Diagnostic criteria used in studies of reflex sympathetic dystrophy

OBJECTIVE

Assessment of the diagnostic criteria of reflex sympathetic dystrophy (RSD) and evaluation of the impact of the introduction of the diagnostic criteria of complex regional pain syndrome (CRPS) on the international application of diagnostic criteria of RSD.

METHODS

Randomized controlled trials and clinical investigations, published between January 1980 and June 2000, were evaluated with regard to the applied diagnostic criteria of RSD.

RESULTS

One hundred seven studies were identified. Thirty-four of these studies were excluded because of inadequate reporting of diagnostic criteria. The 73 included studies were not homogeneous with regard to the diagnostic criteria because they applied many different aspects of sensory and autonomic features. Only 12% of the studies considered the presence of motor features, mostly vaguely described, as mandatory for the diagnosis RSD. Although 10 of the 23 studies published since the introduction of CRPS have applied this term, only 3 used the exact criteria without additions or other modifications.

CONCLUSION

Diagnostic criteria sets of RSD focus on many different aspects of sensory and autonomic features that generally are described vaguely. This has not changed since the introduction of the CPRS criteria. These findings question whether the current criteria adequately define RSD.

Health related quality of life in Parkinson's disease: a systematic review of disease specific instruments

OBJECTIVE

To compare and contrast disease-specific quality of life instruments in Parkinson's disease and assess their clinimetric properties.

METHODS

Two reviewers independently evaluated both thoroughness and results of studies regarding clinimetric characteristics of identified scales.

RESULTS

Twenty studies were found reporting on the clinimetric properties of four scales. The content validity of the Parkinson's disease questionnaire-39 item version (PDQ-39), the Parkinson's disease quality of life questionnaire (PDQL), and the "Fragebogen Parkinson LebensQualität" (Parkinson Quality of Life questionnaire; PLQ) was adequate to good, but for the Parkinson's impact scale (PIMS) it was insufficient. Construct validity of both the PDQ-39 and the PDQL was good, but for the PLQ and the PIMS this was insufficiently evaluated. Internal consistency of all scale totals and of subscale totals of the PDQL were good, whereas for the social support subscale of the PDQ-39 and four subscales of the PLQ this was inadequate. Test-retest reliability was not evaluated for the PDQL and was adequate in the other scales. Responsiveness was partially established for the PDQ-39, and not assessed for the other scales. The number of available translations, as well as the number of studies in which these instruments were used, differed considerably.

CONCLUSIONS

The selection of an instrument partially depends on the goal of the study. In many situations however, the PDQ-39 will probably be the most appropriate HRQoL instrument. The PDQL may be considered as an alternative, whereas the PLQ may be considered in studies involving German speaking patients with Parkinson's disease. Use of the PIMS should be considered only as a means of identifying areas of potential problems.

Clinical aspects of multifocal or generalized tonic dystonia in reflex sympathetic dystrophy

The authors describe 10 patients with reflex sympathetic dystrophy that progressed to a multifocal or generalized tonic dystonia. The neuropsychologic profile was similar to that of other patients with chronic pain, irrespective of its cause. The distribution pattern of dystonia, the stretch reflex abnormalities, and the worsening of dystonia after tactile and auditory stimuli suggest impairment of interneuronal circuits at the brainstem or spinal level. Antibody titers for glutamic acid decarboxylase, tetanus, and Sjögren antigens were all normal.

Quantitative assessment of daytime motor activity provides a responsive measure of functional decline in patients with Huntington's disease

Voluntary motor impairment is a functionally important aspect of Huntington's disease (HD). Therefore, quantitative assessment of disturbed voluntary movement might be important in follow-up. We investigated the relation between quantitatively assessed daytime motor activity and symptom severity in HD and evaluated whether assessment of daytime motor activity is a responsive measure in the follow-up of patients. Sixty-four consecutive HD patients and 67 age- and sex-matched healthy controls were studied. Daytime motor activity was recorded using a wrist-worn activity monitor that counts all movements during a period of five consecutive days. Patients were rated clinically for voluntary motor impairment, dyskinesias, posture & gait, depression, cognitive impairment and functional capacity. Follow-up was available from 40 patients (mean follow-up 2.0 years) and 29 controls (mean follow-up 5.9 years). Despite chorea, patients had less daytime motor activity than controls (P < 0.005). This hypokinesia correlated with impaired voluntary movements (r = 0.37; P < 0.01), disturbed posture & gait (r = 0.38; P < 0.005) and especially with reduced functional capacity (r = 0.51; P < 0.0005). During follow-up, hypokinesia remained unchanged in clinically stable patients, but became worse in those whose functional disability progressed (P < 0.005). Hypokinesia seems a core symptom of HD which is related to functional capacity. Actimetric assessment of hypokinesia is responsive to disease progression and can be used as an objective tool for follow-up.

Innate cytokine profile in patients with complex regional pain syndrome is normal

Complex regional pain syndrome (CRPS) is a disabling disease characterized by the classic symptoms and signs of inflammation. In this study we investigated the innate cytokine profile in patients with CRPS to determine a possible role of the immune system in the pathophysiology of CRPS. The cytokine profile before and after lipopolysaccharide and thrombin stimulation was determined in 26 severely affected CRPS patients and 20 healthy controls. No difference in the production of pro- and anti- inflammatory cytokines between patients and controls was found. Hence, our results do not support a role of genetic factors responsible for the cytokine profile in the pathophysiology of CRPS. These findings encourage further investigations of mechanisms responsible for neurogenic-induced inflammation.

Accelerometric assessment of levodopa-induced dyskinesias in Parkinson's disease

Our objective was to develop parameters for objective ambulatory measurements of levodopa-induced dyskinesias (LID) in patients with Parkinson's disease (PD). Twenty-three PD patients with mild to severe LID were submitted to a standardized protocol of 1-minute recordings during rest, talking, stress, and four activities of daily life (ADL). Patients were simultaneously monitored with portable multi-channel accelerometry (four pairs of bi-axial sensors mounted onto the most affected arm, leg, and at the trunk) and recorded by video. LID severity was assessed with a modified Abnormal Involuntary Movement Scale (m-AIMS). The signals were analyzed, and every 1/8-second interval the amplitude was obtained of the dominant frequency within 1-4 Hz and 4-8 Hz frequency bands (Amp1-4 and Amp4-8). For both measures, convergent validity, reproducibility, and responsiveness were determined. In absence of voluntary movements, a significant relation was found between Amp1-4 and Amp4-8 and m-AIMS. Repeated measurements during rest showed a high reproducibility (intraclass correlation coefficient = 0.90 [Amp1-4] and 0.86 [Amp4-8]). The extent to which LID increased with talking and stress correlated significantly (p = 0.02) between the objective and clinical measures (intraclass correlation for differences = 0.67). During ADL, LID occurred in a similar frequency band as voluntary movements and only Amp1-4 and Amp4-8 of the trunk and leg sensor remained highly correlated with m-AIMS. Although objective measures of LID are reliable and responsive, they fail to distinguish LID from voluntary movements. These measures are of value only when obtained during rest (all sensor sites) or during ADL when derived from those body segments that are normally not involved in these ADL tasks (trunk and leg).

Detection and assessment of the severity of levodopa-induced dyskinesia in patients with Parkinson's disease by neural networks

Levodopa-induced dyskinesias (LID) in Parkinson's disease (PD) have remained a clinical challenge. We evaluated the feasibility of neural networks to detect LID and to quantify their severity in 16 patients with PD at rest and during various activities of daily living. The movements of the patients were measured using four pairs of accelerometers mounted on the wrist, upper arm, trunk, and leg on the most affected side. Using parameters obtained from the accelerometer signals, neural networks were trained to detect and to classify LID corresponding to the modified Abnormal Involuntary Movement Scale. Important parameters for classification appeared to be the mean segment velocity and the cross-correlation between accelerometers on the arm, trunk, and leg. Neural networks were able to distinguish voluntary movements from LID and to assess the severity of LID in various activities. Based on the results in this study, we conclude that neural networks are a valid and reliable method to detect and to assess the severity of LID corresponding to the modified Abnormal Involuntary Movement Scale.

Multifocal or generalized tonic dystonia of complex regional pain syndrome: a distinct clinical entity associated with HLA-DR13

We report on 26 patients with a distinct phenotype of complex regional pain syndrome that progressed toward a multifocal or generalized tonic dystonia. The dystonia initiated distally, involved mainly flexor muscles, and was associated with sensory and autonomic symptoms. Dryness of the eyes or mouth and bladder and bowel disturbances were frequently reported. There was no increase in the familial prevalence of autoimmune-mediated diseases. Compared with controls, a significant elevation of HLA-DR13 was found in the patients. Thus, HLA-DR13 may be a factor indicating susceptibility to this distinct phenotype of complex regional pain syndrome.

Bromocriptine for levodopa-induced motor complications in Parkinson's disease

OBJECTIVES

To assess the efficacy and safety of adjunct bromocriptine (BR) therapy compared to placebo in the treatment of Parkinson's disease (PD) patients with motor complications.

SEARCH STRATEGY

Sources including the Cochrane Library, a MEDLINE search-strategy, reference lists of the reviews found by the MEDLINE search-strategy, Sandoz (producer of BR), symposia reports, PD handbooks, SCISEARCH, contacts with colleagues who had co-ordinated trials on BR and reference lists of all included studies were used to identify randomized controlled trials (RCTs) of interest.

SELECTION CRITERIA

Randomized trials were eligible for inclusion if they evaluated the efficacy of BR as adjunctive to LD-therapy compared to placebo in PD patients with motor complications. Outcome measures that were evaluated, included occurrence and severity of motor complications, scores on impairment and disability, and the occurrence of side effects.

DATA COLLECTION AND ANALYSIS

Three reviewers independently reviewed the quality of identified trials. To determine the feasibility of a quantitative systematic review each eligible study was evaluated concerning the methodological quality.

MAIN RESULTS

This review identified important shortcomings regarding the methodological quality of eight trials. All studies failed to describe adequately their randomization procedure. Consultation with the trialists revealed that three trials adequately randomized their patients. Contrary to the information of the published report, one placebo-controlled trial appeared to be carried out as an open study and was therefore excluded. The remaining seven trials were reported to be carried out according to a double-blind design, although one was unblinded after five weeks. There was a conspicuous variability in the duration of trials: four to forty weeks (mean 14 weeks). None of the included trials was performed according to the intention-to-treat principle. With regard to the inclusion criteria, it frequently remained unclear if PD patients actually suffered from motor complications. Prominent differences between studies regarding the baseline characteristics and the rate by which BR was introduced during the titration phase were found. Major differences between studies emerged concerning the applied outcomes. The various methods used to evaluate the occurrence and/or severity of motor complications lacked a sound clinimetric basis. A great diversity of scales to evaluate impairment and disability was applied. None of the included trials reported whether scores on impairment and disability level referred to the "on"- or "off"-phase.

REVIEWER'S CONCLUSIONS

This review highlights major methodological problems and sources of heterogeneity that not only hamper the comparability of trials but also preclude a conclusion on the efficacy of BR in the adjunct treatment of PD patients with motor complications.

Bromocriptine versus levodopa in early Parkinson's disease

BACKGROUND

Drugs that mimic dopamine as bromocriptine were introduced as monotherapy or in a combination with LD in the hope that this approach would prevent or delay the onset of motor complications in patients with Parkinson's disease (PD). However, hitherto, the role of bromocriptine (BR) in this issue has remained controversial. The present study is a systematic review of all randomized controlled trials of bromocriptine monotherapy compared with levodopa (LD) monotherapy in PD.

OBJECTIVES

To assess the efficacy and safety of bromocriptine (BR) monotherapy for delaying the onset of motor complications associated with levodopa (LD) therapy in patients with Parkinson's disease (PD).

SEARCH STRATEGY

Sources including the Cochrane Library, the search strategy of the Movement Disorders Group (includes computerised searches of MEDLINE and EMBASE and hand searching of appropriate neurology journals), reference lists of the reviews found by the MEDLINE and EMBASE search-strategy, Sandoz -now Novartis- (manufacturer of BR), symposia reports, PD handbooks, contacts with colleagues who had co-ordinated trials on BR and reference lists of all included studies were used to identify randomized controlled trials (RCTs) of interest.

SELECTION CRITERIA

Randomized trials were eligible for inclusion if they evaluated the efficacy of BR monotherapy for delaying the onset of motor complications compared to LD therapy in PD patients. Outcome measures that were evaluated included occurrence and severity of motor complications, changes in impairment and disability, and the occurrence of side effects.

DATA COLLECTION AND ANALYSIS

To determine the feasibility of a quantitative systematic review two independent reviewers evaluated the methodological quality of identified trials.

MAIN RESULTS

Over the period of 1974 to January 1999 we identified six studies randomizing more than 850 patients to a BR or a LD regimen. The majority of the studies lacked sample size calculations and randomization procedure remained unclear in three trials. Only two trials were performed according to a double-blind design. Important differences between studies concerning the duration of trials, the BR titration phase, the achieved mean dose of LD or BR, and the applied outcomes were found. Because of these differences, we could not pool the data from the different trials in an attempt to perform a meta-analysis. Therefore, the available data of the individual trials was re-analysed. Subsequently, the results were interpreted against the background of the sources of heterogeneity between the studies. The occurrence of dyskinesias in three short trials was too low to allow any conclusion. The results of the longer trials indicate a lower occurrence of dyskinesias in the BR tier. In five trials that evaluated dystonia, this motor complication occurred less frequent in the BR tier. However, for both dyskinesias and dystonia a statistically significant difference in favour of BR emerged only in the largest trial. There was a trend for wearing-off and on-off fluctuations to occur less frequently in the BR group. Although all trials evaluated patients at the impairment level, only the largest trial reported a significantly larger improvement for the LD tier during the first year of therapy. Concerning disability, which was evaluated by five trials no statistically significant differences were found. Overall, a statistically larger number of dropouts occurred in the BR group because of an inadequate therapeutic response or intolerable side effects.

REVIEWER'S CONCLUSIONS

This systematic review identified important sources of heterogeneity between trials. Inadequate powering of the studies and clinically relevant differences in trial duration, applied outcomes, and trial design may explain the different results and why many findings failed to reach a statistically significant level. Nevertheless, based on qualitative review of available data we conclude that in the treatment of early Parkinson's disease, bromocriptine may be beneficial in delaying motor complications and dyskinesias with comparable effects on impairment and disability in those patients that tolerate the drug.

Clinimetric issues of screening for responsiveness to intrathecal baclofen in dystonia

OBJECTIVES

In this study we address clinimetric issues that pertain to the screening of responsiveness to intrathecal baclofen (ITB) in dystonia.

METHODS

Eight patients with severe dystonia, who did not respond to oral medication, were evaluated in a double-blind placebo controlled ascending dose screening procedure, which included a randomised sequence of injections of 25, 50 and 75 microg baclofen and placebo. Self-assessments of dystonia severity on a visual analogue scale (VAS) and the Dyskinesia Rating Scale (DRS) were carried out at baseline 1, 4 and 8 hours after a bolus injection.

RESULTS

Compared to the VAS, the DRS lacked responsiveness in all patients. Baseline scores of the VAS scores varied considerably between and within patients and underscore the need to express response scores in relation to the baseline. After placebo administration some patients showed a persistent improvement of about 30% across the day, while at some assessments improvements of >50% were noted. Based on the aforementioned findings, a responsiveness coefficient was used which relates the baclofen effect size to the non-specific score changes that may occur as a placebo effect or as random fluctuations in dystonia. Four patients with a responsiveness coefficient >2 received pump implantation and did well on continuous infusion of ITB. Several side effects occurred during the screening procedure, but none interfered with the execution of the screening procedure.

CONCLUSIONS

This study demonstrates important clinimetric issues that need to be taken into account when screening for responsiveness to ITB.

[Drug therapy in Parkinson's disease]

Levodopa is still the mainstay of the treatment of Parkinson's disease. Limitations of levodopa therapy have led to development of numerous therapeutic approaches at the level of levodopa/dopamine metabolism, dopamine receptors, dopamine transporter, and other neurotransmitter systems. New insights into the pathophysiology of Parkinson's disease have led to the promising concepts of neuroprotection and neurorestoration. In daily practice therapeutic management of Parkinson's disease is still symptomatic.

Bradykinesia and hypokinesia in Parkinson's disease: what's in a name?

Because in the literature bradykinesia and hypokinesia are frequently confounded, we assessed the relation between these two fundamental aspects of altered movement and the influence of disease severity on these measures in 41 patients with Parkinson's disease (PD) and 24 age-matched healthy controls. Bradykinesia was measured with a test microcomputer interfaced with a response-board. Hypokinesia was assessed by activity monitoring at home over a period of 5 successive days. For each subject the choice reaction time and measures reflecting bradykinesia (tap rate, movement time) and hypokinesia (movement index, duration of immobility periods) were calculated. Patients with PD had a normal choice reaction time and a significantly impaired execution of voluntary movement and reduced amount of movement over time. Bradykinesia was clearly present in the less affected patients with PD, and worsened as the disease severity increased. Hypokinesia, however, emerged prominently only in the more affected patients. There was a striking lack of relation between the measures that reflect bradykinesia and hypokinesia. The use of levodopa or dopamine agonists did not confound these findings. Our findings show the very different character and course of two tiers of altered movement in patients with PD and question the causative mechanisms of both motor features in PD. A more precise use of the terms brady- and hypokinesia is a prerequisite for future studies that attempt to provide insight in the causative mechanisms of both motor features.

Movement characteristics in Parkinson's disease: determination of dopaminergic responsiveness and threshold

We evaluated the responsiveness of tap rate (TR), movement time (MT), and reaction time (RT) to intravenous (i.v.) (n = 10) and subcutaneous (s.c.) (n = 16) administration of apomorphine in patients with Parkinson's disease (PD). In the second part of this study, we evaluated the feasibility of the commonly used 15% TR threshold, above which a patient is considered to be a responder. Compared to MT, TR emerged as the most responsive measure of bradykinesia during both i.v. and s.c. administration of apomorphine. RT showed no response to dopaminergic stimulation. To evaluate the influence of threshold on the number of responsive sessions, we determined the baseline variability of TR by means of the coefficient of variation (CV) in 39 patients with PD. Our results show approximately similar numbers of responsive sessions using the 15% and 2CV threshold. Our findings suggest that a simple repetitive motor task--TR--is more responsive than is the MT task. Finally, the 15% threshold may be considered an adequate threshold for TR in assessment of dopaminergic responsiveness of bradykinesia.

Quantitative assessment of bradykinesia in patients with Parkinson's disease

In order to optimize a method for quantitative assessment of bradykinesia, we evaluated the three-dimensional sources of a movement signal of the wrist and influence of tremor on the reliability of bradykinesia measurements. A total of 33 patients with Parkinson's disease, three patients with Multiple System Atrophy and 29 healthy controls performed a test procedure to measure slowness of movement, consisting of a tap rate (TR) test and a movement time (MT) test. Simultaneously, accelerometers were mounted on the wrist and mean bi- and tri-axial vectors were calculated. Thus the acquired means of acceleration were correlated with the commonly used measures of bradykinesia. i.e. tap rate and movement time. Our results show that bradykinesia is reliably measured by the evaluation of the mean acceleration of movements, and support the use of any of the three bi-axial vectors. Compared to the bi-axial vectors, the tri-axial vector provided no relevant additional information. Additionally, the presence of a moderate to severe resting tremor did not influence the assessment of bradykinesia. Because of the possibility of continuous assessment of bradykinesia this new monitor may prove to be of great value in pharmacodynamic studies and the longitudinal follow-up of patients in drug trials.

Autosomal dominant cerebellar ataxia with retinal degeneration (ADCA II): clinical and neuropathological findings in two pedigrees and genetic linkage to 3p12-p21.1

OBJECTIVES

To investigate relations between clinical and neuropathological features and age of onset, presence of anticipation, and genetic linkage in autosomal dominant cerebellar ataxia type II (ADCA II).

METHODS

The natural history of ADCA II was studied on the basis of clinical and neuropathological findings in two pedigrees and genetic linkage studies were carried out with polymorphic DNA markers in the largest, four generation, pedigree.

RESULTS

Ataxia was constant in all age groups. Retinal degeneration with early extinction of the electroretinogram constituted an important component in juvenile and early adult (< 25 years) onset but was variable in late adult presentation. Neuromuscular involvement due to spinal anterior horn disease was an important contributing factor to illness in juvenile cases. Postmortem findings in four patients confirm the general neurodegenerative nature of the disease, which includes prominent spinal anterior horn involvement and widespread involvement of grey and white matter. Genetic linkage was found with markers to chromosome 3p12-p21.1 (maximum pairwise lod score 4.42 at D3S1285).

CONCLUSIONS

The sequence of clinical involvement seems related to age at onset. Retinal degeneration is variable in late onset patients and neuromuscular features are important in patients with early onset. Strong anticipation was found in subsequent generations. Linkage of ADCA II to chromosome 3p12-p21.1 is confirmed.

Periodic fever associated with intermittent rhythmic delta activity: a syndrome of hypothalamic origin?

We report the case of a patient with a 16 year history of periodic (30 day cycle) fever attacks. The infradian cycle, associated clinical features, and the findings of electroencephalogram recorded during two fever attacks suggest a periodic hypothalamic syndrome.

Botulinum toxin versus trihexyphenidyl in cervical dystonia: a prospective, randomized, double-blind controlled trial

BACKGROUND

Botulinum toxin type A (BTA) is replacing trihexyphenidyl as the treatment of choice for idiopathic cervical dystonia (ICD), but there has never been a direct comparative study.

METHODS

This trial compares the effectiveness of BTA with that of trihexyphenidyl in a prospective, randomized, double-blind design. Sixty-six consecutive patients with ICD were randomized to treatment with trihexyphenidyl tablets plus placebo injection or placebo tablets plus BTA injections. Tablets were administered daily according to a fixed schedule. Dysport or saline was injected under EMG guidance at study entry and again after 8 weeks. Patients were assessed for efficacy at baseline and after 12 weeks by different clinical rating scales.

RESULTS

Sixty-four patients completed the study, 32 in each group. Mean dose of BTA was 292 mouse units (first session) and 262 mouse units (second session). Mean dose of trihexyphenidyl was 16.25 mg. The changes on the Disability section of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS-Disability) (primary outcome), Tsui Scale, and the General Health Perception Subscale were significantly in favor of BTA. More patients treated with BTA had an improvement of at least three points on the TWSTRS-Disability (14 versus 6) and on the Tsui Scale (23 versus 12). Adverse effects were significantly less frequent in the BTA group.

CONCLUSION

BTA is significantly more effective in the treatment of ICD, with less adverse effects.

Hypokinesia in Parkinson's disease: influence of age, disease severity, and disease duration

The aim of this cross-sectional study was to compare the role of aging in measures reflecting diurnal activity and immobility in 60 parkinsonian patients with predominant features of hypokinesia and rigidity and 100 healthy subjects aged 50 to 98 years. In the patients, we also studied the relation between disease duration and subjective and objective measures of disease severity. Motor activity was recorded during 5 successive days at home with a wrist-worn activity monitor. For each subject, two mean measures reflecting the diurnal activity level and the relative proportion of activity and immobility were calculated. Diurnal measures of activity revealed in both groups a prominent absolute reduction of activity and an increase of the time spent without movement ("immobility") with advancing age. Parkinsonian patients showed significantly lower values for both motor-activity measures than did the healthy subjects. The rate of the age-related decline of both diurnal activity measures in both groups, however, is comparable. Disease duration showed no relation with subjective and objective measures reflecting disease severity. This study shows that if care is taken to control for disease severity, the rate of the age-related decline of measures reflecting diurnal activity and immobility is similar in both groups. The lack of relation between disease duration and subjective and objective measures of disease severity suggests that the rate of progression of Parkinson's disease can be reliably studied only by means of longitudinal studies.

[Thrombosis of the cerebral veins and sinuses in 62 patients]

OBJECTIVE

Analysis of signs, symptoms, course and treatment of patients with cerebral venous and sinus thrombosis (CVST).

DESIGN

Retrospective study.

SETTING

Neurological departments of Dutch teaching hospitals.

METHOD

Analysis of data of patients admitted to the neurological wards of nine teaching hospitals, diagnosed from 1970 to 1990. All patients with a clinical diagnosis of CVST, confirmed by X-ray angiography, magnetic resonance imaging, surgery or autopsy were included. Patients with cavernous sinus thrombosis were excluded. The clinical condition of patients after 3 months was scored on a 4-point scale.

RESULTS

Of 93 patients 62 fulfilled the inclusion criteria. Three months after the diagnosis 41 patients (66%) had recovered, 10 patients (16%) were seriously disabled, 11 patients (18%) had died. Factors associated with a poor outcome were coma (relative risk 3.5) and hemiparesis (relative risk 2.3) at the time of diagnosis. Signs of cerebral haemorrhage or infarction (by computed X-ray tomography) were associated with disability or death. Anticoagulant treatment was not significantly associated with a better or poorer outcome in these patients.

CONCLUSION

This study confirms the variations in causes, clinical presentation, natural history, and treatment of CVST. No conclusion could be drawn about the effect of anticoagulant treatment.

Wrist actigraphic assessment of sleep in 116 community based subjects suspected of obstructive sleep apnoea syndrome

BACKGROUND

The combined use of wrist actigraphic assessment and self assessment of sleep in the screening of obstructive sleep apnoea syndrome was evaluated in a community based sample.

METHODS

One hundred and sixteen community based subjects clinically suspected of having obstructive sleep apnoea (syndrome) were evaluated by means of simultaneous ambulatory recording of respiration (oronasal flow thermistry), motor activity (wrist actigraphy), and subjective sleep (sleep log) during one night of sleep.

RESULTS

The subjects were distributed according to their apnoea index (AI); AI < 1 (non-apnoeic snorers) 44%; AI 1- < 5 39%; and AI > or = 5 17%. High apnoea index values were associated with self reported disturbed sleep initiation and more fragmented and increased levels of motor activity and decreased duration of immobility periods, particularly in those with an apnoea index of > or = 5. Across subjects the duration of immobility periods was the only predictor of the apnoea index, explaining 11% of its variance. Use of the multiple regression equation to discriminate retrospectively between those with an apnoea index of < 1 and > or = 5 resulted in sensitivity and specificity values of 75% and 43%, and 5% and 100%, respectively.

CONCLUSIONS

The combined use of a sleep log and actigraphic assessment of sleep failed to identify reliably those subjects who suffered from obstructive sleep apnoea (syndrome) in a sample of community based subjects reporting habitual snoring combined with excessive daytime sleepiness and/or nocturnal respiratory arrests.