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Miyaguchi R, Masuda F, Sumi Y, Kadotani H, Ozeki Y, Banno M, Kuniyoshi Y. Prevalence of depression or depressive state in patients with restless legs syndrome: A systematic review and meta-analysis. Sleep Med Rev 2024; 77:101975. [PMID: 39024776 DOI: 10.1016/j.smrv.2024.101975] [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: 02/07/2024] [Revised: 06/19/2024] [Accepted: 07/09/2024] [Indexed: 07/20/2024]
Abstract
Restless legs syndrome (RLS) is a common sleep-related disorder characterized by limb discomfort and the urge to move them when at rest, especially in the evening or at night. Although depression is often linked to various conditions, no systematic review has assessed depression prevalence in patients with RLS after the latest diagnostic criteria revision. This systematic review and meta-analysis aimed to investigate the depression and depressive state prevalence among patients with RLS. We systematically searched databases up to November 2022 and performed meta-analyses of the depression prevalence using a random-effects model and a meta-regression analysis to explore the relationship between the prevalence and severity of depression and factors such as age and RLS severity. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we analyzed 24 studies with 2039 patients. The pooled depression or depressive state prevalence, mostly defined by questionnaire scores, was 30.39 %. Nine studies reported the proportion of patients taking antidepressants (pooled rate: 3.41 %). No specific factors related to the prevalence or severity of depression were identified in patients with RLS. These findings highlight the significant prevalence of depression and underscore the need for future research with standardized diagnostic interviews and consistent methodologies across multi-site studies.
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Affiliation(s)
- Rin Miyaguchi
- Faculty of Medicine, Shiga University of Medical Science, Shiga, Japan
| | - Fumi Masuda
- Department of Psychiatry, Shiga University of Medical Science, Shiga, Japan
| | - Yukiyoshi Sumi
- Department of Psychiatry, Shiga University of Medical Science, Shiga, Japan; Department of Psychiatry, Nagahama Red Cross Hospital, Shiga, Japan
| | - Hiroshi Kadotani
- Department of Psychiatry, Shiga University of Medical Science, Shiga, Japan.
| | - Yuji Ozeki
- Department of Psychiatry, Shiga University of Medical Science, Shiga, Japan
| | - Masahiro Banno
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Psychiatry, Seichiryo Hospital, Nagoya, Japan
| | - Yasutaka Kuniyoshi
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Pediatrics, Tsugaruhoken Medical COOP Kensei Hospital, Aomori, Japan
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Talaia AM, Elnahhas A, Talaia NM, Abdelaal A. Prevalence of restless legs syndrome in adults with epilepsy: A systematic review and meta-analysis of observational studies. Sleep Med 2024; 119:258-266. [PMID: 38710131 DOI: 10.1016/j.sleep.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/27/2024] [Accepted: 05/02/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Epilepsy is a common neurological disorder that significantly contributes to the worldwide disease burden. Restless legs syndrome is sleep-related movement disorder that causes uncomfortable sensations in the legs with an irresistible urge to move them. The aim of this study is to comprehensively assess the current evidence to estimate the prevalence of restless legs syndrome (RLS) in adults with epilepsy (AWE) and to compare it to healthy controls. METHODS PubMed, Medline, Scopus, and Web of Science databases were searched for observational studies reporting the prevalence of RLS in AWE. The modified Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the studies. Comprehensive Meta-Analysis software (version 3.0) was used to perform data analysis. The heterogeneity of the studies was assessed using the I2 index. The pooled prevalence of RLS in AWE and the odds ratio were calculated based on the random-effect model. Sensitivity analysis was assessed. A funnel plot and Egger's test were used to investigate publication bias. Subgroup analysis and univariate meta-regression analysis were done. RESULTS Based on the analysis of 17 studies (2262 AWE patients), the prevalence of RLS was 14.9 % (95%CI, 10.4%-21 %). This rate was highest in the Americas (35.3 %; 95 % CI: 19.7-54.9 %) and lowest in Asian countries (11.6 %). The risk of RLS was significantly higher in AWE patients compared to health controls (12 studies, OR = 2.09; 95 % CI: 1.53-2.85, I2 = 91.69 %, P < 0.001). subgroup analysis showed Variations in RLS rates between studies depending on quality scores, methodology, and diagnostic criteria. The funnel plot and Egger's test suggest there was publication bias. Sensitivity analysis showed that none of the studies on their own significantly affected the results. CONCLUSIONS This meta-analysis provides the first pooled estimate of RLS prevalence in AWE. RLS occurs in 15 out of every 100 AWE patients, and the risk is high compared to healthy controls. However, the findings need to be confirmed in future studies owing to limitations in the analysis and study design.
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Affiliation(s)
| | | | | | - Abdelaziz Abdelaal
- Harvard Medical School, Boston, MA, United States; Doheny Eye Institute, Los Angeles, CA, United States
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Jiao W. Older Adults' Exposure to Food Media Induced Unhealthy Eating during the COVID-19 Omicron Lockdown? Exploring Negative Emotions and Associated Literacy and Efficacy on Shanghainese. Foods 2024; 13:1797. [PMID: 38928739 PMCID: PMC11203190 DOI: 10.3390/foods13121797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
The COVID-19 pandemic, propelled by the highly transmissible Omicron variant, had a global impact and significantly affected Shanghai, a major city in China. This study investigates how food media exposure influenced unhealthy eating habits among older adults during the COVID-19 lockdown in Shanghai, focusing on the roles of negative emotions, food literacy, health consciousness, and eating self-efficacy. The random sample comprised 400 individuals aged ≥50 years who lived in Shanghai from March to June 2022. A path and correlation analysis was performed. The exposure of older adults to food media resulted in the acceleration of unhealthy eating. The relationship was significantly exacerbated by food literacy and negative emotions. In contrast, eating self-efficacy and health consciousness effectively countered the media. The enhanced pathway from food-related media influence to eating habits through negative emotions or self-efficacy towards health awareness and food literacy showed significant effects. The findings provide insights for future research and public health strategies. Importantly, this study has practical significance for media professionals, public health decision-makers, and healthy food businesses regarding how to enhance older adults' cognition to respond to unhealthy eating crises.
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Affiliation(s)
- Wen Jiao
- School of Communication, Soochow University, Suzhou 215123, China
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Liang R, Zhu W, Gao Y, Zhao C, Zhang C, Xu L, Zuo Y, Lv Y, Zhao M, Li C, Gao J, Mei J, Gong X, Zhang L, Shen S, Yang C, Ren J, Liu Y, Wang Z, Wang P, Zhou J, Wang F, Wu J, Chen J, Zhu Y, Zhang C, Dong X, Han F. Clinical features, polysomnography, and genetics association study of restless legs syndrome in clinic based Chinese patients: A multicenter observational study. Sleep Med 2024; 117:123-130. [PMID: 38531167 DOI: 10.1016/j.sleep.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/28/2024]
Abstract
STUDY OBJECTIVES To systemically describe the clinical features, polysomnography (PSG) finding, laboratory tests and single-nucleotide polymorphisms (SNPs) in a clinic based Chinese primary restless legs syndrome (RLS) population. METHODS This observational study, conducted from January 2020 to October 2021 across 22 sleep labs in China, recruited 771 patients diagnosed with RLS following the 2014 RLSSG criteria. Clinical data, PSG testing, and laboratory examination and SNPs of patients with RLS were collected. A total of 32 SNPs in 24 loci were replicated using the Asian Screening Array chip, employing data from the Han Chinese Genomes Initiative as controls. RESULTS In this study with 771 RLS patients, 645 had primary RLS, and 617 has DNA available for SNP study. Among the 645 primary RLS, 59.7% were women. 33% had a family history of RLS, with stronger familial influence in early-onset cases. Clinical evaluations showed 10.4% had discomfort in body parts other than legs. PSG showed that 57.1% of RLS patients had periodic leg movement index (PLMI) of >5/h and 39.1% had PLMI >15/h, respectively; 73.8% of RLS patients had an Apnea-Hypopnea Index (AHI) > 5/h, and 45.3% had an AHI >15/h. The laboratory examinations revealed serum ferritin levels <75 ng/ml in 31.6%, and transferrin saturation (TSAT) of <45% in 88.7% of RLS patients. Seven new SNPs in 5 genes showed a significant allelic association with Chinese primary RLS, with one previously reported (BTBD9) and four new findings (TOX3, PRMT6, DCDC2C, NOS1). CONCLUSIONS Chinese RLS patients has specific characters in many aspects. A high family history with RLS not only indicates strong genetic influence, but also reminds us to consider the familial effect in the epidemiological study. Newly developed sequencing technique with large samples remains to be done.
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Affiliation(s)
- Ruiling Liang
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Wenjun Zhu
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Yinghui Gao
- PKU-UPenn Sleep Center, Peking University International Hospital, Beijing, China
| | - Chen Zhao
- Institute of Neurogenomics, Helmholtz Zentrum München, German Research Center for Environmental Health (GmbH), Neuherberg, Germany
| | - Chi Zhang
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Liyue Xu
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Yuhua Zuo
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Yunhui Lv
- The Sleep Center, The First People's Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Mingming Zhao
- Department of Sleep Medicine, People's Hospital of Guangxi Zhuang Autonomous Region, Nan Ning, China
| | - Chenyu Li
- Department of Neurology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Jie Gao
- Department of Neurology, Chongqing Traditional Chinese Medicine Hospital, Chongqing, China
| | - Junhua Mei
- Department of Neurology, Wuhan First Hospital, Wuhan, China
| | - Xue Gong
- Department of Neurology, Wuhan First Hospital, Wuhan, China
| | - Lisan Zhang
- Department of Neurobiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuxia Shen
- Department of Neurology, Yulin No.2 Hospital, Yulin, Shaanxi, China
| | - Chunbin Yang
- The Sleep Center, People's Hospital of JinChang, JinChang, Gansu, China
| | - Jilin Ren
- The Sleep Center, People's Hospital of JinChang, JinChang, Gansu, China
| | - Yan Liu
- The Sleep Center, WeiNan Central Hospital, WeiNan, Shaanxi, China
| | - Zan Wang
- The Sleep Center, Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Peipei Wang
- Sleep Medicine Department, Sanya Central Hospital, The Third People's Hospital of Hainan, China
| | - Jinxia Zhou
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Feng Wang
- The Sleep Center, General Hospital of the Yangtze River Shipping, Wuhan, Hubei, China
| | - Jun Wu
- Department of Neurology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Juan Chen
- Department of Neurology, The First Hospital of Changsha, Changsha, Hunan, China
| | - Yanmei Zhu
- Department of Neurology, The 2nd Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chunrong Zhang
- Department of Neurology, Qinhuangdao HaiGang Hospital, Qinhuangdao, Hebei, China
| | - Xiaosong Dong
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China
| | - Fang Han
- Division of Sleep Medicine, Peking University People's Hospital, Beijing, China.
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Broström A, Alimoradi Z, Lind J, Ulander M, Lundin F, Pakpour A. Worldwide estimation of restless legs syndrome: a systematic review and meta-analysis of prevalence in the general adult population. J Sleep Res 2023; 32:e13783. [PMID: 36600470 DOI: 10.1111/jsr.13783] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 01/06/2023]
Abstract
This systematic review, meta-analysis and meta-regression assessed the prevalence of restless legs syndrome (RLS) in the general adult population. Studies identified in Scopus, PubMed, Web of Science, and PsycInfo between January 2000 and February 2022 were included if they used a case-control or cross-sectional design and reported data regarding the prevalence of RLS. The protocol was pre-registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022300709). A total of 97 studies including 483,079 participants from 33 different countries met the eligibility criteria. The Newcastle Ottawa Scale was used to evaluate the methodological quality, and the fill-and-trim method was used to correct probable publication bias, while the jack-knife method was performed to assess small study effect. The corrected overall pooled prevalence of RLS was 3% (95% confidence interval [CI] 1.4%-3.8%). The pooled prevalence of RLS syndrome was affected by methodological quality (no data from non-respondents in the included studies), gender (higher among women), study design (lower prevalence in case-control versus cohort and cross-sectional studies). The figures for corrected pooled prevalence among men, women, alcohol consumers and smokers were 2.8% (95% CI 2%-3.7%); 4.7% (95% CI 3.2%-6.3%); 1.4% (95% CI 0%-4.2%); and 2.7% (95% CI 0%-5.3%), respectively. The prevalence among male and female participants was lower in community-based versus non-community-based studies. Moreover, the prevalence was higher in developed versus developing countries and among elders versus adults. In conclusion, RLS is a common disorder in the general adult population, with a higher prevalence in women; however, prevalence data are affected by study design and quality.
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Affiliation(s)
- Anders Broström
- School of Health and Welfare, Jönköping University, Jönköping, Sweden.,Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden
| | - Zainab Alimoradi
- Social Determinants of Health Research Centre, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Jonas Lind
- Department of Biomedical and Clinical Sciences, Division of Neurobiology, Linköping University, Linköping, Sweden.,Section of Neurology, Department of Internal Medicine, County Hospital Ryhov, Jönköping, Sweden
| | - Martin Ulander
- Department of Clinical Neurophysiology, Linköping University Hospital, Linköping, Sweden.,Department of Biomedical and Clinical Sciences, Division of Neurobiology, Linköping University, Linköping, Sweden
| | - Fredrik Lundin
- Department of Neurology and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Amir Pakpour
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
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Wang XX, Feng Y, Tan EK, Ondo WG, Wu YC. Stroke-related restless legs syndrome: epidemiology, clinical characteristics and pathophysiology. Sleep Med 2022; 90:238-248. [DOI: 10.1016/j.sleep.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/23/2022] [Accepted: 02/01/2022] [Indexed: 12/24/2022]
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Abstract
Restless legs syndrome (RLS) is a common sensorimotor disorder characterized by an urge to move that appears during rest or is exacerbated by rest, that occurs in the evening or night and that disappears during movement or is improved by movement. Symptoms vary considerably in age at onset, frequency and severity, with severe forms affecting sleep, quality of life and mood. Patients with RLS often display periodic leg movements during sleep or resting wakefulness. RLS is considered to be a complex condition in which predisposing genetic factors, environmental factors and comorbidities contribute to the expression of the disorder. RLS occurs alone or with comorbidities, for example, iron deficiency and kidney disease, but also with cardiovascular diseases, diabetes mellitus and neurological, rheumatological and respiratory disorders. The pathophysiology is still unclear, with the involvement of brain iron deficiency, dysfunction in the dopaminergic and nociceptive systems and altered adenosine and glutamatergic pathways as hypotheses being investigated. RLS is poorly recognized by physicians and it is accordingly often incorrectly diagnosed and managed. Treatment guidelines recommend initiation of therapy with low doses of dopamine agonists or α2δ ligands in severe forms. Although dopaminergic treatment is initially highly effective, its long-term use can result in a serious worsening of symptoms known as augmentation. Other treatments include opioids and iron preparations.
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The prevalence of the restless legs Syndrome/Willis-Ekbom disease among teenagers, its clinical characteristics and impact on everyday functioning. Sleep Med 2021; 89:48-54. [PMID: 34883398 DOI: 10.1016/j.sleep.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIMS The data on the prevalence of the Restless Legs Syndrome/Willis -Ekbom disease (RLS/WED) in the population of teenagers is scarce. The aim of this study was to determine RLS/WED occurrence in adolescents, its diagnostic accuracy, family history, clinical characteristics and impact on everyday functioning. MATERIAL AND METHODS A group of 2379 pupils (aged 13-18 y.o.) from 6 randomly selected secondary schools in Gdańsk, Poland were screened for RLS/WED with the use of a questionnaire. In order to verify the diagnosis and perform additional tests (neurological examination, psychological evaluation, biochemical blood tests, demographic questionnaire, International RLS rating scale/IRLSS, Epworth daytime sleepiness scale). all of the respondents with RLS/WED suspicion and their parents were asked for a consultation by a child neurologist. Both children and parents with RLS/WED diagnosis were tested with actigraphy at home for at least two consecutive nights. RESULTS Two thousand and ninety seven students (88,15%) filled the questionnaire correctly (1171 girls and 926 boys, 56% and 44%). Sixty four respondents were suspected of having RLS/WED (3,1%), however, 36 of them were diagnosed as RLS/WED-mimics (mainly positional discomfort). Finally, 21 (1%) were diagnosed with definite idiopathic RLS/WED. The average age of symptom onset was 10.96 years. The severity was moderate in the most of the cases (61.9%) and the course of the disease was intermittent in all of them. Family history was positive in 80%. Abnormal actigraphy (PLMS index >5/h) was present in 80%. Blood level of ferritin was low (<50 ng/ml) in 85%. Excessive daytime sleepiness and school problems affected almost half of them. The presence of RLS/WED symptoms was associated with disrupted sleep, behavioral problems (irritability, aggression, hyperactivity), attention deficit and lowered mood. No correlation between RLS/WED and attention deficit hyperactivity disorder (ADHD), nocturnal enuresis or primary headaches was found. Thirty eight percent of the patients sought medical help, but none of them obtained proper diagnosis nor treatment of RLS/WED. CONCLUSIONS In this study restless legs syndrome affected 1% of Polish teenagers, in the majority of cases was idiopathic and associated with positive family history. It affected sleep and everyday functioning. Neurological consultation is essential to avoid false positive diagnoses of RLS/WED in teenagers.
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Zhuang S, Yuan X, Ma C, Yang N, Liu CF, Na M, Winkelman JW, Wu S, Gao X. Restless legs syndrome and perceived olfactory and taste dysfunction: A community-based study. Eur J Neurol 2021; 28:2688-2693. [PMID: 33932063 DOI: 10.1111/ene.14890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/07/2021] [Accepted: 04/23/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND PURPOSE Restless legs syndrome (RLS) has been suggested as a prodromal symptom of Parkinson disease (PD). Olfactory or taste dysfunction can also occur preceding PD diagnosis. However, whether RLS is associated with chemosensory dysfunction remains unknown. We thus aim to investigate the association between RLS and perceived olfactory and taste dysfunction. METHODS We performed a cross-sectional analysis including 90,337 Chinese adults free of neurodegenerative diseases in the Kailuan study in 2016. Presence of RLS was defined using revised RLS diagnostic criteria or the Cambridge-Hopkins questionnaire for RLS. Perceived olfactory and taste dysfunction was collected via a questionnaire. The association between RLS and perceived olfactory and taste dysfunction was assessed using logistic regression model, adjusting for potential cofounders such as age, sex, and medical history. RESULTS RLS was associated with high odds of having perceived olfactory and/or taste dysfunction (adjusted odds ratio = 5.92, 95% confidence interval = 3.11-11.3). The significant association persisted when using the Cambridge-Hopkins questionnaire (adjusted odds ratio = 5.55, 95% confidence interval = 2.37-13.0) or when excluding participants with major chronic diseases. CONCLUSIONS RLS was associated with increased odds of perceived olfactory and taste dysfunction.
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Affiliation(s)
- Sheng Zhuang
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiaodong Yuan
- Department of Neurology, Kailuan General Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Chaoran Ma
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Na Yang
- Department of Neurology, Kailuan General Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Chun-Feng Liu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Muzi Na
- Department of Nutritional Sciences, Pennsylvania State University, University Park, Pennsylvania, USA
| | - John W Winkelman
- Department of Psychiatry and Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Shouling Wu
- Department of Cardiology, Kailuan General Hospital, North China University of Science and Technology, Tangshan, Hebei, China
| | - Xiang Gao
- Department of Nutritional Sciences, Pennsylvania State University, University Park, Pennsylvania, USA
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Luo Q, Tang H, Xu X, Huang J, Wang P, He G, Song X, Huang Y, Chen S, Yan F, Tan Y, Ma J. The Prevalence and Risk Factors of Cerebral Microbleeds: A Community-Based Study in China. Ther Clin Risk Manag 2021; 17:165-171. [PMID: 33658788 PMCID: PMC7917356 DOI: 10.2147/tcrm.s297708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/02/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Cerebral microbleeds (CMBs) are frequently found in the healthy elderly. However, data on the prevalence and risk factors of CMBs in the general population of China are lacking. Methods A cross-sectional study focusing on the prevalence and risk factors of CMBs was conducted in stroke-free elderly from Shanghai Wuliqiao community. MRI was performed at 3Tesla and cardiovascular risk factors (eg, age, smoking history, and hypertension), cerebral small vessel disease (CSVD) markers (eg, white matter hyperintensities, lacunar infarction, and enlarged perivascular space) and genetic information (eg, APOE, CR1) were recorded. Poisson regression was used to analyze the risk factors of the presence and location of microbleeds. Results A total of 199 participants (70.8±7.2 years old; male 31.2%) were finally included in our analysis. The overall prevalence of CMBs was 12.6% (25/199) and increased with age from 7.5% (55-64 years old) to 19.3% (over 75 years old). Of those with CMBs, most of them (16/25) located in the deep/mixed region and had 1-2 CMBs (18/25). Poisson regression analysis showed that white matter hyperintensities (OR=1.22, 95% CI: 1.16-1.29), APOE ε4+ carrier (OR=2.16, 95% CI: 1.18-3.96) and CR1 non-F/F isoform (OR=7.78, 95% CI: 4.34-13.96) were associated with CMBs. Further analysis found that in addition to the above three risk factors, hypertension (OR=2.98, 95% CI: 1.16-7.64), lacunar infarction (OR=2.39, 95% CI: 1.19-4.81) also increased the risk of deep/mixed CMBs. Conclusion The prevalence of cerebral microbleeds is similar to other countries. Cardiovascular risk factors, CSVD markers, and genetic factors (APOE ε4, CR1 non-F/F isoform) were associated with CMBs, suggesting an interaction of multiple pathogenesis in Chinese stroke-free community population.
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Affiliation(s)
- Qi Luo
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Huidong Tang
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xinxin Xu
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Juan Huang
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Pei Wang
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Guiying He
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Xiaoxuan Song
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yumeng Huang
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Shengdi Chen
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Fuhua Yan
- Department of Radiology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yuyan Tan
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Jianfang Ma
- Department of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
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Abstract
Background Several recent genome-wide association studies suggested insomnia and anemia may share some common genetic components. We thus examined whether adults with anemia had higher odds of having insomnia relative to those without anemia in a cross-sectional study and a meta-analysis. Methods Included in this cross-sectional study were 12,614 Chinese adults who participated in an ongoing cohort, the Kailuan Study. Anemia was defined as hemoglobin levels below 12.0 g/dL in women and 13.0 g/dL in men. Insomnia was assessed using the Chinese version of the Athens Insomnia Scale (AIS). A total AIS score ≥6 was considered insomnia. The association between anemia and insomnia was assessed using a logistic regression model, adjusting for potential confounders such as age, sex, chronic disease status, and plasma C-reactive protein concentrations. A meta-analysis was conducted using the fixed effects model to pool results from our study and three previously published cross-sectional studies on this topic in adult populations. Results Individuals with anemia had greater odds of having insomnia (adjusted odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.03–1.70) compared with individuals without anemia. A significant association persisted after we excluded individuals with chronic inflammation, as suggested by C-reactive protein levels >1 mg/L (adjusted OR: 1.68; 95% CI: 1.22–2.32). The meta-analysis results, including 22,134 participants, also identified a positive association between anemia and insomnia (pooled OR: 1.39; 95% CI: 1.22–1.57). Conclusions The presence of anemia was significantly associated with a higher likelihood of having insomnia in adults. Due to the nature of the cross-sectional study design, results should be interpreted with caution.
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ZHANG L, SUN Y, WANG T, PAN Y, YAO Y, PAN L, XU Q, ZHANG W, XU J, HU X. [Restless legs syndrome in ischemic stroke patients: clinical features and significance]. Zhejiang Da Xue Xue Bao Yi Xue Ban 2019; 48:275-281. [PMID: 31496159 PMCID: PMC8800815 DOI: 10.3785/j.issn.1008-9292.2019.06.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/21/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the clinical features and implication of restless legs syndrome (RLS) in ischemic stroke patients. METHODS A total of 199 ischemic stroke patients were enrolled and assessed by polysomnography (PSG). RLS was identified according to criteria of International Restless Legs Syndrome Study Group. Epworth Sleepiness Scale (ESS), Mini-mental State Examination (MMSE) and Patient Health Questionnaire (PHQ-9) were used to evaluate the sleep quality, cognitive function and post-stroke depression, respectively. The National Institute of Health Stroke Scale (NIHSS) was used to evaluate the neurological function 3 months after stroke onset. Gender-and age-matched non-ischemic stroke patients with RLS (primary PLS) were selected as controls. RESULTS Twenty-two cases of RLS were identified among 199 ischemic stroke patients (11.1%). Generalized linear model and logistic regression showed that low serum ferritin level (β=-133.3 mg/L, 95%CI:-200.4--0.1, P<0.01), subcortical infarction (OR=4.05, 95%CI:1.15-14.18, P<0.05) and female (OR=2.54, 95%CI:1.04-6.23, P<0.05) were identified as the risk factors of RLS in ischemic stroke patients. Compared with ischemic stroke patients without RLS, ESS increased by 4.37 (95%CI:2.33-6.41, P<0.01), PHQ-9 increased by 2.17 (95%CI:0.39--3.94, P<0.05), and reduced NIHSS from the baseline deceased by 0.97 (95%CI:-1.79--0.15, P<0.05) in ischemic stroke patients with RLS. In addition, the incidence of moderate-severe depression increased (OR=4.27, 95%CI:1.40-13.10, P<0.05) in ischemic stroke patients with RLS. The index of periodic leg movements of sleep (PLMS) with arousal in ischemic stroke patients with RLS was significantly higher than that in patients with primary RLS (β=12.85, 95%CI:2.04-23.67, P<0.05). CONCLUSIONS RLS is common in ischemic stroke patients and has adverse influences on patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Xingyue HU
- 胡兴越(1962-), 男, 博士, 主任医师, 博士生导师, 主要从事神经内科疾病研究; E-mail:
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https://orcid.org/0000-0003-3458-2590
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Li G, Tang H, Wang C, Qi X, Chen J, Chen S, Ma J. Association of BTBD9 and MAP2K5/SKOR1 With Restless Legs Syndrome in Chinese Population. Sleep 2017; 40:3045871. [PMID: 28329290 DOI: 10.1093/sleep/zsx028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Study Objectives The aim of the study was to investigate the relationship between genetic factors and primary restless legs syndrome (RLS) in Chinese population. Methods A total of 116 RLS patients and 200 controls were recruited and the diagnosis of RLS was based on the criteria of International RLS Study Group. Polymer chain reaction (PCR) and sequencing were used to detect 19 single nucleotide polymorphisms (SNPs) in six genetic loci (MEIS1, BTBD9, PTPRD, MAP2K5/SKOR1, TOX3, and Intergenic region of 2p14). Results Our study found that one SNP increased the risk of RLS in Chinese population: rs6494696 of MAP2K5/SKOR1 (odds ratio [OR] = 0.09, p < .0001, recessive model). A further meta-analysis of RLS in Asian population found that two SNPs of BTBD9 increased the risk of RLS: rs9296249 of BTBD9 (OR = 1.44, p = .000, T allele), rs9357271 of BTBD9 (OR = 1.38, p = .021, dominant model). Conclusion Our results confirmed the association of BTBD9 and MAP2K5/SKOR1 with primary RLS in Chinese population.
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Affiliation(s)
- Gen Li
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Huidong Tang
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Cheng Wang
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuemei Qi
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jie Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Shengdi Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianfang Ma
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Restless legs syndrome in maintenance hemodialysis patients: an epidemiologic survey in Hefei. Int Urol Nephrol 2017; 49:1267-1272. [DOI: 10.1007/s11255-017-1573-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
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15
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Sherbin N, Ahmed A, Fatani A, Al-Otaibi K, Al-Jahdali F, Ali YZ, Al-Harbi A, Khan M, Baharoon S, Al-Jahdali H. The prevalence and associated risk factors of restless legs syndrome among Saudi adults. Sleep Biol Rhythms 2017. [DOI: 10.1007/s41105-017-0089-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Fawale MB, Ismail IA, Mustapha AF, Komolafe MA, Adedeji TA. Restless Legs Syndrome in a Nigerian Elderly Population. J Clin Sleep Med 2016; 12:965-72. [PMID: 27070251 DOI: 10.5664/jcsm.5926] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/03/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The prevalence of restless legs syndrome (RLS) is highest in the elderly in Caucasian populations; the prevalence of RLS in elderly Africans is not known. This study aimed at determining the frequency and associations of RLS in a Nigerian elderly population. METHODS The study population comprised of 633 consecutive elderly individuals aged 65-105 years attending the general outpatient clinic of the State Hospital, Ilesa, for minor complaints and routine check-up. The diagnosis of RLS was made using the 2003 minimal criteria of the International Restless Legs Syndrome Study Group. Relevant sociodemographic and clinical data, including sleep duration, were also obtained. RESULTS Restless legs syndrome was found in 3.5% of the study population with a male-female ratio of 2:1. There was no significant age (p = 0.427) or gender (p = 0.178) influence on the prevalence of RLS except in the 75- to 84-year age group where there was significant male preponderance (p = 0.044). A strong independent association between RLS and sleep duration (OR, 3.229; 95% CI, 1.283-8.486; p = 0.013) and past history of head injury (OR, 4.691; 95% CI, 1.750-12.577; p = 0.002) was found. CONCLUSIONS Our finding support previous reports of a possible lower prevalence of RLS in Africans. Restless legs syndrome independently increases the odds of habitual sleep curtailment in elderly individuals. Head injury may be a risk factor for future RLS; this requires further investigation as indirect evidence for a possible link between RLS and traumatic brain injury exists.
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Affiliation(s)
- Michael B Fawale
- Neurology Unit, Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | | | - Adekunle F Mustapha
- Neurology Unit, Department of Medicine, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Nigeria
| | - Morenikeji A Komolafe
- Neurology Unit, Department of Medicine, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Tewogbade A Adedeji
- Department of Chemical Pathology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
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Cho SJ, Chung YK, Kim JM, Chu MK. Migraine and restless legs syndrome are associated in adults under age fifty but not in adults over fifty: a population-based study. J Headache Pain 2015; 16:554. [PMID: 26272681 PMCID: PMC4536239 DOI: 10.1186/s10194-015-0554-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent studies have shown an association between migraine and restless legs syndrome (RLS). However, migraine prevalence peaks from the 20s to 40s whereas RLS prevalence peaks after the 50s. Despite this, reports on how migraine and RLS may be associated by age is limited. Therefore, the purpose of this study is to investigate the comorbidity between migraine and RLS according to age. METHODS We selected a stratified random population sample of Koreans aged 19 to 69 years and evaluated them with a 60-item semi-structured interview designed to identify RLS, headache type, and clinical characteristics of migraine. To assess the association between migraine and RLS according to age, we divided participants into 5 age groups (19-29, 30-39, 40-49, 50-59, and 60-69 years) and analysed each group. RESULTS Subjects with migraine showed an increased RLS prevalence in the 19-29 (Odds ratio [OR] = 6.6, 95 % confidence interval [CI] = 1.2-36.8) and 40-49 (OR = 6.7, 95 % CI = 1.5-33.5) age groups compared to non-headache controls but failed to showed a significant association in the 50-59 (OR = 1.1, 95 % CI = 0.2-5.6) and 60-69 (OR = 0.4, 95 % CI = 0.1-4.0) age groups. Migraineurs with 1-10 (12.5 %, OR = 2.0, 95 % CI = 1.3-3.2, p = 0.003) and >10 (12.5 %, OR = 2.5, 95 % CI = 1.0-5.6, p = 0.038) attacks per month showed an increased RLS prevalence compared to migraineurs with <1 attack per month (2.1 %). Subjects with non-migraine headaches showed an increased odds for RLS (OR = 1.8, 95 % CI = 1.3-2.7) compared to non-headache controls. There was no significant difference (9.1 % vs. 6.9 %, p = 0.339) in the RLS prevalence between migraineurs and non-migraine headache subjects. CONCLUSIONS Our results suggest that migraine and RLS are differently associated according to age.
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Affiliation(s)
- Soo-Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
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Koo BB. Restless Leg Syndrome Across the Globe: Epidemiology of the Restless Legs Syndrome/Willis-Ekbom Disease. Sleep Med Clin 2015; 10:189-205, xi. [PMID: 26329429 DOI: 10.1016/j.jsmc.2015.05.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There are more than 50 epidemiologic studies measuring the prevalence of restless legs syndrome/Willis-Ekbom disease (RLS/WED) across 5 of the 6 inhabited continents (not Australia), most conducted in North America and Europe. Sufficient studies have been conducted in Asia, North America, and Europe to make inferences on RLS/WED prevalence by region. RLS/WED prevalence is thought to be highest in North America and Europe and lower in Asia. These differences across regions may be explained by cultural, environmental, and genetic factors. Future investigation is needed to determine to what extent these factors affect expression of RLS/WED according to world region.
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Affiliation(s)
- Brian B Koo
- Department of Neurology, Yale University School of Medicine, 15 York Street, New Haven, CT 06510, USA; Department of Neurology, West Haven VAMC, Connecticut Veterans Affairs Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA.
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Prevalence and risk factors of restless legs syndrome among Chinese adults in a rural community of Shanghai in China. PLoS One 2015; 10:e0121215. [PMID: 25803876 PMCID: PMC4372383 DOI: 10.1371/journal.pone.0121215] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 02/12/2015] [Indexed: 11/19/2022] Open
Abstract
Aims The primary objective of this study was to investigate the prevalence and risk factors of restless legs syndrome (RLS) in an adult Chinese population living in a rural community. We also aimed to determine the predictive diagnostic value of the 4-item screening questionnaire for RLS in this population. Methods This study was designed as a 2-phase survey. In phase 1 we performed a face-to-face interview of eligible individuals living in a rural community in Shanghai using a 4-item screening questionnaire. In phase 2, sleep specialists performed a phone interview of the individuals who screened positive to diagnosis RLS. Results Forty-one RLS cases were confirmed among 2941 eligible individuals 18 years of age or older in the study community. The prevalence of RLS was 1.4% (95% confidence interval (CI) =1.0-1.9%), with a significantly higher rate observed in females (1.9% [95%CI =1.3-2.7%]) than that in males (0.9% [95%CI =0.5-1.5%], p=0.019). The prevalence rate increased significantly with age, from 0.2% (95% CI =0.08-0.6%) in those 18-39 years old to 4.1% (95% CI =2.1-7.9%) in those ≥70 years old (p<0.001). The multivariate logistic regression analysis indicated that gastritis, anemia and hypertension were risk factors for RLS. The sensitivity and specificity of the 4-item screening questionnaire used in this study were 63.4% and 97.5%, respectively. Conclusion RLS prevalence is relatively low among Chinese adults living in rural Shanghai. Furthermore, population-based studies with a larger sample size and a longitudinal follow-up may help to determine the risk factors of RLS and potential interventions for RLS.
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Burtscher C, Baxmann A, Kassubek J, Hornyak M, Matuja W, Schmutzhard E, Winkler AS. Prevalence of restless legs syndrome in an urban population of eastern Africa (Tanzania). J Neurol Sci 2014; 346:121-7. [DOI: 10.1016/j.jns.2014.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 07/06/2014] [Accepted: 08/05/2014] [Indexed: 12/01/2022]
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Zhang J, Lam SP, Li SX, Li AM, Kong APS, Wing YK. Restless legs symptoms in adolescents: epidemiology, heritability, and pubertal effects. J Psychosom Res 2014; 76:158-64. [PMID: 24439693 DOI: 10.1016/j.jpsychores.2013.11.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/28/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022]
Abstract
AIMS We aimed to determine the prevalence, pubertal effect, familial aggregation, and heritability of restless legs (RLS) symptoms in Chinese adolescents. In addition, the correlates and consequences of RLS symptoms were examined. METHODS This was a population-based family study that involved 1549 adolescents (probands), their parents and siblings. RLS symptoms were assessed by a single question measuring the core features of RLS. Subjects with RLS symptoms for at least once per week were considered as abnormal. Impairment of daytime functions, behavioral problems, health status, and lifestyle practice were also documented. RESULTS The prevalence of RLS symptoms was 2.8% in adolescents and 7.4% in their parents with female preponderance. Gender difference of RLS symptoms emerged in mid-pubertal adolescents (Tanner stage 3 or above). RLS symptoms were closely associated with various sleep problems (range of ORs=2.24 to 32.5, p<0.05), except habitual snoring. They were also independently associated with impairment of daytime functions, poor general health and frequent temper outbursts but not caffeine or alcohol intake or cigarette smoking after adjustment for age, sex, and other comorbid sleep problems. RLS symptoms presented with a modest familial aggregation and heritability (h²±SE=0.17±0.04, p<0.001). INTERPRETATION RLS symptoms are common in Chinese adolescents with significant health repercussions. Puberty plays a critical role in the emergence of gender difference of RLS symptoms, which are accounted for by both genetic and environmental factors.
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Affiliation(s)
- Jihui Zhang
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region
| | - Siu Ping Lam
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region
| | - Shirley Xin Li
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region
| | - Albert Martin Li
- Department of Pediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region
| | - Alice Pik-Shan Kong
- Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region
| | - Yun-Kwok Wing
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region.
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Fulda S. Gender differences in the prevalence of restless legs syndrome/Willis-Ekbom disease. SOMNOLOGIE 2013. [DOI: 10.1007/s11818-013-0636-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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