M. Orth

Driving simulator and neuropsychological [corrected] testing in OSAS before and under CPAP therapy.

Patients with obstructive sleep apnoea syndrome (OSAS) have an increased car accident rate. Investigations on accident frequency are based on case history, insurance reports and driving simulator studies. The present study combines neuropsychological testing of different attention aspects engaged in driving a car and driving simulation to evaluate a suitable instrument for assessing therapeutic effects of continuous positive airway pressure (CPAP). Driving simulator investigation and neuropsychological testing of alertness, vigilance and divided attention were performed in 31 patients with polysomnographically confirmed OSAS (apnoea–hypopnoea index 24.8±21.5·h−1) before, and 2 and 42 days after initiation of CPAP. Divided attention and alertness improved significantly during CPAP, whereas vigilance remained unchanged. However, accident frequency (OSAS before therapy: 2.7±2.0; 2 days after CPAP: 1.5±1.4; 42 days after CPAP: 0.9±1.3) and frequency of concentration faults (OSAS before therapy: 12.4±5.1; 2 days after CPAP: 6.5±3.9; 42 days after CPAP: 4.9±3.3) decreased in the simulated driving situation after 2 and 42 days of therapy. There was no relation between accident frequency, concentration faults and daytime sleepiness, as measured by the Epworth Sleepiness Scale, and polysomnographic or neuropsychological findings, respectively. In conclusion, the present results suggest that driving simulation is a possible benchmark parameter of driving performance in obstructive sleep apnoea syndrome patients.

Assessment of Driving Performance in Patients with Relapsing-Remitting Multiple Sclerosis by a Driving Simulator

Objective: To compare the driving performance using a driving simulator with physical and cognitive functions as measured by the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Functional Composite (MSFC) in patients suffering from the relapsing-remitting form of multiple sclerosis (RRMS). Methods: 31 RRMS patients (18 women, 13 men, mean age 35.6 ± 8.3 years, EDSS 2.8 ± 1.4) were compared with 10 healthy controls (8 men, 2 woman, age 45.1 ± 7.8 years). Results: Compared with controls, the accident rate (5.3 ± 3.8 vs. 1.3 ± 1.5, p < 0.001) and concentration faults (21.1 ± 15.5 vs. 7.1 ± 2.6, p < 0.01) of RRMS patients using the driving simulator were increased. While there was no correlation with the EDSS score, the accident rate was correlated with the MSFC (r = –0.5, p < 0.05). Regarding the three dimensions of the MSFC, accidents were related to the number of correct answers and Z-score in the paced auditory serial addition test (PASAT) as a measure for cognitive function (r = –0.33, p < 0.05). Conclusion: The current study demonstrates the need to focus also on driving skills in MS patients. The risk of accidents should be evaluated after relapses in particular. However, there are great interindividual differences. In the MSFC, most deficits could be evaluated in the PASAT. As there was a significant correlation between the accident rate in the driving simulator and the PASAT results, accidents seem to be more influenced by cognitive decline than by physical impairment. This indicates that the MSFC is a broader, more dimensional scale than the EDSS and should be preferred in the case of driving assessment. At the present time, the driving simulator seems to be a useful instrument judging driving ability, especially in cases with ambiguous neuropsychological results.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version.

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Comparison of driving simulator performance and neuropsychological testing in Narcolepsy

Daytime sleepiness and cataplexy can increase automobile accident rates in narcolepsy. Several countries have produced guidelines for issuing a driving license. The aim of the study was to compare driving simulator performance and neuropsychological test results in narcolepsy in order to evaluate their predictive value regarding driving ability. Thirteen patients with narcolepsy (age: 41.5+/-12.9 years) and 10 healthy control patients (age: 55.1+/-7.8 years) were investigated. By computer-assisted neuropsychological testing, vigilance, alertness and divided attention were assessed. In a driving simulator patients and controls had to drive on a highway for 60 min (mean speed of 100 km/h). Different weather and daytime conditions and obstacles were presented. Epworth Sleepiness Scale-Scores were significantly raised (narcolepsy patients: 16.7+/-5.1, controls: 6.6+/-3.6, P < or = 0.001). The accident rate of the control patients increased (3.2+/-1.8 versus 1.3+/-1.5, P < or = 0.01). Significant differences in concentration lapses (e.g. tracking errors and deviation from speed limit) could not be revealed (9.8+/-3.5 versus 7.1+/-3.2, pns). Follow-up investigation in five patients after an optimising therapy could demonstrate the decrease in accidents due to concentration lapses (P < or = 0.05). Neuropsychological testing (expressed as percentage compared to a standardised control population) revealed deficits in alertness (32.3+/-28.6). Mean percentage scores of divided attention (56.9+/-25.4) and vigilance (58.7+/-26.8) were in a normal range. There was, however, a high inter-individual difference. There was no correlation between driving performance and neuropsychological test results or ESS Score. Neuropsychological test results did not significantly change in the follow-up. The difficulties encountered by the narcolepsy patient in remaining alert may account for sleep-related motor vehicle accidents. Driving simulator investigations are closely related to real traffic situations than isolated neuropsychological tests. At the present time the driving simulator seems to be a useful instrument judging driving ability especially in cases with ambiguous neuropsychological results.

Long-term effects of nasal continuous positive airway pressure on vasodilatory endothelial function in obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) is associated with a dysfunction of vascular endothelial cells. The aim of this study was to investigate long-term improvement of endothelial dysfunction in OSAS with nasal continuous positive airway pressure (nCPAP) treatment. We investigated endothelium-dependent and endothelium-independent vasodilatory function in patients with OSAS using the hand vein compliance technique. Dose–response curves to endothelium-dependent vasodilator bradykinin were obtained in 16 subjects with OSAS before and after 6 months of nCPAP therapy and in 12 control subjects without OSAS. Maximum dilation (Emax) to bradykinin, being impaired in all OSAS patients, was completely restored with nCPAP. Mean Emax to bradykinin rose from 54.9±18.5 to 108.2±28.7% with 164.4±90.0 nights of nCPAP therapy (p<0.0001; Emax healthy controls, 94.8±9.5%). At treatment follow-up, endothelium-dependent vasodilatory capacity was not significantly different in nCPAP-treated OSAS patients vs healthy controls. Mean vasodilation with endothelium independently acting nitroglycerin was not altered initially and did not change with nCPAP therapy indicating that nCPAP restored endothelial cell function and not unspecific, endothelium-independent factors. These results suggest that regular nocturnal nCPAP treatment leads to a sustained restoration of OSAS-induced impaired endothelium-dependent nitric oxide-mediated vasodilation, suggesting an improvement of systemic endothelial dysfunction in patients studied.

Respiratory monitoring in neuromuscular disease — capnography as an additional tool?

Daytime complaints like fatigue, sleepiness and cognitive dysfunction in neuromuscular disease can be due to nocturnal hypercapnia and hypoxemia. Daytime respiratory diagnostics does not reflect sleep disordered breathing. Nocturnal pulse oxymetry and capnography were performed in 11 patients (15-75 years old) with different slowly progressive neuromuscular diseases. Only four patients complained of dyspnea. Pulmonary function was abnormal in three patients. Blood gas samples showed a hypoxemia in three patients. Pulse oxymetry results were pathological in six patients. Nine patients presented abnormal capnographies. According to these results either nocturnal oxygen application was initiated or ventilatory parameters were modified. Daytime symptoms and muscular strength improved markedly. Capnography and pulse oxymetry should be performed during the course of neuromuscular disease to detect respiratory insufficiency. Capnography seems to be a more sensitive indicator for respiratory impairment especially when artificial ventilation has been initiated.

Vascular endothelial dysfunction in patients with mild Obstructive Sleep Apnea Syndrome

ZusammenfassungHINTERGRUND: Untersucht wurde das Vorhandensein einer vaskulären endothelialen Dysfunktion, eine Frühform der Atherosklerose, bei Patienten mit leichtgradigem obstruktivem Schlafapnoe-Syndrom (OSAS) (5/h < AHI < 15/h). PATIENTEN UND METHODE: Wir testeten die endothelzellabhängige und -unabhängige Gefäßreagibilität bei 10 Patienten mit leichtgradigem OSAS, 12 Gesunden und 20 Patienten mit mittel- bis schwergradigem OSAS (AHI > 15/h) mit der Handvenen-Compliance Messtechnik. ERGEBNISSE: Patienten mit leichtgradigem OSAS wiesen eine signifikante Einschränkung ihrer maximalen endothelzellabhängigen Vasodilatation nach Bradykinin-stimulation (Emax: 68,6 ± 30,2 %) gegenüber der gesunden Kontrollgruppe (94,8 ± 9,5 %; p < 0,05) auf, unterschieden sich hierin jedoch nicht signifikant von Patienten mit mittel- bis schwergradigem OSAS (57,1 ± 23,4 %, p = 0,33). Die endothelzellunabhängige Vasodilation war jeweils ungestört. 7 Patienten mit leichtgradigem OSAS zeigten eine Normalisierung ihrer Endothelzellfunktion nach 160,7 ± 82,2 Nächten CPAP-Therapie (Emax 90,8 ± 23,8 %; p < 0,01 vs. Ausgangsmessung; p = 0,7 vs. Gesunde). SCHLUSSFOLGERUNGEN: Eine endotheliale Dysfunktion ist bereits bei Patienten mit leichtgradigem OSAS nachweisbar. Daher ist auch in dieser Patientengruppe ein erhöhtes kardiovaskuläres Risiko anzunehmen und eine CPAP-Therapie empfohlen.SummaryBACKGROUND: We investigated endothelial dysfunction, an early manifestation of atherosclerosis, in patients with mild obstructive sleep apnea syndrome (OSAS) (5/h < AHI < 15/h). PATIENTS AND METHODS: Endothelium-dependent and -independent vasodilatory function was tested in 10 patients with mild OSAS, 12 healthy controls and 20 subjects with moderate to severe OSAS using the hand vein compliance technique. RESULTS: Maximum endothelium-dependent vasodilation to bradykinin (Emax) was significantly blunted in patients with mild OSAS (68.6 ± 30.2 %) compared to healthy controls (94.8 ± 9.5 %; p < 0.05; moderate to severe OSAS: 57.1 ± 23.4 %; p = 0.33). Mean endothelium-independent venodilation was not altered. After 160.7 ± 82.2 nights of CPAP therapy, mean Emax was significantly improved to 90.8 ± 23.8 % (p < 0.01 vs. baseline; p = 0.7 vs. healthy controls) in 7 patients with mild OSAS. CONCLUSIONS: Systemic endothelium-dependent venodilation is markedly reduced in subjects with mild OSAS, which may imply adverse cardiovascular consequences. CPAP-treatment leads to a sustained restoration of endothelial dysfunction in these patients and is thus highly recommended.

Begutachtung der Tagesschläfrigkeit bei neurologischen Erkrankungen und dem obstruktiven Schlafapnoesyndrom (OSAS)

ZusammenfassungPatienten mit erhöhter Tagesschläfrigkeit sind in allen Bereichen des sozialen Umfeldes beeinträchtigt. Gutachterliche Stellungnahmen werden im Rentenverfahren, zur Beurteilung der Einsatzmöglichkeiten am Arbeitsplatz und zur Fahrtauglichkeit gefordert. Der Gutachter muss zur Objektivierung der Schläfrigkeit geeignete Testverfahren auswählen. Vor der endgültigen Begutachtung sollten alle schlafmedizinischen Differenzialdiagnosen abgeklärt und eine optimale Behandlung angestrebt worden sein. Gesetzliche Regelungen für die Bewertung von Schläfrigkeit liegen in den Leitlinien zur Begutachtung der Kraftfahreignung vor. Die Bedeutung der Tagesschläfrigkeit in anderen Berufsgruppen ist arbeitsplatzbezogen zu bewerten. Die Bewertung sollte dem Patienten im Hinblick auf Berufswahl und Arbeitsplatzgestaltung mitgeteilt werden. Der Gutachter hat somit die verantwortungsvolle Aufgabe, eine fachübergreifende Differenzialdiagnostik pathologischer Schläfrigkeit durchzuführen und durch geeignete Untersuchungsverfahren Therapieerfolge zu kontrollieren. Die vorliegende Übersicht soll gesetzliche Grundlagen und geeignete Untersuchungsverfahren darstellen.AbstractPatients with increased daytime sleepiness are impaired in all areas of their social environment. Expert opinions are recommended for pension proceedings, regarding driving licenses as well as for restrictions at the workplace. All possibilities should be considered in the differential diagnosis of sleep disorders, which have to be treated before an expert opinion is submitted. Statutory regulations on evaluation of sleepiness are contained in the guidelines for assessing a patient’s fitness to drive. The importance of daytime sleepiness in other occupations should be assessed according to the respective workplace. The patient should be informed of the appraisal with regard to career choice and workplace design. The expert thus has the responsible task of carrying out interdisciplinary differential diagnosis of pathological sleepiness and monitoring treatment success with appropriate test methods. In the present paper the legal guidelines in Germany and available test methods are presented.

Das obstruktive Schlafapnoe-Syndrom: Ein kardiovaskulärer Risikofaktor?

Introduction Obstructive sleep apnea syndrome (OSAS) is frequently associated with cardiovascular disease. We investigated endothelium-dependent and endothelium-independent nitric oxide-mediated vasodilatory function in normotensive patients with OSAS using the hand vein compliance technique. Patients and methods Dose-response curves to the endothelium-dependent vasodilator bradykinin were obtained in 23 male subjects with OSAS and 12 male control subjects of comparable age, height, and weight. Results Mean (±SD) maximum dilation (Emax) to bradykinin was significantly lower in OSAS patients than in controls (59.8±26.0 vs. 94.8±9.5%, p<0.0001). Mean vasodilation with nitroglycerin was not diminished in the OSAS group (90.7±30.5 vs. 100.3±12.9% in controls; n.s.). In 11 OSAS patients, a follow-up investigation was performed after at least 2 months of treatment with nasal continuous positive airway pressure (CPAP): Emax to bradykinin rose from 54.5±19.2% to 111.5±25.1% after treatment (p<0.001). Mean vasodilation to nitroglycerin was unchanged. Conclusions These results suggest that endothelium-dependent nitric oxide-mediated vasodilation is impaired in patients with OSAS due to an impaired function in the endothelial cells. This impairment is reversible with CPAP treatment. Einleitung Das obstruktive Schlafapnoe-Syndrom (OSAS) ist häufig mit kardiovaskulären Erkrankungen assoziiert. Zur Erkennung möglicher pathophysiologischer Zusammenhänge zwischen OSAS und kardiovaskulären Erkrankungen untersuchten wir daher die Gefäßreagibilität bei normotensiven OSAS-Patienten. Patienten und Methodik Bei 23 männlichen OSAS-Patienten und 12 gesunden männlichen Kontrollprobanden mit vergleichbarem Alter, Größe und Gewicht wurden Dosis-Wirkungskurven nach Gabe des endothelabhängigen Vasodilatators Bradykinin und einer Einzeldosis des endothelunabhängig wirkenden Nitroglycerins mit der Handvenen-Compliancetechnik in vivo bestimmt. Ergebnisse Die mittlere (±Standardabweichung) maximale Gefäßdilatation (Emax) nach Gabe von Bradykinin war bei den OSAS-Patienten signifikant niedriger als in der Kontrollgruppe (59,8±26,0 vs. 94,8±9,5%, p<0,0001). Hingegen war die mittlere Gefäßdilatation nach Gabe von Nitroglycerin in der OSAS-Gruppe nicht signifikant erniedrigt (90,7±30,5 vs. 100,3±12,9% in der Kontrollgruppe; n.s.). Bei 11 der OSAS-Patienten konnte eine Verlaufsuntersuchung nach mindestens zweimonatiger Behandlung mit einer nasalen Überdruck (CPAP)- Therapie durchgeführt werden. Bei diesen Patienten wurde eine Verbesserung der Emax-Werte nach Bradykiningabe von initial 54,5±19,2% auf 111,5±25,1% unter CPAP-Therapie erreicht (p<0,001). Die Vasodilatation nach Nitroglycerin blieb hingegen im Mittel unverändert. Schlussfolgerungen Es konnte gezeigt werden, dass die endothelabhängige Vasodilatation bei Patienten mit OSAS aufgrund einer Dysfunktion der Gefäßendothelzellen gestört ist. Diese endotheliale Dysfunktion ist unter nCPAP-Therapie reversibel.

Quality of life in restless legs syndrome. Influence of daytime sleepiness and fatigue

ZusammenfassungHintergrund und Ziel:Das Restless-Legs-Syndrom (RLS) stellt eine häufige neurologische Erkrankung dar, die durch unangenehme Missempfindungen in den Beinen und motorische Unruhe insbesondere in Ruhe und nachts charakterisiert ist. Diskutiert werden das Ausmaß der aus den nächtlichen Problemen resultierenden Tagesschläfrigkeit und Fatigue und ihr Einfluss auf die Lebensqualität des Patienten. In der vorliegenden Studie sollen unterschiedliche Skalen zur Quantifizierung der Tagessymptomatik verglichen werden.Patienten und Methodik:Untersucht wurden 28 RLS-Patienten (19 Frauen, neun Männer, 58,6 ± 11,9 Jahre alt), davon 78% mit einer schweren Form, mittels der Epworth Sleepiness Scale (ESS), der Fatigue Severity Scale (FSS) und des Lebensqualitätsfragebogens SF-36.Ergebnisse:Jeweils 17 Patienten wiesen eine vermehrte Schläfrigkeit (ESS) und Fatigue (FSS) auf, wobei diese Symptome nicht korrelierten. Subskalen des SF-36 beurteilen entweder eher physische oder mentale Komponenten. Hier ergab sich eine stärkere Einschränkung der physischen Gesundheit bei höheren Fatigue-Werten, eine Einschränkung der mentalen Gesundheit eher bei erhöhter Tagesschläfrigkeit.Schlussfolgerung:Eine Beeinträchtigung der Tagessymptomatik und Lebensqualität durch das RLS lässt sich somit eindeutig belegen. Unterschiedliche Skalen sollten zur objektiven Quantifizierung eingesetzt werden, um eine differenzierte Therapie planen zu können.AbstractBackground and Purpose:Restless legs syndrome (RLS) is a frequent neurologic disorder characterized by leg paresthesia and motor restlessness. It is still under debate to which amount the disease affects quality of life as it causes daytime sleepiness and fatigue. The presented study evaluates the daytime problems by different scales.Patients and Methods:28 patients (19 women, nine men, aged 58.6 ± 11.9 years) with RLS (78% with a severe form) were evaluated with the Epworth Sleepiness Scale (ESS), the Fatigue Severity Scale (FSS) and the SF-36 to judge quality of life. Subscales of the SF-36 contain either rather physical or mental components.Results:17/28 patients showed an increased daytime sleepiness (ESS) and 17/28 increased fatigue (FSS), whereby these symptoms did not correlate. With regard to the SF-36 scores higher values of fatigue caused a greater limitation of the physical health, daytime sleepiness correlated with limitation of the mental health.Conclusion:The study clearly demonstrates an impairment by fatigue and daytime sleepiness in RLS patients. Daytime symptoms worsen quality of life. Different scales have to be used to measure the different daytime symptoms. Therapy must be adjusted to the leading symptoms (e. g., stimulants in daytime sleepiness).