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Miano S, Kheirandish-Gozal L, De Pieri M. Comorbidity of obstructive sleep apnea and narcolepsy: A challenging diagnosis and complex management. Sleep Med X 2024; 8:100126. [PMID: 39386319 PMCID: PMC11462365 DOI: 10.1016/j.sleepx.2024.100126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 08/23/2024] [Accepted: 09/16/2024] [Indexed: 10/12/2024] Open
Abstract
Introduction Narcolepsy and obstructive sleep apnea syndrome (OSA) are relevant causes of excessive daytime sleepiness (EDS); although different for etiopathogenesis and symptoms, differential diagnosis is sometimes difficult, and guidelines are lacking concerning their management when coexisting in a same patient. Methods A narrative review of the literature was realized including PubMed, Scopus and Embase, aimed to regroup studies and case reports evaluating epidemiology, clinical and instrumental features and treatment of patients presenting comorbid NT1 and OSA. Moreover, a snowball search on the pathophysiology underpinnings of the association of the two disorder was realized. Results For adults, the prevalence of OSA in NT1 ranged from 24.8 % to 51.4 %. No studies were found concerning the treatment of EDS in double-diagnosis patients, but only case reports; these latter and the experience on patients with either NT or OSA suggest that modafinil, methylphenidate, pitolisant and solriamfetol are effective. Discussion Adults with NT1 showed a higher prevalence of OSA compared to the general population, but the reach of the results reviewed here is limited by the retrospective design of most of the studies and by the inhomogeneous utilization of diagnostic criteria. The association with OSA is likely to be explained by the involvement of orexin in hypercapnic-hypoxic responses: a deficit of orexin may promote obstructive events during sleep. Open questions warrant further investigation, especially orexin's involvement in other sleep disorders associated with EDS, and the more appropriate treatment for the OSA-narcolepsy comorbidity.
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Affiliation(s)
- Silvia Miano
- Sleep Medicine Unit, Neurocenter of Southern Switzerland, Civic Hospital, EOC, Faculty of Biomedical Sciences, Università della Svizzera Italiana, 6900, Lugano, Switzerland
| | | | - Marco De Pieri
- Division of Adult Psychiatry, Department of Psychiatry, University Hospitals of Geneva, 2 Chemin du Petit-Bel-Air, CH-1226, Thonex, Switzerland
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2
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Thorpy MJ, Siegel JM, Dauvilliers Y. REM sleep in narcolepsy. Sleep Med Rev 2024; 77:101976. [PMID: 39186901 DOI: 10.1016/j.smrv.2024.101976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 06/28/2024] [Accepted: 07/09/2024] [Indexed: 08/28/2024]
Abstract
Narcolepsy is mainly associated with excessive daytime sleepiness, but the characteristic feature is abnormal rapid eye movement (REM) sleep phenomena. REM sleep disturbances can manifest as cataplexy (in narcolepsy type 1), sleep paralysis, sleep-related hallucinations, REM sleep behavior disorder, abnormal dreams, polysomnographic evidence of REM sleep disruption with sleep-onset REM periods, and fragmented REM sleep. Characterization of REM sleep and related symptoms facilitates the differentiation of narcolepsy from other central hypersomnolence disorders and aids in distinguishing between narcolepsy types 1 and 2. A circuit comprising regions within the brainstem, forebrain, and hypothalamus is involved in generating and regulating REM sleep, which is influenced by changes in monoamines, acetylcholine, and neuropeptides. REM sleep is associated with brainstem functions, including autonomic control, and REM sleep disturbances may be associated with increased cardiovascular risk. Medications used to treat narcolepsy (and REM-related symptoms of narcolepsy) include stimulants/wake-promoting agents, pitolisant, oxybates, and antidepressants; hypocretin agonists are a potential new class of therapeutics. The role of REM sleep disturbances in narcolepsy remains an area of active research in pathophysiology, symptom management, and treatment. This review summarizes the current understanding of the role of REM sleep and its dysfunction in narcolepsy.
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Affiliation(s)
| | - Jerome M Siegel
- Department of Psychiatry and Brain Research Institute, University of California, Los Angeles, CA, USA; Department of Veterans Affairs, Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Yves Dauvilliers
- Sleep and Wake Disorders Centre, Department of Neurology, Gui de Chauliac Hospital, University Montpellier, INSERM INM, France
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3
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Edlinger F, Böck M, Seidel S, Trimmel K. Loss of rapid eye movement atonia in rapid eye movement sleep behaviour disorder and narcolepsy. J Sleep Res 2024:e14322. [PMID: 39168479 DOI: 10.1111/jsr.14322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 07/30/2024] [Accepted: 08/10/2024] [Indexed: 08/23/2024]
Abstract
A reduction of physiological muscle atonia during rapid eye movement sleep is characteristic in patients with rapid eye movement sleep behaviour disorder, however, it can also be found in narcolepsy patients. We evaluated rapid eye movement sleep associated electromyographic activity to set cut-off values of rapid eye movement sleep without atonia, differentiating rapid eye movement sleep behaviour disorder and narcolepsy patients from controls to enable more precise future diagnostic criteria for these disorders. We retrospectively analysed polysomnography recordings of 16 rapid eye movement sleep behaviour disorder patients, 15 narcolepsy patients, and 19 controls. The combination of phasic and tonic electromyographic activity was recorded in the mentalis and tibialis anterior muscles and analysed in 3 second miniepochs. The cut-off value for a diagnosis of rapid eye movement sleep behaviour disorder was 17.07% (100% sensitivity, 94.7% specificity, area under the curve 0.997). For the diagnosis of narcolepsy, we yielded a cut-off value of 8.4% (86.4% sensitivity, 68.4% specificity, area under the curve 0.850). Rapid eye movement sleep without atonia significantly (p = 0.046) increased in the second night half in rapid eye movement sleep behaviour disorder patients, while it remained moderately increased in the narcolepsy group. Polysomnographic evaluation proves significantly higher rates of rapid eye movement sleep without atonia in rapid eye movement sleep behaviour disorder than in narcolepsy patients, allowing differentiation from controls with high sensitivity and specificity. An increase throughout the night is characteristic for rapid eye movement sleep behaviour disorder, whereas a consistent elevation is typical in narcolepsy patients.
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Affiliation(s)
| | - Marion Böck
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Seidel
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Karin Trimmel
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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4
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Barone DA. Secondary RBD: Not just neurodegeneration. Sleep Med Rev 2024; 76:101938. [PMID: 38657360 DOI: 10.1016/j.smrv.2024.101938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/20/2024] [Accepted: 04/11/2024] [Indexed: 04/26/2024]
Abstract
Rapid eye movement sleep behavior disorder is a parasomnia characterized by excessive muscle activity during rapid eye movement sleep (rapid eye movement sleep without atonia), along with dream enactment behavior. Isolated rapid eye movement sleep behavior disorder tends to occur in older males and is of concern due to the known link to Parkinson's disease and other synucleinopathies. When rapid eye movement sleep behavior disorder occurs in association with other neurological or general medical conditions, or resulting from the use of various substances, it is called secondary rapid eye movement sleep behavior disorder; the most common cause is neurodegenerative illness, specifically the synucleinopathies. Here, the focus will be on the subset of secondary rapid eye movement sleep behavior disorder in which there is no neurodegenerative disease.
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Affiliation(s)
- Daniel A Barone
- Weill Cornell Center for Sleep Medicine, 425 East 61st Street, New York, NY, 10065, USA.
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Chen G, Wang W, Wu H, Zhao X, Kang X, Ren J, Zhang J, Sun Y, He J, Sun S, Zhong Z, Shang D, Fan M, Cheng J, Zhang D, Su C, Lin J. Disrupted topological properties of structural brain networks present a glutamatergic neuropathophysiology in people with narcolepsy. Sleep 2024; 47:zsae002. [PMID: 38173348 DOI: 10.1093/sleep/zsae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/18/2023] [Indexed: 01/05/2024] Open
Abstract
STUDY OBJECTIVES Growing evidences have documented various abnormalities of the white matter bundles in people with narcolepsy. We sought to evaluate topological properties of brain structural networks, and their association with symptoms and neuropathophysiological features in people with narcolepsy. METHODS Diffusion tensor imaging was conducted for people with narcolepsy (n = 30) and matched healthy controls as well as symptoms assessment. Structural connectivity for each participant was generated to analyze global and regional topological properties and their correlations with narcoleptic features. Further human brain transcriptome was extracted and spatially registered for connectivity vulnerability. Genetic functional enrichment analysis was performed and further clarified using in vivo emission computed tomography data. RESULTS A wide and dramatic decrease in structural connectivities was observed in people with narcolepsy, with descending network degree and global efficiency. These metrics were not only correlated with sleep latency and awakening features, but also reflected alterations of sleep macrostructure in people with narcolepsy. Network-based statistics identified a small hyperenhanced subnetwork of cingulate gyrus that was closely related to rapid eye movement sleep behavior disorder (RBD) in narcolepsy. Further imaging genetics analysis suggested glutamatergic signatures were responsible for the preferential vulnerability of connectivity alterations in people with narcolepsy, while additional PET/SPECT data verified that structural alteration was significantly correlated with metabotropic glutamate receptor 5 (mGlutR5) and N-methyl-D-aspartate receptor (NMDA). CONCLUSIONS People with narcolepsy endured a remarkable decrease in the structural architecture, which was not only closely related to narcolepsy symptoms but also glutamatergic signatures.
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Affiliation(s)
- Guoyan Chen
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Wen Wang
- Department of Radiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Haoyang Wu
- Basic Medicine School, Air Force Medical University, Xi'an, China
| | - Xianchao Zhao
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Xiaopeng Kang
- School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China
| | - Jiafeng Ren
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jun Zhang
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Yingzhi Sun
- Department of Radiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jiaxiu He
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Shihui Sun
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Zhao Zhong
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Danqing Shang
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Mengmeng Fan
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jinxiang Cheng
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Dan Zhang
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Changjun Su
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Jiaji Lin
- Department of Neurology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
- Department of Radiology, Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
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Yu J, Zhang Y, Cai L, Sun Q, Li W, Zhou J, Liang J, Wang Z. The Changed Nocturnal Sleep Structure and Higher Anxiety, Depression, and Fatigue in Patients with Narcolepsy Type 1. Nat Sci Sleep 2024; 16:725-735. [PMID: 38873239 PMCID: PMC11170032 DOI: 10.2147/nss.s452665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/11/2024] [Indexed: 06/15/2024] Open
Abstract
Purpose This study aimed to evaluate nocturnal sleep structure and anxiety, depression, and fatigue in patients with narcolepsy type 1 (NT1). Methods Thirty NT1 patients and thirty-five healthy controls were enrolled and evaluated using the Epworth sleepiness scale (ESS), Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Fatigue Severity Scale (FSS), polysomnography, multiple sleep latency test, and brain function state monitoring. Statistical analyses were performed using SPSS Statistics for Windows, version 23.0. Benjamini-Hochberg correction was performed to control the false discovery rate. Results Apart from typical clinical manifestations, patients with NT1 are prone to comorbidities such as nocturnal sleep disorders, anxiety, depression, and fatigue. Compared with the control group, patients with NT1 exhibited abnormal sleep structure, including increased total sleep time (P adj=0.007), decreased sleep efficiency (P adj=0.002), shortening of sleep onset latency (P adj<0.001), elevated wake after sleep onset (P adj=0.002), increased N1% (P adj=0.006), and reduced N2%, N3%, and REM% (P adj=0.007, P adj<0.001, P adj=0.013). Thirty-seven percent of patients had moderate to severe obstructive sleep apnea-hypopnea syndrome. And sixty percent of patients were complicated with REM sleep without atonia. Patients with NT1 displayed increased anxiety propensity (P adj<0.001), and increased brain fatigue (P adj=0.020) in brain function state monitoring. FSS scores were positively correlated with brain fatigue (P adj<0.001) and mean sleep latency was inversely correlated with FSS scores and brain fatigue (P adj=0.013, P adj=0.029). Additionally, ESS scores and brain fatigue decreased after 3 months of therapy (P=0.012, P=0.030). Conclusion NT1 patients had abnormal nocturnal sleep structures, who showed increased anxiety, depression, and fatigue. Excessive daytime sleepiness and fatigue improved after 3 months of treatment with methylphenidate hydrochloride prolonged-release tablets in combination with venlafaxine.
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Affiliation(s)
- Jieyang Yu
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Yanan Zhang
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Lijia Cai
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Qingqing Sun
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Wanru Li
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Junfang Zhou
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Jianmin Liang
- Department of Pediatric Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
| | - Zan Wang
- Sleep Centre, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin Province, People’s Republic of China
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7
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Martinet V, Sinkunaite L, Bruyneel M. An Unusual Cause of Increasing Excessive Daytime Sleepiness in a CPAP-treated Obstructive Sleep Apnea Patient. Sleep Sci 2024; 17:e208-e211. [PMID: 38846592 PMCID: PMC11152635 DOI: 10.1055/s-0043-1777832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 08/02/2023] [Indexed: 06/09/2024] Open
Abstract
The onset of narcolepsy type 1 (NT1) occurs after 50 years of age in less than 2% of the cases. In older adults, the diagnosis is often delayed due to the presence of neurological degenerative and inflammatory comorbidities and overlapping sleep disorders. We report the case of a 63-year-old man with a 5-year history of excessive daytime sleepiness (EDS) and a 2-year diagnosis of obstructive sleep apnea syndrome (OSAS), which. OSAS was confirmed by respiratory polygraphy that showed an apnea-hypopnea index (AHI) of 71 events/hour of sleep associated with significant nocturnal hypoxemia (lowest oxygen saturation: 53%), which lead to the initiation of continuous positive airway pressure (CPAP) treatment. Cognitive complaints, unexplained spells of dizziness, and lack of improvement in EDS with CPAP led to further diagnostic investigation of infectious, inflammatory, and neurodegenerative disorders. Low hypocretin levels in the cerebrospinal fluid (CSF) confirmed the diagnosis of NT1, and the patient's symptoms improved with the treatment with pitolisant. Though exceptional in older adults, NT1 should be suspected in the presence of atypical EDS with neurological complaints, unexplained dizzy spells, or OSAS that resists the CPAP treatment. Low levels of hypocretin in the CSF are highly specific and rule out other neurological and sleep disorders.
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Affiliation(s)
- Valerie Martinet
- Department of Geriatrics, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Brussels, Belgium
| | - Laura Sinkunaite
- Department of Neurology, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Brussels, Belgium
| | - Marie Bruyneel
- Department of Pneumology, Centre Hospitalier Universitaire (CHU) Saint-Pierre, Brussels, Belgium
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8
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Wu M, Li X, Li SX, Tan L, Fang J, Zhou J, Tang X. Early- and late-onset narcolepsy: possibly two distinct clinical phenotypes. Sleep Breath 2023; 27:2443-2452. [PMID: 37046113 DOI: 10.1007/s11325-023-02820-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/23/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023]
Abstract
PURPOSE To investigate the clinical characteristics and the risk factors associated with excessive daytime sleepiness (EDS) in patients with early- and late-onset narcolepsy. METHODS Patients with narcolepsy were consecutively recruited. All patients were separated into early- and late-onset groups according to the onset age of disease ≤ 15 and > 15 years, respectively. Demographic, clinical, and sleep parameters were compared between the two groups. Linear regressions were performed to examine the risk factors of subjective and objective EDS in patients with early- and late-onset narcolepsy. RESULTS A total of 101 patients with narcolepsy (median age at recruitment = 18.0 years) were classified into an early-onset group (67 patients with median age at onset = 12.0 years) and a late-onset group (34 patients with median age at onset = 28.5 years). Compared with early-onset group, late-onset group scored significantly higher on Epworth Sleepiness Scale (ESS), Ullanlinna Narcolepsy Scale (UNS), sleep paralysis, rapid eye movement (REM) sleep behavior disorder (RBD) questionnaire-Hong Kong (all P < 0.050). UNS-cataplexy and sleep paralysis had significantly positive associations with subjective EDS, and N1%, arousal index, and periodic limb movements index were positively associated with objective EDS in the early-onset group (all P < 0.050). However, these associations were not observed in late-onset narcolepsy. CONCLUSION Late onset narcolepsy had more severe self-reported narcolepsy symptoms. REM sleep related symptoms and disrupted nighttime sleep were associated with EDS in early-onset narcolepsy. These findings suggest that early- and late-onset narcolepsy may represent two distinct phenotypes.
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Affiliation(s)
- Min Wu
- Sleep Medicine Center, West China Hospital, Sichuan University, 28 Dian Xin Nan Jie, Chengdu, 610041, Sichuan Province, China
- Shihezi University School of Medicine, Shihezi University, Shihezi, China
| | - Xiao Li
- Department of Psychology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Shirley Xin Li
- Department of Psychology, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Lu Tan
- Sleep Medicine Center, West China Hospital, Sichuan University, 28 Dian Xin Nan Jie, Chengdu, 610041, Sichuan Province, China
| | - Jinbo Fang
- West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China
| | - Junying Zhou
- Sleep Medicine Center, West China Hospital, Sichuan University, 28 Dian Xin Nan Jie, Chengdu, 610041, Sichuan Province, China.
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiangdong Tang
- Sleep Medicine Center, West China Hospital, Sichuan University, 28 Dian Xin Nan Jie, Chengdu, 610041, Sichuan Province, China.
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9
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Dye TJ, Simakajornboon N. Narcolepsy in Children: Sleep disorders in children, A rapidly evolving field seeking consensus. Pediatr Pulmonol 2022; 57:1952-1962. [PMID: 34021733 DOI: 10.1002/ppul.25512] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/09/2022]
Abstract
Narcolepsy is a life-long sleep disorder with two distinct subtypes, narcolepsy type I and narcolepsy type II. It is now well recognized that the loss of hypocretin neurons underlies the pathogenesis of narcolepsy type I, however, the pathogenesis of narcolepsy type II is currently unknown. Both genetic and environmental factors play an important role in the pathogenesis of narcolepsy. There is increasing evidence that autoimmune processes may play a critical role in the loss of hypocretin neurons. Infections especially streptococcus and influenza have been proposed as a potential trigger for the autoimmune-mediated mechanism. Several recent studies have shown increased cases of pediatric narcolepsy following the 2009 H1N1 pandemic. The increased cases in Europe seem to be related to a specific type of H1N1 influenza vaccination (Pandemrix), while the increased cases in China are related to influenza infection. Children with narcolepsy can have an unusual presentation at disease onset including complex motor movements which may lead to delayed diagnosis. All classic narcolepsy tetrads are present in only a small proportion of children. The diagnosis of narcolepsy is confirmed by either obtaining cerebrospinal fluid hypocretin or overnight sleep study with the multiple sleep latency test (MSLT). There are limitations of using MSLT in young children such that a negative MSLT test cannot exclude narcolepsy. HLA markers have limited utility in narcolepsy, but it may be useful in young children with clinical suspicion of narcolepsy. For management, both pharmacologic and non-pharmacologic treatments are important in the management of narcolepsy. Pharmacotherapy is primarily aimed to address excessive daytime sleepiness and REM-related symptoms such as cataplexy. In addition to pharmacotherapy, routine screening of behavioral and psychosocial issues is warranted to identify patients who would benefit from bio-behavior intervention.
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Affiliation(s)
- Thomas J Dye
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Narong Simakajornboon
- Division of Pulmonary and Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Ralls F, Cutchen L, Grigg-Damberger MM. What Is the Prognostic Significance of Rapid Eye Movement Sleep Without Atonia in a Polysomnogram? J Clin Neurophysiol 2022; 39:346-355. [PMID: 35239559 DOI: 10.1097/wnp.0000000000000826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Freud said we are lucky to be paralyzed during sleep, so we cannot act out our dreams. Atonia of skeletal muscles normally present during rapid eye movement sleep prevents us from acting out our dreams. Observing rapid eye movement sleep without atonia in a polysomnogram in older adults first and foremost warrants consideration of rapid eye movement behavior disorder. Seventy-five to 90% of older adults with isolated rapid eye movement behavior disorder will develop a neurodegenerative disease within 15 years, most often a synucleinopathy. Rapid eye movement sleep without atonia in those younger than 50 years is commonly found in individuals with narcolepsy and those taking antidepressant medications.
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Affiliation(s)
- Frank Ralls
- New Mexico Sleep Labs, Rio Rancho, New Mexico, U.S.A
| | - Lisa Cutchen
- Omni Sleep, Albuquerque, New Mexico, U.S.A.; and
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The REM-sleep related characteristics of narcolepsy: A nation-wide multi-center study in Turkey, the REMCON study. Sleep Med 2022; 94:17-25. [DOI: 10.1016/j.sleep.2022.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/18/2022]
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12
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Baltzan M, Yao C, Rizzo D, Postuma R. Dream enactment behavior: review for the clinician. J Clin Sleep Med 2020; 16:1949-1969. [PMID: 32741444 PMCID: PMC8034224 DOI: 10.5664/jcsm.8734] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/24/2020] [Accepted: 07/24/2020] [Indexed: 12/12/2022]
Abstract
NONE Dream enactment behavior commonly occurs on occasion in normal children and adults. Disruptive and frequent dream enactment behavior may come to the attention of the clinician either as the primary reason for consultation or as a prominent characteristic of a patient with other sleep disorders. Questioning patients with chronic neurologic and psychiatric disorders may also reveal previously unrecognized behavior. In the absence of sleep pathology, process of dream enactment likely begins with active, often emotionally charged dream content that may occasionally break through the normal REM sleep motor suppressive activity. Disrupted sleep resulting from many possible causes, such as circadian disruption, sleep apnea, or medications, may also disrupt at least temporarily the motor-suppressive activity in REM sleep, allowing dream enactment to occur. Finally, pathological neurological damage in the context of degenerative, autoimmune, and infectious neurological disorders may lead to chronic recurrent and severe dream enactment behavior. Evaluating the context, frequency, and severity of dream enactment behavior is guided first and foremost by a structured approach to the sleep history. Physical exam and selected testing support the clinical diagnosis. Understanding the context and the likely cause is essential to effective therapy.
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Affiliation(s)
- Marc Baltzan
- Faculty of Medicine, Department of Epidemiology Biostatistics and Occupational Health, McGill University, Montréal, Canada
- Centre Intégré Universitaire des Soins et Services Sociaux du Nord de L’île de Montréal, Montréal, Canada
- Mount Sinai Hospital, Centre Intégré Universitaire des Soins et Services Sociaux du Centre-ouest de L’île de Montréal, Montréal, Canada
- Institut de Médecine du Sommeil, Montréal, Canada
| | - Chun Yao
- Integrated Program in Neuroscience, McGill University, Montréal, Canada
- Research Institute of McGill University Health Centre, Montréal, Canada
| | - Dorrie Rizzo
- Faculty of Medicine, Department of Family Medicine, McGill University, Montréal, Canada
- Lady Davis Institute for Medical Research, Centre Intégré Universitaire des Soins et Services Sociaux de l’ouest de l’île, Montréal, Canada
| | - Ron Postuma
- Research Institute of McGill University Health Centre, Montréal, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, Canada
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Escalona Belmonte JJ, Romero Molina S, Sepúlveda Haro E, Malo Manso A, Guerrero Orriach JL. Narcolepsy and opioid-free anesthesia: a review and case report. ACTA ACUST UNITED AC 2020; 68:165-170. [PMID: 33160690 DOI: 10.1016/j.redar.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Narcolepsy is the second most common sleep disorder. It is characterised by excessive daytime sleepiness together with other symptoms such as cataplexy, sleep paralysis, and hallucinations. The pathophysiology and treatment of this disease, together with its associated syndromes, can severely interfere with anaesthesia. METHODOLOGY Due to the lack of quality evidence on which to base a high grade of recommendation for anaesthesia in these patients, we performed a non-systematic, narrative review of the literature in Pubmed. We used the descriptors narcolepsy, anesthesia, surgery, perioperative, opioid, obstructive, apnea and sleep both individually and with AND and OR connectors. CONCLUSION The recommendation to avoid opioids and the stability of opioid-free anaesthesia (OFA) make this approach an option to consider in these patients. We describe a case in which it was used safely.
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Affiliation(s)
- J J Escalona Belmonte
- Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, IBIMA, grupo de investigación A-21, Málaga, España
| | - S Romero Molina
- Hospital Universitario Virgen de la Victoria, Málaga, España
| | | | - A Malo Manso
- Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, IBIMA, grupo de investigación A-21, Málaga, España.
| | - J L Guerrero Orriach
- Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, IBIMA, grupo de investigación A-21, Málaga, España
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Zhang M, Inocente CO, Villanueva C, Lecendreux M, Dauvilliers Y, Lin JS, Arnulf I, Gustin MP, Thieux M, Franco P. Narcolepsy with cataplexy: Does age at diagnosis change the clinical picture? CNS Neurosci Ther 2020; 26:1092-1102. [PMID: 32761857 PMCID: PMC7539846 DOI: 10.1111/cns.13438] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/06/2020] [Accepted: 06/15/2020] [Indexed: 11/29/2022] Open
Abstract
Objective To compare symptoms and sleep characteristics in patients diagnosed with narcolepsy‐cataplexy (NC) before and after the age of 18 years. Methods De novo patients with NC diagnosis completed a standardized questionnaire and interview, followed by a sleep study. The clinical and sleep measures were compared between patients diagnosed before (46 children, median age: 12 year old) and after (46 adults, median age: 28.5 year old) 18 years of age. Results The frequency of obesity (54% vs 17%), night eating (29% vs 7%), parasomnia (89% vs 43%), sleep talking (80% vs 34%), and sleep drunkenness (69% vs 24%) were higher in children than in adults, the frequency of sleep paralysis was lower (20% vs 55%) but the frequency of cataplexy and the severity of sleepiness were not different. Children scored higher than adults at the attention‐deficit/hyperactivity disorder (ADHD) scale. Depressive feelings affected not differently children (24%) and adults (32%). However, adults had lower quality of life than children. There was no difference between groups for insomnia and fatigue scores. Quality of life was essentially impacted by depressive feelings in both children and adults. Obstructive apnea‐hypopnea index (OAHI) was lower in children with higher mean and minimal oxygen saturation than in adults. No between‐group differences were found at the multiple sleep latency test. The body mass index (z‐score) was correlated with OAHI (r = .32). Conclusion At time of NC diagnosis, children have more frequent obesity, night eating, parasomnia, sleep talking, drunkenness, and ADHD symptoms than adults, even if sleepiness and cataplexy do not differ. These differences should be considered to ensure a prompt diagnosis.
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Affiliation(s)
- Min Zhang
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Clara Odilia Inocente
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Carine Villanueva
- Endocrinology Pediatric Unit, Woman Mother Child Hospital, Civil Hospices of Lyon, Lyon, France
| | - Michel Lecendreux
- Pediatric Sleep Centre, Hospital Robert-Debre, Paris, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Paris, France
| | - Yves Dauvilliers
- National Reference Network for Narcolepsy, Sleep-Wake Disorder Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,Inserm U1061, University of Montpellier, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France
| | - Jian-Sheng Lin
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France
| | - Isabelle Arnulf
- AP-HP, Pitié-Salpêtrière Hospital, Sleep Disorder Unit & Sorbonne University, Paris, France
| | - Marie-Paule Gustin
- Emerging Pathogens Laboratory-Fondation Mérieux, International Center for Infectiology Research (CIRI), Inserm U1111, CNRS UMR5308, ENS de Lyon, Lyon, France.,Institute of Pharmaceutic and Biological Sciences, Public Health Department, Biostatistics, University Claude Bernard Lyon 1, Villeurbanne, France
| | - Marine Thieux
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France.,Sleep Pediatric Unit, Woman Mother Child Hospital, Civil Hospices of Lyon, Lyon, France
| | - Patricia Franco
- Integrative Physiology of the Brain Arousal Systems, CRNL, INSERM-U1028, CNRS UMR5292, University of Lyon 1, Lyon, France.,Sleep Pediatric Unit, Woman Mother Child Hospital, Civil Hospices of Lyon, Lyon, France
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15
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Plazzi G, Clawges HM, Owens JA. Clinical Characteristics and Burden of Illness in Pediatric Patients with Narcolepsy. Pediatr Neurol 2018; 85:21-32. [PMID: 30190179 DOI: 10.1016/j.pediatrneurol.2018.06.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 06/19/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Narcolepsy is a chronic and lifelong neurologic disorder with onset commonly occurring in childhood or adolescence, and affecting approximately 0.025% to 0.05% of the general population. The primary symptom is excessive daytime sleepiness, which is accompanied by cataplexy in 70% of patients. Other common symptoms include sleep paralysis, hallucinations upon falling asleep or waking, and disrupted nocturnal sleep. Narcolepsy is associated with a considerable burden of illness (BOI), which has been well characterized in adults, and is exacerbated by delays in symptom recognition, diagnosis, and intervention. METHODS This review describes the specific characteristics and BOI of pediatric narcolepsy, using a wide range of published research data. RESULTS Pediatric narcolepsy presents distinct challenges in diagnosis and management. Narcolepsy symptoms often initially manifest differently in children and adolescents versus adults, which may pose diagnostic dilemmas. Children often respond to sleepiness with irritability, hyperactivity, and poor attention, which may be misinterpreted as misbehavior or neurocognitive sequelae of other conditions. Pediatric cataplexy symptoms may include subtle and unusual facial expressions or choreic-like movements, which are not observed in adults. Insufficient sleep and circadian rhythm disorders presenting with excessive daytime sleepiness are common in adolescents, potentially confounding narcolepsy diagnosis. Pediatric narcolepsy is also associated with comorbidities including rapid weight gain, precocious puberty, and attention deficit hyperactivity disorder, and increased risk for deficits in social functioning, depression, and anxiety. School performance is also typically impaired, requiring special education services. CONCLUSIONS Thus, the discrete BOI of pediatric narcolepsy underscores the need for prompt and accurate diagnosis, and appropriate treatment of this disorder.
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Affiliation(s)
- Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
| | - Heather M Clawges
- Department of Pediatrics, Sleep Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WestVirginia
| | - Judith A Owens
- Division of Neurology, Boston Children's Hospital, Harvard Medical School, Waltham, Massachusetts
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Swick TJ. Patients with central disorders of excessive hypersomnolence and their perioperative risks and anesthetic management. J Clin Anesth 2017; 41:35-37. [DOI: 10.1016/j.jclinane.2017.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 04/21/2017] [Accepted: 04/29/2017] [Indexed: 10/19/2022]
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Antelmi E, Pizza F, Vandi S, Neccia G, Ferri R, Bruni O, Filardi M, Cantalupo G, Liguori R, Plazzi G. The spectrum of REM sleep-related episodes in children with type 1 narcolepsy. Brain 2017; 140:1669-1679. [PMID: 28472332 DOI: 10.1093/brain/awx096] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 02/26/2017] [Indexed: 11/14/2022] Open
Abstract
Type 1 narcolepsy is a central hypersomnia due to the loss of hypocretin-producing neurons and characterized by cataplexy, excessive daytime sleepiness, sleep paralysis, hypnagogic hallucinations and disturbed nocturnal sleep. In children, close to the disease onset, type 1 narcolepsy has peculiar clinical features with severe cataplexy and a complex admixture of movement disorders occurring while awake. Motor dyscontrol during sleep has never been systematically investigated. Suspecting that abnormal motor control might affect also sleep, we systematically analysed motor events recorded by means of video polysomnography in 40 children with type 1 narcolepsy (20 females; mean age 11.8 ± 2.6 years) and compared these data with those recorded in 22 age- and sex-matched healthy controls. Motor events were classified as elementary movements, if brief and non-purposeful and complex behaviours, if simulating purposeful behaviours. Complex behaviours occurring during REM sleep were further classified as 'classically-defined' and 'pantomime-like' REM sleep behaviour disorder episodes, based on their duration and on their pattern (i.e. brief and vivid-energetic in the first case, longer and with subcontinuous gesturing mimicking daily life activity in the second case). Elementary movements emerging either from non-REM or REM sleep were present in both groups, even if those emerging from REM sleep were more numerous in the group of patients. Conversely, complex behaviours could be detected only in children with type 1 narcolepsy and were observed in 13 patients, with six having 'classically-defined' REM sleep behaviour disorder episodes and seven having 'pantomime-like' REM sleep behaviour disorder episodes. Complex behaviours during REM sleep tended to recur in a stereotyped fashion for several times during the night, up to be almost continuous. Patients displaying a more severe motor dyscontrol during REM sleep had also more severe motor disorder during daytime (i.e. status cataplecticus) and more complaints of disrupted nocturnal sleep and of excessive daytime sleepiness. The neurophysiological hallmark of this severe motor dyscontrol during REM sleep was a decreased atonia index. The present study reports for the first time the occurrence of a severe and peculiar motor disorder during REM sleep in paediatric type 1 narcolepsy and confirms the presence of a severe motor dyscontrol in these patients, emerging not only from wakefulness (i.e. status cataplecticus), but also from sleep (i.e. complex behaviours during REM sleep). This is probably related to the acute imbalance of the hypocretinergic system, which physiologically acts by promoting movements during wakefulness and suppressing them during sleep.
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Affiliation(s)
- Elena Antelmi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,IRCSS, Institute of Neurological Sciences, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,IRCSS, Institute of Neurological Sciences, Bologna, Italy
| | - Stefano Vandi
- IRCSS, Institute of Neurological Sciences, Bologna, Italy
| | - Giulia Neccia
- IRCSS, Institute of Neurological Sciences, Bologna, Italy
| | - Raffaele Ferri
- Sleep Research Centre, Department of Neurology, I.C., Oasi Institute (IRCCS), Troina, Italy
| | - Oliviero Bruni
- Department of Social and Developmental Psychology, University of Rome La Sapienza, Rome, Italy
| | - Marco Filardi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Gaetano Cantalupo
- Child Neuropsychiatry, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Rocco Liguori
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,IRCSS, Institute of Neurological Sciences, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,IRCSS, Institute of Neurological Sciences, Bologna, Italy
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Cavalcante AN, Hofer RE, Tippmann-Peikert M, Sprung J, Weingarten TN. Perioperative risks of narcolepsy in patients undergoing general anesthesia: A case-control study. J Clin Anesth 2017; 41:120-125. [PMID: 28433385 DOI: 10.1016/j.jclinane.2017.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To compare the perioperative outcomes between patients with narcolepsy and matched controls undergoing anesthetic management. DESIGN Retrospective 2:1 matched study design. SETTING Large tertiary medical center. PATIENTS Narcoleptic patients who underwent general anesthesia from January 1, 2011, through September 30, 2015, were matched with controls by age, sex, and type and year of surgery. MEASUREMENTS Medical records were reviewed for episodes of respiratory depression during phase I recovery and for other meaningful perioperative outcomes. MAIN RESULTS The perioperative courses of 76 narcoleptic patients and their controls were examined. Compared to controls, narcoleptic patients were more often prescribed central nervous system stimulants (73.7% vs 4.0%, P<0.001) and antidepressants (46.1% vs 27.6%, P=0.007) and more often had obstructive sleep apnea (40.8% vs 19.1%, P<0.001). The intraoperative course was similar. The number of episodes of respiratory depression was not different between patients and controls (5 [6.6%] vs 12 [7.9%], respectively; P=0.80). Narcoleptic patients had a higher frequency of emergency response team activations (5 of 76 [6.6%]; 95% CI, 2.2%-14.7%) compared to controls (2 of 152 [1.3%]; 95% CI, 0.2%-4.7%) (P=0.04). Hemodynamic instability was the indication for all emergency response team activations except 1, which was for a narcoleptic patient who had excessive postoperative sedation and respiratory depression. CONCLUSIONS Narcoleptic patients had similar intraoperative courses as the matched controls, including phase I anesthetic recovery. However, they had a higher rate of emergency response team activations than the controls, which suggests that patients with narcolepsy may be at increased perioperative risk.
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Affiliation(s)
- Alexandre N Cavalcante
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Mayo Clinic, Rochester, MN, United States
| | - Ryan E Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | | | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States.
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Gehrmann J, Siegler D, Ignacy E, Reimer I. [Narcolepsy in childhood and adolescence: symptoms, diagnosis, and therapy. A case report]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2017; 45:149-157. [PMID: 28320246 DOI: 10.1024/1422-4917/a000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Narcolepsy is a rare, multifactorial disease of the hypothalamus characterized by its leading symptoms of excessive daytime sleepiness and cataplexy. Sleep-EEG and a HLA-DR-genotype serve to secure the diagnosis. We report here on a 14-year-old girl suffering from anxieties, depression, school refusal, social withdrawal as well as very frequent attacks of sleep during the day and cataplexy. Currently, there is no approved drug for children and adolescents suffering from narcolepsy. Our patient benefited significantly and quickly from an off-label treatment with methylphenidate in combination with psychoeducation, cognitive behavioral therapy, and family therapy. Narcolepsy is a very rare but probably underestimated differential diagnosis applied to unclear daytime sleepiness, anxieties, or depression in childhood and adolescence. Both the key symptoms and the comorbid symptoms improve significantly under treatment with stimulants, albeit at a higher dosage.
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Affiliation(s)
- Jochen Gehrmann
- 1 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Ludwigshafen a. Rh., Deutschland
| | - Dominik Siegler
- 1 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Ludwigshafen a. Rh., Deutschland
| | - Evelin Ignacy
- 1 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Ludwigshafen a. Rh., Deutschland
| | - Inga Reimer
- 1 Klinik für Kinder- und Jugendpsychiatrie und Psychotherapie, Ludwigshafen a. Rh., Deutschland
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Kovalská P, Kemlink D, Nevšímalová S, Maurovich Horvat E, Jarolímová E, Topinková E, Šonka K. Narcolepsy with cataplexy in patients aged over 60 years: a case-control study. Sleep Med 2016; 26:79-84. [DOI: 10.1016/j.sleep.2016.05.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 01/13/2023]
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21
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Irfan M, Howell MJ. Rapid Eye Movement Sleep Behavior Disorder: Overview and Current Perspective. CURRENT SLEEP MEDICINE REPORTS 2016. [DOI: 10.1007/s40675-016-0038-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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22
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Abstract
Much of the understanding of the hypocretin/orexin (HCRT/OX) system in sleep-wake regulation came from narcolepsy-cataplexy research. The neuropeptides hypocretin-1 and -2/orexin-A and -B (HCRT-1 and -2/OX-A and -B, respectively), as we know, are intimately involved in the regulation wakefulness. The HCRT/OX system regulates sleep-wake control through complex interactions between monoaminergic/cholinergic (wake-promoting) and gamma-aminobutyric acid-ergic (sleep-promoting) neuronal systems. Deficiency of HCRT/OX results in loss of sleep-wake control or stability with consequent unstable transitions between wakefulness to nonrapid eye movement and rapid eye movement sleep. This manifests clinically as abnormal daytime sleepiness with sleep attacks and cataplexy. Research on the development of HCRT/OX agonists and antagonists for the treatment of sleep disorders has dramatically increased with the US Food and Drug Administration approval of the first-in-class dual HCRT/OX receptor antagonist for the treatment of insomnia. This review focuses on the origin, mechanisms of HCRT/OX receptors, clinical progress, and applications for the treatment of sleep disorders.
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Affiliation(s)
- Matthew Chow
- Department of Psychiatry and Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Michelle Cao
- Department of Psychiatry and Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Sasai-Sakuma T, Kinoshita A, Inoue Y. Polysomnographic Assessment of Sleep Comorbidities in Drug-Naïve Narcolepsy-Spectrum Disorders--A Japanese Cross-Sectional Study. PLoS One 2015; 10:e0136988. [PMID: 26322978 PMCID: PMC4556112 DOI: 10.1371/journal.pone.0136988] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 08/11/2015] [Indexed: 01/01/2023] Open
Abstract
This is a large cross-sectional study which aimed to investigate comorbidity rate, degree of sleep-related breathing disorder, polysomnigraphically diagnosible rapid eye movement sleep behavior disorder/rapid eye movement sleep without atonia and periodic limb movements during sleep in Japanese drug-naïve patients with narcolepsy-spectrum disorders. A total of 158 consecutive drug naïve patients with narcolepsy with cataplexy, 295 patients with narcolepsy without cataplexy and 395 patients with idiopathic hypersomnia without long sleep time were enrolled. From retrospectively analyzed data of nocturnal polysomnography and multiple sleep latency test, higher rates of periodic limb movements during sleep (> = 15 h-1) (10.2%) and polysomnographically diagnosable rapid eye movement sleep behavior disorder (1.9%) were found in patients with narcolepsy with cataplexy. They had more severe periodic limb movements during sleep especially during rapid eye movement sleep and higher percentages of rapid eye movement sleep without atonia than the other two patient groups. In the present large sample study, Japanese drug naïve patients with narcolepsy with cataplexy showed the highest comorbidity rates of periodic limb movements during sleep, polysomnographically diagnosable rapid eye movement sleep behavior disorder and rapid eye movement sleep without atonia among those with the other narcolepsy-spectrum disorders; the rates were lower than those for Western patients.
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Affiliation(s)
- Taeko Sasai-Sakuma
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
- Department of Life Sciences and Bio-informatics, Division of Biomedical Laboratory Sciences, Graduate School of Health Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- * E-mail:
| | - Akihiko Kinoshita
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
| | - Yuichi Inoue
- Department of Somnology, Tokyo Medical University, Tokyo, Japan
- Japan Somnology Center, Neuropsychiatric Research Institute, Tokyo, Japan
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Suzuki S, Uehara T, Ohira Y, Ikusaka M. Narcolepsy with Cataplexy in an Elderly Woman. J Gen Intern Med 2015; 30:1222-4. [PMID: 25784528 PMCID: PMC4510249 DOI: 10.1007/s11606-015-3277-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
A 72-year-old woman was referred for a 15-year history of brief attacks of generalized weakness that occurred when she was tense or startled. During these episodes, she squatted, closed her eyes, and had difficulty speaking, but there was no disturbance of consciousness. The cerebrospinal fluid level of orexin/hypocretin was low (92 ng/L), leading to a diagnosis of narcolepsy with cataplexy according to the International Classification of Sleep Disorders (ICSD)-2 criteria. Cataplexy should be considered for sudden attacks of weakness lasting less than 2 minutes and with no alteration of consciousness. Measurement of cerebrospinal fluid levels of orexin/hypocretin is recommended when the diagnosis is uncertain.
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Affiliation(s)
- Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, 1-8-1, Inohana, Chuo-ku, Chiba-city, Chiba, 260-8677, Japan,
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Ylikoski A, Martikainen K, Sarkanen T, Partinen M. Parkinson's disease and narcolepsy-like symptoms. Sleep Med 2015; 16:540-4. [DOI: 10.1016/j.sleep.2014.12.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 11/25/2014] [Accepted: 12/29/2014] [Indexed: 01/10/2023]
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26
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Abstract
Cataplexy is defined as episodes of sudden loss of voluntary muscle tone triggered by emotions generally lasting <2 minutes. Cataplexy is most commonly associated with and considered pathognomonic for narcolepsy, a sleep disorder affecting ~0.05% of the general population. Knowledge of the pathophysiology of cataplexy has advanced through study of canine, murine, and human models. It is now generally considered that loss of signaling by hypothalamic hypocretin/orexin-producing neurons plays a key role in the development of cataplexy. Although the cause of hypocretin/orexin neuron loss in narcolepsy with cataplexy is unknown, an autoimmune etiology is widely hypothesized. Despite these advances, a literature review shows that treatment of cataplexy remains limited. Multiple classes of antidepressants have been commonly used off-label for cataplexy in narcolepsy and are suggested for this use in expert consensus guidelines based on traditional practice, case reports, and small trials. However, systematic research evidence supporting antidepressants for cataplexy is lacking. The single pharmacotherapy indicated for cataplexy and the guideline-recommended first-line treatment in Europe and the US is sodium oxybate, the sodium salt of gamma-hydroxybutyrate. Clinical trial evidence of its efficacy and safety in cataplexy is robust, and it is hypothesized that its therapeutic effects may occur through gamma-aminobutyric acid receptor type B-mediated effects at noradrenergic, dopaminergic, and thalamocortical neurons. Additional possible mechanisms for cataplexy therapy suggested by preliminary research include antagonism of the histamine H3 autoreceptor with pitolisant and intravenous immunoglobulin therapy for amelioration of the presumed autoimmune-mediated hypocretin/orexin cell loss. Further research and development of therapeutic approaches to cataplexy are needed.
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Affiliation(s)
- Todd J Swick
- Department of Neurology, University of Texas School of Medicine-Houston, Houston, TX, USA ; The Sleep Center at North Cypress Medical Center, Cypress, TX, USA ; Apnix Sleep Diagnostics, Houston, TX, USA ; Neurology and Sleep Medicine Consultants, Houston, TX, USA
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27
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Affiliation(s)
- Gulnur Com
- University of Arkansas Medical Sciences, Little Rock, AR, USA
| | - Mali A Einen
- Stanford University Center for Narcolepsy, Redwood City, CA, USA
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Anderson KN. An update in sleep neurology: the latest bedtime stories. J Neurol 2014; 262:487-91. [PMID: 25491077 DOI: 10.1007/s00415-014-7602-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 11/27/2014] [Indexed: 01/17/2023]
Abstract
In the 24/7 modern society, sleep disorders and the role of normal amounts and timing of sleep for health are often neglected by both doctors and their patients. Sleep has been said to be "of the brain, by the brain and for the brain" and the most immediate and obvious consequence of disrupted sleep is impaired brain function. This review will cover some of the recent papers published in both the Journal of Neurology and elsewhere in 2013/2014 that have advanced our knowledge of sleep and circadian rhythm disorders.
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Affiliation(s)
- K N Anderson
- Regional Sleep Service, Freeman Hospital, Newcastle Upon Tyne, UK,
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29
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Scholle S, Scholle HC. Leg movements and periodic leg movements during sleep in the development across childhood and adolescence from 1 to 18 years. Sleep Med 2014; 15:1068-74. [DOI: 10.1016/j.sleep.2014.04.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/15/2014] [Accepted: 04/19/2014] [Indexed: 10/25/2022]
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Kumar S, Sagili H. Etiopathogenesis and neurobiology of narcolepsy: a review. J Clin Diagn Res 2013; 8:190-5. [PMID: 24701532 DOI: 10.7860/jcdr/2014/7295.4057] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 11/28/2013] [Indexed: 12/26/2022]
Abstract
Narcolepsy is a chronic lifelong sleep disorder and it often leaves a debilitating effect on the quality of life of the sufferer. This disorder is characterized by a tetrad of excessive daytime sleepiness, cataplexy (brief loss of muscle tone following strong emotion), hypnogogic hallucinations and sleep paralysis. There are two distinct subgroups of Narcolepsy: Narcolepsy with cataplexy and Narcolepsy without cataplexy. For over 100 years, clinicians have recognised narcolepsy, but only in the last few decades have scientists been able to shed light on the true cause and pathogenesis of narcolepsy. Recent studies have shown that a loss of the hypothalamic neuropeptide Hypocretin/Orexincauses Narcolepsy with cataplexy and that an autoimmune mechanism may be responsible for this loss. Our understanding of the neurophysiologic aspect of narcolepsy has also significantly improved. The basic neural mechanisms behind sleepiness and cataplexy, the two defining symptoms of narcolepsy have started to become clearer. In this review, we have provided a detailed account of the key aspects of etiopathogenesis and neurobiology of narcolepsy, along with a critical appraisal of the more recent and interesting causal associations.We have also looked at the contributions of neuroimaging to the etiopathogenesis of Narcolepsy.
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Affiliation(s)
- Swarup Kumar
- Intern, Department of Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , India
| | - Haritha Sagili
- Associate Professor, Department of Obstetrics and Gynaecology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) , India
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Frauscher B, Ehrmann L, Mitterling T, Gabelia D, Gschliesser V, Brandauer E, Poewe W, Högl B. Delayed diagnosis, range of severity, and multiple sleep comorbidities: a clinical and polysomnographic analysis of 100 patients of the innsbruck narcolepsy cohort. J Clin Sleep Med 2013; 9:805-12. [PMID: 23946711 DOI: 10.5664/jcsm.2926] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES Narcolepsy is reported to affect 26-56/100,000 in the general population. We aimed to describe clinical and polysomnographic features of a large narcolepsy cohort in order to comprehensively characterize the narcoleptic spectrum. METHODS We performed a chart- and polysomnographybased review of all narcolepsy patients of the Innsbruck narcolepsy cohort. RESULTS A total of 100 consecutive narcolepsy patients (87 with cataplexy [NC], 13 without cataplexy [N]) were included in the analysis. All subjects had either excessive daytime sleepiness or cataplexy as their initial presenting clinical feature. Age at symptom onset was 20 (6-69) years. Diagnostic delay was 6.5 (0-39) years. The complete narcolepsy tetrad was present in 36/100 patients; 28/100 patients had three cardinal symptoms; 29/100 had two; and 7/100 had only excessive daytime sleepiness. Severity varied broadly with respect to excessive daytime sleepiness (median Epworth Sleepiness Scale score: 18, range 10-24), cataplexy (8-point Likert scale: median 4.5, range 1-8), hypnagogic hallucinations (median 4.5, range 1-7), and sleep paralysis (median 3, range 1-7). Sleep comorbidity was highly prevalent and ranged from sleeprelated movement disorders (n = 55/100), parasomnias (n = 34/100), and sleeprelated breathing disorders (n = 24/100), to insomnia (n = 28/100). REM sleep without atonia or a periodic limb movement in sleep index > 5/h were present in most patients (90/100 and 75/100). A high percentage of narcoleptic patients in the present study had high frequency leg movements (35%) and excessive fragmentary myoclonus (22%). Of the narcolepsy patients with clinical features of REM sleep behavior disorder (RBD), 76.5% had EMG evidence for RBD on the multiple sleep latency test (MSLT), based on a standard cutoff of a minimum of 18% of 3-sec miniepochs. CONCLUSION This study is one of the largest monocentric polysomnographic studies to date of patients with narcolepsy and confirms the frequent comorbidity of narcolepsy with many other sleep disorders. Our study is the first to evaluate the percentage of patients with high frequency leg movements and excessive fragmentary myoclonus in narcolepsy and is the first to demonstrate EMG evidence of RBD in the MSLT. These findings add to the growing body of literature suggesting that motor instability is a key feature of narcolepsy.
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Affiliation(s)
- Birgit Frauscher
- Innsbruck Medical University, Department of Neurology, Innsbruck, Austria
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Mahlios J, De la Herrán-Arita AK, Mignot E. The autoimmune basis of narcolepsy. Curr Opin Neurobiol 2013; 23:767-73. [PMID: 23725858 DOI: 10.1016/j.conb.2013.04.013] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 04/19/2013] [Accepted: 04/19/2013] [Indexed: 01/04/2023]
Abstract
Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness, cataplexy, hypnagonic hallucinations, sleep paralysis, and disturbed nocturnal sleep patterns. Narcolepsy is caused by the loss of hypocretin (orexin)-producing neurons in the lateral hypothalamus. Evidence, such as a strong association with HLA DQB1*06:02, strongly suggests an autoimmune basis targeting hypocretin neurons. Genome-wide association studies have strengthened the association between narcolepsy and immune system gene polymorphisms, including the identification of polymorphisms in the T cell receptor alpha locus, TNFSF4 (also called OX40L), Cathepsin H (CTSH) the purinergic receptor P2RY11, and the DNA methyltransferase DNMT1. Recently, attention has been raised regarding a spike in cases of childhood narcolepsy in 2010 following the 2009 H1N1 pandemic (pH1N1) in China and vaccination with Pandemrix, an adjuvanted H1N1 vaccine that was used in Europe. How the immune system may be involved in disease initiation and/or progression remains a challenge to researchers. Potential immunological pathways that could lead to the specific elimination of hypocretin producing neurons include molecular mimicry or bystander activation, and are likely a combination of genetic and environmental factors, such as upper airway infections.
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Affiliation(s)
- Josh Mahlios
- Stanford Center for Sleep Sciences and Medicine, Stanford University School of Medicine, 1050 A, Arastradero Road, Palo Alto, CA 94034, USA
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Inocente CO, Lavault S, Lecendreux M, Dauvilliers Y, Reimao R, Gustin MP, Castets S, Spiegel K, Lin JS, Arnulf I, Franco P. Impact of obesity in children with narcolepsy. CNS Neurosci Ther 2013; 19:521-8. [PMID: 23574649 DOI: 10.1111/cns.12105] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 02/25/2013] [Accepted: 02/26/2013] [Indexed: 12/20/2022] Open
Abstract
AIMS To evaluate the impact of obesity on clinical and sleep characteristics in a population of narcoleptic children. METHODS Data from the children diagnosed with idiopathic narcolepsy in the National Reference Centers for Narcolepsy were collected between 2008 and 2011. Clinical and electrophysiological characteristics were compared between obese (body mass index [BMI] greater than P97) and nonobese children. RESULTS The 117 children (65 boys, 59 de novo patients) had a mean age of 11.6 ± 3.1 years on diagnosis. Cataplexy was present in 81%, DQB1*0602 in 91%. Mean BMI was 23.2 ± 5.2 kg/m(2) and BMI z-score was 2.9 ± 2.6. Obesity was found in 60% with a similar prevalence in treated versus de novo patients and in patients with and without cataplexy. Sleepiness and cataplexy started earlier in obese children. Obese narcoleptic children had lower sleep efficiency, higher apnea hypopnea index and respiratory arousals index (RAI) than nonobese children. BMI z-score was positively correlated with RAI. Obese children were more tired and missed more often school than nonobese children. CONCLUSION Obesity affects more than 50% of narcoleptic children, mostly younger at disease onset, and has a deleterious impact on sleep quality as well as on school attendance.
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Affiliation(s)
- Clara Odilia Inocente
- Integrative Physiology of Brain Arousal System, CRNL, University Lyon 1, Lyon, France
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