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Dye TJ. Clinical Evaluation and Management of Narcolepsy in Children and Adolescents. Semin Pediatr Neurol 2023; 48:101089. [PMID: 38065636 DOI: 10.1016/j.spen.2023.101089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 12/18/2023]
Abstract
While sleepiness is common among children, and particularly adolescents, profound sleepiness in the setting of apparently adequate sleep should prompt consideration of a central disorder of hypersomnolence. These disorders, which include narcolepsy, idiopathic hypersomnia, Kleine-Levin syndrome, and others, are likely underrecognized in the pediatric population. Narcolepsy in particular should be of interest to child neurologists as the unique signs and symptoms of this disease often prompt evaluation in pediatric neurology clinics. While sleepiness may appear to be a straightforward complaint, its evaluation requires a nuanced approach. Cataplexy, a hallmark of narcolepsy, can be confused for other neurologic conditions, though understanding its various manifestations makes it readily identifiable. Clinicians should be aware of these symptoms, as delay in diagnosis and misdiagnosis are common in childhood narcolepsy. While treatment options have been limited in the past, many new therapeutic options have become available and can result in significant improvement in symptoms. Given the age at presentation, paroxysmal and chronic features, diagnostic modalities, and available treatment options, the field of child neurology is well equipped to see patients with narcolepsy. In this review, I will focus on the presentation, evaluation, and management of pediatric patients with narcolepsy.
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Affiliation(s)
- Thomas J Dye
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Pulmonary - Sleep Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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Carls G, Reddy SR, Broder MS, Tieu R, Villa KF, Profant J, Halbower AC. Burden of disease in pediatric narcolepsy: a claims-based analysis of health care utilization, costs, and comorbidities. Sleep Med 2020; 66:110-118. [DOI: 10.1016/j.sleep.2019.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 01/06/2023]
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Almeneessier AS, Al-Jebrin S, Labani R, Alkaff H, Al-Rahbeeni O, Alageel M, Olaish A, BaHammam AS. Medical specialty visits and diagnoses received by Saudi patients prior to a diagnosis of narcolepsy. Sleep Breath 2019; 23:603-609. [PMID: 30820852 DOI: 10.1007/s11325-019-01807-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/09/2019] [Accepted: 02/14/2019] [Indexed: 01/07/2023]
Abstract
PURPOSE Narcolepsy is an uncommon neurological disorder characterized by excessive daytime sleepiness (EDS) and multiple other symptoms. Due to the under-recognition of narcolepsy symptoms, patients are often misdiagnosed. This study aimed to assess the types of specialties visited and the diagnoses received by Saudi patients prior to their narcolepsy diagnosis. METHODS The study included 55 consecutive patients with type-1 and type-2 narcolepsy who attended the narcolepsy clinic between August 2017 and December 2017. Narcolepsy was diagnosed according to the International Classification of Sleep Disorders-third edition criteria. We evaluated sociodemographic data, the specialties visited, and diagnoses and treatments received prior to visiting a sleep specialist. RESULTS The mean diagnostic delay was 9.1 ± 8.4 years (1-43 years). Multiple linear regression analysis identified early onset as the only predictor of a delayed diagnosis (β coefficient = - 0.262, p = 0.03). EDS was the main symptom that prompted patients to seek medical consultation, and only one patient had been (1.8%) referred with the diagnosis of narcolepsy. In the study group, 82% of the patients were misdiagnosed with a mental or neurological disorder or were thought to be afflicted by "envy," "evil eye," or "black magic" before receiving a correct diagnosis. No significant differences were detected between patients with narcolepsy type-1 and narcolepsy type-2. CONCLUSIONS Delays in diagnosing narcolepsy remain a major problem for Saudi patients with this disorder. We found that Saudi patients with narcolepsy had visited several medical specialists and faith healers and were misdiagnosed prior to visiting a sleep specialist.
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Affiliation(s)
- Aljohara S Almeneessier
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Sara Al-Jebrin
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Reem Labani
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Hussain Alkaff
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Omar Al-Rahbeeni
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Musab Alageel
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Awad Olaish
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia
| | - Ahmed S BaHammam
- Department of Medicine, College of Medicine, The University Sleep Disorders Center, King Saud University, Box 225503, Riyadh, 11324, Saudi Arabia.
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Vignatelli L, Antelmi E, Ceretelli I, Bellini M, Carta C, Cortelli P, Ferini-Strambi L, Ferri R, Guerrini R, Ingravallo F, Marchiani V, Mari F, Pieroni G, Pizza F, Verga MC, Verrillo E, Taruscio D, Plazzi G. Red Flags for early referral of people with symptoms suggestive of narcolepsy: a report from a national multidisciplinary panel. Neurol Sci 2018; 40:447-456. [PMID: 30539345 PMCID: PMC6433801 DOI: 10.1007/s10072-018-3666-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/28/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Narcolepsy is a lifelong disease, manifesting with excessive daytime sleepiness and cataplexy, arising between childhood and young adulthood. The diagnosis is typically made after a long delay that burdens the disease severity. The aim of the project, promoted by the "Associazione Italiana Narcolettici e Ipersonni" is to develop Red Flags to detect symptoms for early referral, targeting non-sleep medicine specialists, general practitioners, and pediatricians. MATERIALS AND METHODS A multidisciplinary panel, including patients, public institutions, and representatives of national scientific societies of specialties possibly involved in the diagnostic process of suspected narcolepsy, was convened. The project was accomplished in three phases. Phase 1: Sleep experts shaped clinical pictures of narcolepsy in pediatric and adult patients. On the basis of these pictures, Red Flags were drafted. Phase 2: Representatives of the scientific societies and patients filled in a form to identify barriers to the diagnosis of narcolepsy. Phase 3: The panel produced suggestions for the implementation of Red Flags. RESULTS Red Flags were produced representing three clinical pictures of narcolepsy in pediatric patients ((1) usual sleep symptoms, (2) unusual sleep symptoms, (3) endocrinological signs) and two in adult patients ((1) usual sleep symptoms, (2) unusual sleep symptoms). Inadequate knowledge of symptoms at onset by medical doctors turned out to be the main reported barrier to diagnosis. CONCLUSIONS This report will hopefully enhance knowledge and awareness of narcolepsy among non-specialists in sleep medicine in order to reduce the diagnostic delay that burdens patients in Italy. Similar initiatives could be promoted across Europe.
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Affiliation(s)
- L Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - E Antelmi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - I Ceretelli
- Associazione Italiana Narcolettici e Ipersonni (AIN), Florence, Italy
| | - M Bellini
- Azienda USL Toscana centro Sedi di Prato, Prato, Italy
| | - C Carta
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - P Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - L Ferini-Strambi
- Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R Ferri
- Sleep Research Centre, Department of Neurology I.C., Oasi Research Institute - IRCCS, Troina, Italy
| | - R Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - F Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - V Marchiani
- Child Neuropsychiatric Unit, Polyclinic S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - F Mari
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - G Pieroni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - F Pizza
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - M C Verga
- Primary Care Pediatrics, ASL Salerno, Vietri sul Mare, SA, Italy
| | - E Verrillo
- Sleep and Long Term Ventilation Unit, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Academic Department of Pediatrics (DPUO) Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - D Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy.
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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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Marcus CL. Daytime sleepiness in children: When a quiet child is not necessarily a good thing. Paediatr Respir Rev 2018; 25:1-2. [PMID: 28209474 DOI: 10.1016/j.prrv.2017.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Carole L Marcus
- Sleep Center, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
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7
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Pamula Y, Nixon GM, Edwards E, Teng A, Verginis N, Davey MJ, Waters K, Suresh S, Twiss J, Tai A. Australasian Sleep Association clinical practice guidelines for performing sleep studies in children. Sleep Med 2017. [DOI: 10.1016/j.sleep.2017.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Maski K, Owens JA. Insomnia, parasomnias, and narcolepsy in children: clinical features, diagnosis, and management. Lancet Neurol 2017; 15:1170-81. [PMID: 27647645 DOI: 10.1016/s1474-4422(16)30204-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Revised: 08/03/2016] [Accepted: 08/12/2016] [Indexed: 12/17/2022]
Abstract
Sleep problems are frequently encountered as presenting complaints in child neurology clinical practice. They can affect the functioning and quality of life of children, particularly those with primary neurological and neurodevelopmental disorders, since coexisting sleep problems can add substantially to neurocognitive and behavioural comorbidities. Additionally, symptoms of some sleep disorders such as parasomnias and narcolepsy can be confused with those of other neurological disorders (eg, epilepsy), posing diagnostic challenges for paediatric neurologists. The understanding of the neurophysiology of sleep disorders such as insomnia, parasomnias, and narcolepsy is still evolving. There is a complex relation between the sleeping brain and its waking function. The interplay among genetic factors, alterations in neurotransmitters, electrophysiological changes, and environmental factors potentially contribute to the genesis of these sleep disorders.
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Affiliation(s)
- Kiran Maski
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Judith A Owens
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
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Kallweit U, Schmidt M, Bassetti CL. Patient-Reported Measures of Narcolepsy: The Need for Better Assessment. J Clin Sleep Med 2017; 13:737-744. [PMID: 28162143 DOI: 10.5664/jcsm.6596] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 12/22/2017] [Indexed: 12/19/2022]
Abstract
STUDY OBJECTIVES Narcolepsy, a chronic disorder of the central nervous system, is clinically characterized by a symptom pentad that includes excessive daytime sleepiness, cataplexy, sleep paralysis, hypnopompic/hypnagogic hallucinations, and disrupted nighttime sleep. Ideally, screening and diagnosis instruments that assist physicians in evaluating a patient for type 1 or type 2 narcolepsy would be brief, easy for patients to understand and physicians to score, and would identify or rule out the need for electrophysiological testing. METHODS A search of the literature was conducted to review patient-reported measures used for the assessment of narcolepsy, mainly in clinical trials, with the goal of summarizing existing scales and identifying areas that may require additional screening questions and clinical practice scales. RESULTS Of the seven scales reviewed, the Epworth Sleepiness Scale continues to be an important outcome measure to screen adults for excessive daytime sleepiness, which may be associated with narcolepsy. Several narcolepsy-specific scales have demonstrated utility, such as the Ullanlinna Narcolepsy Scale, Swiss Narcolepsy Scale, and Narcolepsy Symptom Assessment Questionnaire, but further validation is required. CONCLUSIONS Although the narcolepsy-specific scales currently in use may identify type 1 narcolepsy, there are no validated questionnaires to identify type 2 narcolepsy. Thus, there remains a need for short, easily understood, and well-validated instruments that can be readily used in clinical practice to distinguish narcolepsy subtypes, as well as other hypersomnias, and for assessing symptoms of these conditions during treatment.
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Affiliation(s)
- Ulf Kallweit
- Neurology Department, Bern University Hospital, Bern, Switzerland
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Savaş T, Erol I, Saygı S, Habeşoğlu MA. Narcolepsy and cataplexy: a pediatric case report. TURK PEDIATRI ARSIVI 2016; 51:221-223. [PMID: 28123336 PMCID: PMC5242251 DOI: 10.5152/turkpediatriars.2016.2180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 04/27/2015] [Indexed: 06/06/2023]
Abstract
Narcolepsy is characterized by excessive sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis during the rapid eye movement period of sleep. Herein, we present a boy aged eight years who was diagnosed as having narcolepsy and cataplexy about thirteen months after his first presentation. He was admitted with symptoms of daytime sleepiness. In the follow-up, cataplexy in the form of head dropping attacks developed seven months after the first admission. The patient was investigated for different prediagnoses and was eventually diagnosed as having narcolepsy and cataplexy through polysomnography and multiple sleep latency tests thirteen months after the first presentation. He is being followed up and is under drug therapy; his symptoms have improved substantially.
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Affiliation(s)
- Tülin Savaş
- Clinic of Pediatric Neurology, Başkent University School of Medicine Hospital, Adana, Turkey
| | - ilknur Erol
- Clinic of Pediatric Neurology, Başkent University School of Medicine Hospital, Adana, Turkey
| | - Semra Saygı
- Clinic of Pediatric Neurology, Başkent University School of Medicine Hospital, Adana, Turkey
| | - Mehmet Ali Habeşoğlu
- Clinic of Pulmonology, Başkent University School of Medicine Hospital, Adana, Turkey
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Bogan R, Swick T, Mamelak M, Kovacevic-Ristanovic R, Lai C, Black J, Villa KF, Montplaisir J. Evaluation of Quality of Life in Patients With Narcolepsy Treated With Sodium Oxybate: Use of the 36-Item Short-Form Health Survey in a Clinical Trial. Neurol Ther 2016; 5:203-213. [PMID: 27778193 PMCID: PMC5130920 DOI: 10.1007/s40120-016-0053-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Indexed: 12/29/2022] Open
Abstract
Introduction The present post hoc analysis was designed to evaluate health-related quality of life (HRQoL) using the 36-item Short Form Health Status Survey (SF-36) during an 8-week trial of sodium oxybate (SXB). Methods SF-36 was assessed in a phase 3 placebo-controlled trial in patients with narcolepsy (N = 228) randomized to placebo or SXB in doses of 4.5, 6, or 9 g nightly for 8 weeks. Changes from baseline in SF-36 (last observation carried forward) were compared between SXB and placebo, and effect sizes (ES) were estimated. Results Baseline SF-36 values were lower than normative values for the US general population. After 8 weeks of treatment, mean (±standard deviation) improvement from baseline on the Physical Component Summary (PCS) was significantly greater with SXB 9 g/night than placebo (6.3 ± 9.1 vs. 1.5 ± 6.2; p = 0.005), with moderate ES; no significant difference was found between the SXB and placebo groups on the Mental Component Summary. SXB 9 g/night resulted in significantly (p < 0.05) greater improvements than placebo in Physical Functioning (4.4 ± 9.2 vs. 1.0 ± 8.0), General Health (GH; 3.1 ± 7.0 vs. 0.4 ± 6.8), and Social Functioning (6.8 ± 16.8 vs. 1.1 ± 9.6). All SXB doses resulted in significant improvement (p < 0.05) relative to placebo for Vitality, with moderate ES. No significant differences versus placebo were observed for Role–Physical, Role–Emotional, or Mental Health domains. Conclusion Treatment with SXB was associated with a dose-dependent improvement in HRQoL, with the 9-g nightly dose demonstrating a positive impact on PCS and individual SF-36 domains of Vitality, GH, and Physical and Social Functioning. Trial registration NCT00049803. Funding Jazz Pharmaceuticals.
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Affiliation(s)
- Richard Bogan
- Medical University of South Carolina School of Medicine, Charleston, SC, USA.
| | - Todd Swick
- Neurology and Sleep Medicine Consultants of Houston, University of Texas-Houston School of Medicine, Houston, TX, USA
| | - Mortimer Mamelak
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | | | - Jed Black
- Jazz Pharmaceuticals, Palo Alto, CA, USA.,Stanford Center for Sleep Research and Medicine, Stanford, CA, USA
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Ruoff C, Rye D. The ICSD-3 and DSM-5 guidelines for diagnosing narcolepsy: clinical relevance and practicality. Curr Med Res Opin 2016; 32:1611-1622. [PMID: 27359185 DOI: 10.1080/03007995.2016.1208643] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Narcolepsy is a chronic neurological disease manifesting as difficulty with maintaining continuous wake and sleep. Clinical presentation varies but requires excessive daytime sleepiness (EDS) occurring alone or together with features of rapid-eye movement (REM) sleep dissociation (e.g., cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis), and disrupted nighttime sleep. Narcolepsy with cataplexy is associated with reductions of cerebrospinal fluid (CSF) hypocretin due to destruction of hypocretin peptide-producing neurons in the hypothalamus in individuals with a specific genetic predisposition. Updated diagnostic criteria include the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) and International Classification of Sleep Disorders Third Edition (ICSD-3). DSM-5 criteria require EDS in association with any one of the following: (1) cataplexy; (2) CSF hypocretin deficiency; (3) REM sleep latency ≤15 minutes on nocturnal polysomnography (PSG); or (4) mean sleep latency ≤8 minutes on multiple sleep latency testing (MSLT) with ≥2 sleep-onset REM-sleep periods (SOREMPs). ICSD-3 relies more upon objective data in addition to EDS, somewhat complicating the diagnostic criteria: 1) cataplexy and either positive MSLT/PSG findings or CSF hypocretin deficiency; (2) MSLT criteria similar to DSM-5 except that a SOREMP on PSG may count as one of the SOREMPs required on MSLT; and (3) distinct division of narcolepsy into type 1, which requires the presence of cataplexy or documented CSF hypocretin deficiency, and type 2, where cataplexy is absent, and CSF hypocretin levels are either normal or undocumented. We discuss limitations of these criteria such as variability in clinical presentation of cataplexy, particularly when cataplexy may be ambiguous, as well as by age; multiple and/or invasive CSF diagnostic test requirements; and lack of normative diagnostic test data (e.g., MSLT) in certain populations. While ICSD-3 criteria reflect narcolepsy pathophysiology, DSM-5 criteria have greater clinical practicality, suggesting that valid and reliable biomarkers to help standardize narcolepsy diagnosis would be welcomed.
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Affiliation(s)
- Chad Ruoff
- a Center for Sleep Sciences and Medicine, and Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Palo Alto , CA , USA
| | - David Rye
- b Department of Neurology and Program in Sleep , Emory University School of Medicine , Atlanta , GA , USA
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Rocca FL, Finotti E, Pizza F, Ingravallo F, Gatta M, Bruni O, Plazzi G. Psychosocial Profile and Quality of Life in Children With Type 1 Narcolepsy: A Case-Control Study. Sleep 2016; 39:1389-98. [PMID: 27166243 DOI: 10.5665/sleep.5970] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/25/2016] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES To investigate behavioral aspects and quality of life in children and adolescents with type 1 narcolepsy (NT1). METHODS We performed a case-control study comparing 29 patients with NT1 versus sex- and age-matched patients with idiopathic epilepsy (n = 39) and healthy controls (n = 39). Behavior and quality of life were evaluated by self-administered questionnaires (Child Behavior Checklist, Pediatric Quality of Life Inventory). Patient groups were contrasted and scale results were correlated with clinical and polysomnographic parameters, and cerebrospinal fluid hypocretin-1 levels. RESULTS Young patients with NT1 showed increased internalizing problems associated with aggressive behavior. Emotional profile in patients with NT1 positively correlated with age at onset, diagnostic delay, and subjective sleepiness, whereas treatment and disease duration were associated with fewer behavioral problems (attention problems, aggressive behavior, and attention deficit/hyperactivity disorder). Psychosocial health domains of pediatric NT1 were worse than in healthy controls, whereas the physical health domains were comparable. CONCLUSIONS Young NT1 patients show a discrete pattern of altered behavioral, thought, and mood profile in comparison with healthy controls and with idiopathic epilepsy patients thus suggesting a direct link with sleepiness. Further studies investigating behavior in patients with idiopathic hypersomnia or type 2 narcolepsy are needed to disentangle the role of REM sleep dysfunction and hypocretin deficiency in psychiatric disorders. Symptoms of withdrawal, depression, somatic complaints, thought problems, and aggressiveness were common, NT1 children perceived lower school competencies than healthy children, and their parents also reported worse psychosocial health. Our data suggest that early effective treatment and disease self-awareness should be promoted in NT1 children for their positive effect on behavior and psychosocial health.
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Affiliation(s)
| | - Elena Finotti
- Department of Rehabilitation, Child and Adolescent Neuropsychiatry Unit, ULSS 6 Vicenza, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Institute of Neurological Sciences, ASL di Bologna, Bologna, Italy
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Michela Gatta
- Department of Woman and Child Health, University of Padua, Italy
| | - Oliviero Bruni
- Department of Developmental Neurology and Psychiatry, Centre for Pediatric Sleep Disorders, Sapienza University, Rome, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,IRCCS Institute of Neurological Sciences, ASL di Bologna, Bologna, Italy
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Filardi M, Pizza F, Bruni O, Natale V, Plazzi G. Circadian Rest-Activity Rhythm in Pediatric Type 1 Narcolepsy. Sleep 2016; 39:1241-7. [PMID: 27091539 DOI: 10.5665/sleep.5842] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/07/2016] [Indexed: 01/13/2023] Open
Abstract
STUDY OBJECTIVES Pediatric type 1 narcolepsy is often challenging to diagnose and remains largely undiagnosed. Excessive daytime sleepiness, disrupted nocturnal sleep, and a peculiar phenotype of cataplexy are the prominent features. The knowledge available about the regulation of circadian rhythms in affected children is scarce. This study compared circadian rest-activity rhythm and actigraphic estimated sleep measures of children with type 1 narcolepsy versus healthy controls. METHODS Twenty-two drug-naïve type 1 narcolepsy children and 21 age- and sex- matched controls were monitored for seven days during the school week by actigraphy. Circadian activity rhythms were analyzed through functional linear modeling; nocturnal and diurnal sleep measures were estimated from activity using a validated algorithm. RESULTS Children with type 1 narcolepsy presented an altered rest-activity rhythm characterized by enhanced motor activity throughout the night and blunted activity in the first afternoon. No difference was found between children with type 1 narcolepsy and controls in the timing of the circadian phase. Actigraphic sleep measures showed good discriminant capabilities in assessing type 1 narcolepsy nycthemeral disruption. CONCLUSIONS Actigraphy reliably renders the nycthemeral disruption typical of narcolepsy type 1 in drug-naïve children with recent disease onset, indicating the sensibility of actigraphic assessment in the diagnostic work-up of childhood narcolepsy type 1.
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Affiliation(s)
- Marco Filardi
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Fabio Pizza
- DIBINEM - Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS - Istituto delle Scienze Neurologiche, AUSL di Bologna, Italy
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University, Rome, Italy
| | - Vincenzo Natale
- Department of Psychology, University of Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- DIBINEM - Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS - Istituto delle Scienze Neurologiche, AUSL di Bologna, Italy
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Taddei RN, Werth E, Poryazova R, Baumann CR, Valko PO. Diagnostic delay in narcolepsy type 1: combining the patients' and the doctors' perspectives. J Sleep Res 2016; 25:709-715. [DOI: 10.1111/jsr.12420] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/25/2016] [Indexed: 12/17/2022]
Affiliation(s)
- Raquel N. Taddei
- Department of Neurology; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Esther Werth
- Department of Neurology; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Rositsa Poryazova
- Department of Neurology; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Christian R. Baumann
- Department of Neurology; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Philipp O. Valko
- Department of Neurology; University Hospital Zurich; University of Zurich; Zurich Switzerland
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16
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Park EG, Lee J, Joo EY, Lee M, Lee J. Narcolepsy in a three-year-old girl: A case report. Brain Dev 2016; 38:139-41. [PMID: 26126836 DOI: 10.1016/j.braindev.2015.06.003] [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: 02/20/2015] [Revised: 06/06/2015] [Accepted: 06/22/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Narcolepsy is characterized by excessive daytime somnolence associated with sleep paralysis, hallucinations when falling asleep or awakening, and cataplexy. Early recognition of pediatric narcolepsy is essential for growth and development. We experienced a case of narcolepsy in a three-year-old girl. METHODS The patient underwent brain MRI and 24h video-electroencephalogram (EEG) monitoring. Polysomnography (PSG) with multiple sleep latency test (MSLT) and human leukocyte antigen (HLA) DQ typing was performed. RESULTS The brain MRI was normal. 24h video-EEG monitoring revealed no abnormal slow or epileptiform discharge on interictal EEG, and no EEG change during tongue thrusting, dropping head with laughter, or flopping down, which was consistent with cataplexy associated with narcolepsy. A mean sleep latency of 2.5 min and four episodes of sleep-onset REM periods in five naps were observed in PSG with MSLT. She was positive in HLA-DQB1*0602. Based on these findings, she was diagnosed as narcoleptic with cataplexy. CONCLUSION The history, combined with PSG and MSLT, was helpful in the diagnosis of narcolepsy. We report a case of early-onset narcolepsy presenting with excessive sleepiness and cataplexy.
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Affiliation(s)
- Eu Gene Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jiwon Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun Yeon Joo
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Munhyang Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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17
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Aydinoz S, Huang YS, Gozal D, Inocente CO, Franco P, Kheirandish-Gozal L. Allergies and Disease Severity in Childhood Narcolepsy: Preliminary Findings. Sleep 2015; 38:1981-4. [PMID: 25902808 DOI: 10.5665/sleep.5254] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/06/2015] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Narcolepsy frequently begins in childhood, and is characterized by excessive daytime sleepiness, with the presence of cataplexy reflecting a more severe phenotype. Narcolepsy may result from genetic predisposition involving deregulation of immune pathways, particularly involving T helper 2 cells (Th2). Increased activation of Th2 cells is usually manifested as allergic conditions such as rhinitis, atopic dermatitis, and asthma. We hypothesized that the presence of allergic conditions indicative of increased Th2 balance may dampen the severity of the phenotype in children with narcolepsy. METHODS A retrospective chart review of childhood narcolepsy patients was conducted at three major pediatric sleep centers. Patients were divided into those with narcolepsy without cataplexy (NC-) and narcolepsy with cataplexy (NC+). Demographics, polysomnographic and multiple sleep latency test data, and extraction of information on the presence of allergic diseases such allergic rhinitis, atopic dermatitis, and asthma was performed. RESULTS There were 468 children identified, with 193 children in NC- group and 275 patients in the NC+ group. Overall, NC+ children were significantly younger, had higher body mass index, and had shorter mean sleep latencies and increased sleep onset rapid eye movement events. The frequency of allergic conditions, particularly asthma and allergic rhinitis, was markedly lower in NC+ (58/275) compared to NC- patients (94/193; P < 0.0001). CONCLUSION Involvement of the immune system plays an important role in the pathophysiology of narcolepsy. Current findings further suggest that an increased shift toward T helper 2 cells, as indicated by the presence of allergic conditions, may modulate the severity of the phenotype in childhood narcolepsy, and reduce the prevalence of cataplexy in these patients.
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Affiliation(s)
- Secil Aydinoz
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Yu-Shu Huang
- Department of Child Psychiatry and Sleep Center, Chang Gung Memorial Hospital, Gueishan Township, Taoyuan Country, Taiwan
| | - David Gozal
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL
| | - Clara O Inocente
- Unité de Sommeil Pédiatrique & INSERM U1028 Service Epilepsie-Sommeil-Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme-Mère-Enfant 59, Bron, Lyon, France
| | - Patricia Franco
- Unité de Sommeil Pédiatrique & INSERM U1028 Service Epilepsie-Sommeil-Explorations Fonctionnelles Neurologiques Pédiatriques, Hôpital Femme-Mère-Enfant 59, Bron, Lyon, France
| | - Leila Kheirandish-Gozal
- Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL
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18
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Carter LP, Acebo C, Kim A. Patients' Journeys to a Narcolepsy Diagnosis: A Physician Survey and Retrospective Chart Review. Postgrad Med 2015; 126:216-24. [DOI: 10.3810/pgm.2014.05.2769] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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19
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Primeau MM, Tal JZ, O’Hara R. Depression. Sleep Med 2015. [DOI: 10.1007/978-1-4939-2089-1_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Thorpy MJ, Krieger AC. Delayed diagnosis of narcolepsy: characterization and impact. Sleep Med 2014; 15:502-7. [PMID: 24780133 DOI: 10.1016/j.sleep.2014.01.015] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 01/15/2014] [Accepted: 01/31/2014] [Indexed: 02/04/2023]
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21
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Rosenberg R, Kim AY. The AWAKEN survey: knowledge of narcolepsy among physicians and the general population. Postgrad Med 2014; 126:78-86. [PMID: 24393754 DOI: 10.3810/pgm.2014.01.2727] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Narcolepsy can be a debilitating sleep disorder resulting from the dysregulation of pathways that control the sleep and wake states of patients. Although overall knowledge of narcolepsy has increased, no previous studies characterize awareness and perceptions of this condition in the general population or among physicians. Our survey evaluated the understanding and perceptions of narcolepsy among individuals from the general population and from a sample of physicians, including sleep specialists. The Awareness and Knowledge of Narcolepsy (AWAKEN) survey included a sample of 1000 US adults, 300 primary care physicians (PCPs), and 100 sleep medicine specialists (36% board certified) and was conducted online by Harris Interactive in May 2012. Descriptive analysis was performed using 2-tailed t tests with a significance of P < 0.05. Although 70% of the general public respondents had heard of narcolepsy, it ranked lowest in awareness relative to other chronic diseases requiring long-term treatment. Overall, 62% of sleep specialists and 24% of PCPs considered themselves "very" or "extremely" knowledgeable about narcolepsy; however, only 42% and 9% of sleep specialists and PCPs, respectively, felt "very" or "extremely" comfortable diagnosing the disorder. Only 22% of sleep specialists and 7% of PCPs identified all 5 key narcolepsy symptoms; no participant in the general population could identify all 5 symptoms. Sixty-three percent of sleep specialists and 39% of PCPs recognized both of the most prominent narcolepsy symptoms, which are excessive daytime sleepiness and cataplexy. Substantial gaps exist in understanding narcolepsy and its symptoms, even among sleep medicine specialists. Our findings suggest a need for educational initiatives for physicians to improve recognition of narcolepsy symptoms.
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Affiliation(s)
- Russell Rosenberg
- 1Director of Research, NeuroTrials Research, Inc; Director, The Atlanta School of Sleep Medicine and Technology, Atlanta, GA.
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