowania rTMS w chorobach, w których skuteczność terapeutyczna jest wystarczająco udokumentowana. Najszerzej omówione zostaną choroby, w których skuteczność terapeutyczną rTMS można uznać za pewną, czyli choroba afektywna jednobiegunowa i ból neuropatyczny, a także te, w których skuteczność jest prawdopodobna, czyli negatywne objawy schizofrenii oraz niedowład po udarze mózgu. Ponadto w artykule wspomniane są potencjalne zastosowania rTMS, wymagające jeszcze badań klinicznych, np. szumy uszne, migrena, a także nowoczesne paradygmaty stymulacji, jak stymulacja theta burst. W artykule omówiono także, zyskujące ostatnio na znaczeniu, merytoryczne i etyczne kwestie stymulacji rTMS osób zdrowych w celu podniesienia wydajności funkcji poznawczych. Słowa kluczowe: rTMS, depresja, długofalowa potencjacja, długofalowa depresja, ból neuropatyczny.

P1042: Relation of sleep stages and sleep period to the cortical excitability in Parkinson’s disease

in patients referred to Telemetry Unit for seizure disorders evaluation. Some of the patients referred to Telemetry unit are for assessment of Non-Respiratory Sleep Disorders (NRSDs) and can benefit from HVT-P. Question: Can HVT-P be performed successfully at the patients’ own homes? Methods: An observational study comprising of eleven adult patients with NRSDs was carried out. Patients underwent 2-3 nights of HVT-P at their homes. Recorded data was retrieved daily for analysis. Data acquisition included Video synchronised with sleep staging parameters consisting of 27 channels (19 EEGs, 2 EOGs, 5 EMGs and 1 ECG). Conventional parameters for duration, continuity and quality of Sleep Period Time (SPT) were applied for sleep scoring. Video quality was graded according to its ability to characterise behavioural events occurring during sleep period. Results: Duration and continuity were good in 10/11. The EEG and Chin EMG signal were good in 10/11. The EOG signal was good in 9/11 and satisfactory in 1/11. Video was good in 6/11 and satisfactory in 5/11. Audio was good in 7/11 and satisfactory in 4/11. Conclusions: Previous studies indicate that that sleep staging signals are most susceptible to quality loss making sleep analysis difficult. This study shows an overall quality of 91% for EEG/EMG signals and 82% for EOG signals. This suggests HVT-P can successfully be performed at the patients’ home and compares favourably with laboratory based recordings.