Alerting effects of methylphenidate under basal and sleep-deprived conditions

Six men and 3 women on each of 4 days received 10 mg of methylphenidate or placebo (2 times a day) at 0800 and 1200 after 8 hr or 0 hr of sleep. Sleep latency was measured by the Multiple Sleep Latency Test (MSLT) at 0930, 1130, 1330, 1530, and 1730. Participants also completed divided-attention and auditory vigilance tasks at 1000 and 1400 and the Profile of Mood States (POMS) and the Addiction Research Center Inventory (ARCI) after the 0930 and 1330 latency tests. The drug increased mean latency on the MSLT in both sleep conditions. Performance only showed drug effects after prior sleep deprivation. On the POMS, the drug increased Vigor and reduced Fatigue and Depression scale scores, primarily after sleep deprivation. The drug increased the ARCI Amphetamine and Morphine-Benzedrine scores only in the basal state. The ARCI Pentobarbital score was increased by sleep deprivation and decreased by the drug.

Daytime sleepiness: an epidemiological study of young adults

OBJECTIVES

Although excessive daytime sleepiness is associated with increased risks for accidents, decreased productivity, and interpersonal difficulties, information on its epidemiology is scarce. This paper examines correlates of and suspected risk factors for daytime sleepiness from a longitudinal epidemiological study of young adults.

METHODS

The sample consisted of 1007 randomly selected young adults from a large health maintenance organization in southeast Michigan. Data were gathered in personal interviews conducted with 97% of the sample 5.5 years after baseline. Information on sleep characteristics in the last 2 weeks, including daytime sleepiness, nocturnal sleep onset, snoring, and hours of sleep, was collected on a self-administered instrument. Psychiatric disorders were measured by the National Institute of Mental Health's Diagnostic Interview Schedule.

RESULTS

The average length of nocturnal sleep on weekdays was 6.7 hours. Daytime sleepiness was inversely related to hours of sleep and positively related to the ease of falling asleep at night; it varied significantly by employment and marital status. Snoring was associated with increased daytime sleepiness, as was recent major depression.

CONCLUSIONS

Factors that might increase daytime sleepiness among young adults include social factors (being single and being employed full time) and pathological conditions (frequent snoring and major depression).

Safety and effectiveness of placement of pacemaker and defibrillator leads in the axillary vein guided by contrast venography

Despite evidence of an increased incidence of lead fracture, the infraclavicular subclavian approach remains the dominant approach for placement of pacemaker and implantable defibrillator leads. Although this complication can be prevented by lead placement in the cephalic vein or by recently described approaches for lead placement in the axillary vein, these approaches have not gained widespread acceptance. The purpose of this study was to evaluate the safety and efficacy of an alternative technique for lead placement that uses contrast-guided venipuncture of the axillary vein with a 5Fr micropuncture introducer set. A total of 50 patients underwent an attempt at placement of pacemaker or implantable defibrillator leads via the axillary vein using this new technique. Patients were randomized into 2 groups based on whether the initial attempt at axillary vein access was performed medial or lateral to the rib cage margin. Lead placement was successfully accomplished in 49 of the 50 patients using this technique. Initial success was achieved in each of 25 patients randomized to the medial approach compared with 18 of 24 patients randomized to the lateral approach to the axillary vein (75%). In each of the 6 patients in whom the initial technique failed, lead placement was subsequently achieved with the medial approach. In addition to a higher initial success rate, the medial approach was determined to be preferable as evidenced by a shorter lead placement time, a smaller number of contrast injections, and a reduced requirement for additional micropuncture guidewires. There were no major complications associated with either approach. Contrast-guided venipuncture of the axillary vein is a safe and effective approach to placement of endocardial leads.

Hypnotic self administration: forced-choice versus single-choice

Twenty-four men and women with insomnia, age 21-50 years, self administered hypnotics under a single-choice with placebo, single-choice with triazolam (0.25 mg), or forced-choice of placebo versus triazolam (0.25 mg) paradigm. Subjects received 4- sampling nights of placebo or triazolam in the single-choice conditions or 2 nights of each in the forced-choice condition. Then on 7 choice nights they could self administer a capsule, or not, in the single-choice conditions, or were required to choose one of two color-coded capsules in the forced-choice condition. In the single-choice conditions, subjects chose placebo 80% of nights and triazolam 77% of nights, while in the forced-choice condition triazolam was chosen on 86% of nights. Thus, the self administration of triazolam did not vary significantly between single or forced choice conditions, but that of placebo did. Placebo rate was high when it was the only alternative, but low when competing with triazolam. On sampling nights, compared to placebo, triazolam produced a significant increase in total sleep time, a reduction in latency to sleep, wake after sleep onset, and percentage stage 1 sleep. Triazolam, relative to placebo, also improved mood in the morning on some sampling nights. For subjects choosing capsules < 100% of opportunities (n = 14), on nights a capsule was chosen versus nights none was chosen (regardless of whether placebo or triazolam was the choice), self-ratings 30 min before bedtime on the Profile of Mood States vigor scale were significantly higher.

A new system for posterior restorations: a combination of ceramic optimized polymer and fiber-reinforced composite

Due to the need for increased strength characteristics and enhanced aesthetic expectations of the patients, metal-free, aesthetic restorative systems for the anterior and posterior dentition are currently available. A new "space-age" restorative material has been developed that is a combination of a ceramic optimized polymer (Ceromer) (Targis/Vectris, Ivoclar Williams, Amherst, NY) and a fiber-reinforced composite framework material. The purpose of this article is to discuss the qualities that render this material particularly suitable for a variety of indications, including laboratory-fabricated restorations for the stress-bearing posterior regions. The material lends itself to diversification. Its indication for inlays, onlays, full-coverage crown restorations, and conservative single pontic inlay bridges is presented.

The sleep/wake habits of patients diagnosed as having obstructive sleep apnea

STUDY OBJECTIVE

To determine the sleep/wake habits of patients diagnosed as having obstructive sleep apnea (ie, respiratory event index [REI] > or = 5).

DESIGN

Case series with prospective data collection to determine the relationship among sleepiness, REI, and sleep/wake habits. Patients were grouped according to their multiple sleep latency test (MSLT) results (< or = 5 and > 5) and REI (mild REI < or = 20; moderate REI > 20 but < or = 60; and severe REI > 60).

SETTING

An American Sleep Disorders Association-accredited sleep laboratory.

PATIENTS

Three hundred ninety (325 male, 65 female) consecutive patients seen between June 1993 and January 1995 for evaluation of sleep apnea. This included a sleep, medical, and psychiatric evaluation followed by a physical examination. Sleep histories and sleep/wake habits were recorded by a physician trained in sleep medicine. Polysomnographic evaluation consisted of a nocturnal clinical polysomnogram (CPSG) and an MSLT on the following day. Of 390 patients, 268 completed polysomnographic evaluation (CPSG and MSLT).

MEASUREMENTS AND RESULTS

Sleepy (MSLT < or = 5) patients with mild (REI < or = 20) and moderate apnea (REI > 20 < or = 60) reported spending significantly less time in bed than sleepy patients with severe apnea (REI > 60). Those with severe apnea (REI > 60) reported napping significantly more and experienced a more severe disruption of their routine daily activities because of sleepiness when compared with mild and moderate OSA patients.

CONCLUSIONS

These data suggest that sleep habits have an important modulatory effect on the level of sleepiness and this effect is lost as the severity of sleep-disordered breathing increases.

Midline glossectomy and epiglottidectomy for obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome is caused by narrowing of the pharyngeal airway and loss of dilator tone during sleep. In patients with severe apnea surgical correction often requires attention to both the oropharynx and hypopharynx. Tongue reduction surgery has been described for persistent apnea after failure of palatal surgery. We describe our experience with midline glossectomy with epiglottidectomy in 12 patients with a mean age of 48.8 +/- 14.2 years and body mass index of 36.0 +/- 8.8 kg/m2. Response to treatment was defined as a postoperative respiratory disturbance index (RDI) below 20. Three patients (25%) responded to treatment. The mean apnea index decreased from 48.9 to 35.7, RDI decreased from 73.3 to 46.6, and lowest oxygen saturation increased from 65.9 to 77.9%. RDI in responders decreased from 69.7 to 10. Midline glossectomy with epiglottidectomy has variable results, yet is effective in selected patients with hypopharyngeal narrowing related to macroglossia.

The alerting effects of short and long naps in narcoleptic, sleep deprived, and alert individuals

Eleven narcoleptic patients and 22 age- and gender-matched normal controls participated in a study to determine the alerting effects of differing nap lengths. All narcoleptic patients had been previously diagnosed [mean sleep latency on the multiple sleep latency test (MSLT) < or = 5 minutes with two or more sleep-onset rapid eye movement periods (SOREMPs)]. Healthy, normal subjects with a mean sleep latency on the screening MSLT > or = 8 minutes were randomly assigned to one of two groups (i.e. sleep-deprived and alert). All subjects completed two experimental night and days with at least 5 days between sessions. On the evening prior to each experimental day, narcoleptic and alert subjects spent 8 hours in bed and sleep-deprived subjects spent 0 hours in bed. The following day, all subjects underwent one of two napping conditions, 15 or 120 minutes in bed. Both naps were terminated at noon. Every subject underwent both conditions and the order of conditions was counterbalanced. From 1215 to 1355 hours all subjects underwent a modified MSLT. At 1500 hours, the subjects had a 1-hour nap. The results showed that the 120-minute nap condition was more beneficial than the 15-minute nap. Narcoleptic and sleep deprived subjects were shown to have comparable levels of sleepiness on the modified MSLT. However, a differential response pattern on their latency to sleep was noted on the 1-hour nap. Sleep-deprived subjects were shown to be differentially more alert following a 120-minute nap opportunity. In contrast, for narcoleptic patients the beneficial effects of the nap were lost when tested 3 hours later. These results show that narcoleptic patients benefit from a longer nap but that these benefits are short-lived.

A factor replication of the Sleep-Wake Activity Inventory (SWAI) in a Mexican population

The purpose of this study was to describe the factor structure of the Sleep-Wake Activity Inventory (SWAI) in a Mexican population. In a sample of 722 Mexican college students, we replicated five of the six factors originally described in the SWAI. Retained factors included: excessive daytime sleepiness (similarity coefficient of 0.735), psychic distress (0.609), social desirability (0.638), individual's ability to relax (0.864), and nocturnal sleep (0.660). These results confirm the factor structure and extend the possible utility of the SWAI in a siesta culture.

Closure of permanent tracheostomy in patients with sleep apnea: a comparison of two techniques

A "permanent" skin-lined tracheostomy is used for patients with severe obstructive sleep apnea syndrome who fall, refuse, or can't tolerate continuous positive airway pressure. Closure of the stoma may be performed if the apnea has been controlled by surgeries that enlarge and stabilize the upper airway, if adequate weight loss occurs, or if the patient decides to accept continuous positive airway pressure. Two different closure techniques are compared. Sixty-nine three-layer closures were performed in 66 patients from 1980 to 1990. Postoperative complications, including stridor, subcutaneous emphysema, pneumomediastinum, tracheal granuloma, hematoma, and respiratory arrest, occurred in 30% of patients, and three required reopening of their tracheostomy sites. After 1990 a simple deepithelialization technique was used in 10 patients without any major complications. This technique is simpler and quicker and can be performed with the patient under local anesthesia.

Closure of Permanent Tracheostomy in Patients with Sleep Apnea: A Comparison of Two Techniques

A “permanent” skin-lined tracheostomy is used for patients with severe obstructive sleep apnea syndrome who fail, refuse, or can't tolerate continuous positive airway pressure. Closure of the stoma may be performed if the apnea has been controlled by surgeries that enlarge and stabilize the upper airway, if adequate weight loss occurs, or if the patient decides to accept continuous positive airway pressure. Two different closure techniques are compared. Sixty-nine three-layer closures were performed in 66 patients from 1980 to 1990. Postoperative complications, including stridor, subcutaneous emphysema, pneumomediastinum, tracheal granuloma, hematoma, and respiratory arrest, occurred in 30% of patients, and three required reopening of their tracheostomy sites. After 1990 a simple deepithelialization technique was used in 10 patients without any major complications. This technique is simpler and quicker and can be performed with the patient under local anesthesia.

The frequency of multiple sleep onset REM periods among subjects with no excessive daytime sleepiness

The multiple sleep latency test (MSLT) is a valuable tool in the assessment of excessive daytime sleepiness (EDS). Additionally, multiple sleep onset rapid eye movement periods (SOREMPs) are a frequent occurrence in patients with narcolepsy. To date, however, few studies have evaluated the frequency of SOREMPs in a population of healthy control subjects. Subjects participating in a variety of sleep studies were screened with a nocturnal clinical polysomnogram, followed by the MSLT. Subjects were required to be drug free and have no sleep-related symptoms or medical or psychiatric conditions. Of the 139 subjects who were screened, 24 (17%) had two or more SOREMPs. These individuals were more likely to be male, younger, and sleepier than those with one or zero SOREMPs. The etiology of two or more SOREMPs in healthy controls was not apparent from the clinical or polysomnographic evaluation. Although it is possible that these findings are early signs of narcolepsy, subjects reported being free of any sleep-related complaints. Further investigations into the determinants of multiple SOREMPs and their reliability among asymptomatic populations are warranted.

Consensus on diuresis renography for investigating the dilated upper urinary tract. Radionuclides in Nephrourology Group. Consensus Committee on Diuresis Renography

There is great variation in technique and interpretation of diuresis renography between different establishments.

METHODS

To address this problem, an International Consensus Committee was appointed by the Ninth International Symposium on Radionuclides in Nephrourology in 1994.

RESULTS

The final document was produced and addressed: objectives, equipment, data acquisition, choice of radiopharmaceutical, patient preparation, position, dosage of furosemide, timing of furosemide, role of bladder catheter, duration of study, pediatric considerations, evaluation of the furosemide response, interpretation, and conclusion.

CONCLUSION

The report presents a standardized approach to diuresis renography that, if adopted, will improve reproducibility between centers, discourage unacceptable practice and stimulate further discussion between nuclear medicine and urology health care professionals who treat patients with dilated and obstructed upper urinary tracts.

Hypnotic self administration and dose escalation

The dependence liability of benzodiazepines in the context of their use as hypnotics (i.e. by insomnia patients as pre-sleep medications) is unresolved. A recent study found that insomniacs self administer capsules at bedtime at a high rate, with triazolam (0.25 mg) taken as often as placebo. This study sought to determine if differential self administration would develop when multiple capsules are available nightly. Eighteen men and women, age 21-45 years, with insomnia complaints (nine with objective sleep disturbance and nine without) were studied, 1 week with placebo and 1 week with triazolam (0.25 mg). The two conditions were administered double-blind and presented in a counter-balanced order with a week between conditions. In each condition, after 3 consecutive sampling nights of the available single capsule for that condition, subjects could self administer 0-3 capsules before bed on the 4 subsequent nights. Triazolam was self administered as many nights as placebo, but the number of placebo capsules self administered was twice that of triazolam capsules. The objective insomniacs self administered more capsules than the subjective insomniacs and neither group differentially choose triazolam over placebo. The number of triazolam capsules taken nightly was stable and the number of placebo capsules variable. It is concluded that insomniacs show no short-term escalation of triazolam dose, but do choose an increased and variable number of placebos, a pattern which is interpreted as being insomnia relief-seeking behavior.

A two-week sleep extension in sleepy normals

Thirty-four healthy, normal young men and women (21-35 years), with no sleep complaints and a normal screening polysomnogram, some with short (< or = 6-minute) and some with long (> or = 16-minute) average daily sleep latencies on a screening multiple sleep latency test, were studied on two baseline nights (8 hours) and in the "sleepy" group, for 14 consecutive nights of extended (10-hour) or habitual (7.8 +/- 0.7-hour) bedtimes. The screening differences between the groups in average daily sleep latency were consistently seen on the two further baseline nights and days. The extension of bedtime in sleepy subjects was followed by an increase in average daily sleep latency relative to randomly chosen sleepy subjects maintained on their habitual sleep schedule for the 14 nights. The increase in average daily sleep latency was associated with a gradual reduction in sleep efficiency over the 14 nights. Some (36%) of the sleepy subjects did not have increased average sleep latencies during the 10-hour bedtime extension. Those showing no increase in average daily sleep latency had an immediate drop in sleep efficiency when the bedtime was increased to 10 hours, suggesting they were unable to sleep longer during the extension. Their short average daily sleep latency was a result of causes other than chronic insufficient sleep.

Temporal variations of adenosine metabolism in human blood

Eight diurnally active (06:00-23:00 h) subjects were adapted for 2 days to the room conditions where the experiments were performed. Blood sampling for adenosine metabolites and metabolizing enzymes was done hourly during the activity span and every 30 min during sleep. The results showed that adenosine and its catabolites (inosine, hypoxanthine, and uric acid), adenosine synthesizing (S-adenosylhomocysteine hydrolase and 5'-nucleotidase), degrading (adenosine deaminase) and nucleotide-forming (adenosine kinase) enzymes as well as adenine nucleotides (AMP, ADP, and ATP) undergo statistically significant fluctuations (ANOVA) during the 24 h. However, energy charge was invariable. Glucose and lactate chronograms were determined as metabolic indicators. The same data analyzed by the chi-square periodogram and Fourier series indicated ultradian oscillatory periods for all the metabolites and enzymatic activities determined, and 24-h oscillatory components for inosine, hypoxanthine, adenine nucleotides, glucose, and the activities of SAH-hydrolase, 5'-nucleotidase, and adenosine kinase. The single cosinor method showed significant oscillatory components exclusively for lactate. As a whole, these results suggest that adenosine metabolism may play a role as a biological oscillator coordinating and/or modulating the energy homeostasis and physiological status of erythrocytes in vivo and could be an important factor in the distribution of purine rings for the rest of the organism.

The reliability of the diagnostic features in patients with narcolepsy

This study determined the test-retest reliability of the polysomnographic findings in narcolepsy. The diagnosis of narcolepsy was based on clinical symptoms and polysomnographic signs. Control subjects were screened before participation and were split based on their screening multiple sleep latency test (MSLT) into high- and low-MSLT groups. Subjects completed two polysomnographic evaluations with at least 5 days between laboratory tests. Narcoleptics had lower sleep efficiencies and high stage 1% when compared to the low MSLT control group. They had more awakenings and less stage 2% than the control groups. Narcoleptics had a shorter latency to 1 when compared to the high-MSLT group but comparable to that of the low-MSLT group. Narcoleptics had a higher number of sleep-onset rapid eye movement periods (SOREMPs) than both control groups. The MSLT scores were stable across the two evaluations and showed a statistically significant correlation. Twenty-eight of the 30 narcoleptic subjects had two or more SOREMPs on reevaluation. None of the controls had multiple SOREMPs. Thus, multiple SOREMPs were shown to be a reliable finding in patients with narcolepsy.

Nocturnal sleep latencies among alert, alert-deprived and sleepy subjects

Twenty-seven healthy, asymptomatic subjects participated in a study to determine repeated nocturnal sleep latencies as a function of level of daytime sleepiness. Subjects were screened polysomnographically and were determined to be free of any sleep pathology. Nine subjects had a screening multiple sleep latency test (MSLT) of < or = 5 min and 18 had a MSLT of > or = 10 min. Subjects were assigned to 3 groups, sleepy (MSLT < or = 5 min), alert, and alert sleep-deprived groups (MSLT > or = 10 min). Repeated nocturnal latencies to sleep were determined at 2300, 0110, 0310 and 0510 h on 2 nights with at least 5 days between nights. The results showed a main effect of group on the repeated nocturnal sleep latencies. Post-hoc tests demonstrated longer repeated nocturnal latencies among alert subjects compared to the sleepy and alert sleep-deprived subjects. The latter two groups had comparable sleep latencies. A significant main effect of time of night was also shown. The 0510 h latency was significantly shorter than the latencies at 2300 and 0110 h. The 0310 h latency was significantly shorter than the 0110 h latency and comparable to the 2300 and 0510 h latency. Significant correlations were found between daytime MSLT, repeated nocturnal sleep latencies, and nocturnal sleep time. These results show systematic differences in repeated nocturnal sleep latencies among sleep and alert subjects and extend the already described characteristics of these subjects by comparing them to a group of alert sleep-deprived subjects.

Phase advance in moderately sleepy and alert normals

Phase advanced sleep (by 4 hours) was studied in 28 healthy, normal men and women, aged 21-50 years, without nocturnal sleep or daytime sleepiness complaints. Eleven subjects (6 men and 5 women) with moderately short (< or = 10 minutes) average daily sleep latencies on the multiple sleep latency test (MSLT) were compared to 17 (11 men and 6 women) with relatively long (> or = 12 minutes) latencies. Nocturnal sleep on both a baseline and a shift night differed between the groups. The moderately "sleepy" group had shorter sleep latencies and less wakefulness during sleep than the moderately "alert" group. The phase advanced sleep schedule reduced sleep efficiency in both groups, but the moderately sleepy group showed a lessened effect of the shift. Additionally, sleep efficiency was reduced in the moderately sleepy group only during the first 2 hours of the sleep period, while sleep efficiency was uniformly disturbed in the moderately alert group throughout the night during the phase advance.

Melanoma awareness and self-examination practices: results of a United States survey

BACKGROUND

Skin cancers are common and there has been a dramatic increase in their incidence, particularly melanoma. However, little is known about awareness of melanoma and early detection practices in the general U.S. population.

OBJECTIVE

In 1995, the American Academy of Dermatology increased their efforts to promote awareness of melanoma. This study was conducted to document current knowledge of melanoma and self-examination practices.

METHODS

In February 1995, a telephone survey was conducted in a nationally representative sample of 1001 persons at least 18 years of age (3% margin of error) that included questions on knowledge, attitudes, and practices regarding early detection of melanoma.

RESULTS

Almost 42% of those surveyed were unaware of melanoma, and only 26% of those who were aware could identify its specific signs. Most recognized at least one common risk factor for melanoma (e.g., sun exposure, fair skin). However, many did not distinguish melanoma from other skin cancers in terms of risk factors, signs of early disease, and body site distribution. The lowest measures of melanoma knowledge and attitudes were found among those who are male, nonwhite, and parents, and those with the lowest level of education and income. More than half (54%) did not conduct a self-examination. This practice was most frequently reported by women, white persons, and the elderly, as well as those with a greater knowledge of melanoma.

CONCLUSION

Our research documents deficiencies in knowledge and practices related to early detection of melanoma in the general U.S. population and supports the need for public education about melanoma.

Auditory awakening thresholds in sleepy and alert individuals

Twenty-seven healthy men and women with regular sleep-wake habits (and no habitual napping) participated in a study to determine the relation between auditory awakening thresholds (AAT) and multiple sleep latency test (MSLT) scores. Subjects were free of any sleep complaints and were screened polysomnographically. Nine subjects had a screening MSLT of < or = 5 minutes (sleepy group), and 18 subjects had an MSLT of > or = 10 minutes. Subjects were assigned to three groups: a sleepy group, alert group and an alert sleep-deprived group. Subjects underwent 2 nights of AAT testing with at least 5 days in between each study night. AATs were determined at 0100, 0300, 0500 and 0730 hours. There were a total of 209 available AAT determinations, with a comparable number of trials across the groups. Because 68% of AAT determinations were done out of stage 2 non-rapid eye movement (NREM) sleep, the thrust of the analysis was based on the results of this stage of sleep. The AATs were averaged across the two experimental nights. Trials 1 and 2 (first half of the night) and 3 and 4 (second half of the night) were averaged for each subject. There was no main effect of group on AATs. However, there was a significant main effect of time and a significant group by time interaction. The former indicated an overall decline in AATs across the night. More importantly, the three groups had comparable AAT levels during the first half of the night:. Sleepy and alert-deprived subjects, however, failed to show a decline in AATs, whereas the alert group showed a significant decline in the second half of the night. This differential rate of decline in AATs is suggested to be related to the differences in sleep homeostasis among alert and sleepy individuals.