1
|
Stenmanns C, Frohnhofen H. [Sleep and sleep disorders in old age]. Z Gerontol Geriatr 2024:10.1007/s00391-024-02363-8. [PMID: 39365311 DOI: 10.1007/s00391-024-02363-8] [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: 07/24/2024] [Accepted: 08/26/2024] [Indexed: 10/05/2024]
Abstract
The increasing interruptions of nocturnal sleep with aging must be distinguished from actual sleep disorders. Morbidity and medication have an impact on sleep. The relationship between sleep and morbidity is mutual. Disturbed sleep modifies many clinical symptoms and diseases affect sleep and the ability to sleep. Geriatric syndromes such as falls, depression and dementia are modified by sleep disorders. Geriatric syndromes can be favorably influenced by the treatment of sleep disorders. Adequate diagnostics are important prerequisites. Coincidences of different sleep disorders are frequent. The medical history of patients and a sleep diary form the basis of the diagnostics. Sleep medicine provides further technical examination procedures. Older people should be examined in a sleep laboratory if the results have consequences that are accepted by the patient. This should be clarified in advance.
Collapse
Affiliation(s)
- Carla Stenmanns
- Klinik für Orthopädie und Unfallchirurgie/Altersmedizin, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
| | - Helmut Frohnhofen
- Klinik für Orthopädie und Unfallchirurgie/Altersmedizin, Universitätsklinikum Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Deutschland.
- Fakultät für Gesundheit, Department Humanmedizin, Geriatrie, Universität Witten-Herdecke, Witten, Deutschland.
| |
Collapse
|
2
|
Biscarini F, Barateau L, Pizza F, Plazzi G, Dauvilliers Y. Narcolepsy and rapid eye movement sleep. J Sleep Res 2024:e14277. [PMID: 38955433 DOI: 10.1111/jsr.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/06/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024]
Abstract
Since the first description of narcolepsy at the end of the 19th Century, great progress has been made. The disease is nowadays distinguished as narcolepsy type 1 and type 2. In the 1960s, the discovery of rapid eye movement sleep at sleep onset led to improved understanding of core sleep-related disease symptoms of the disease (excessive daytime sleepiness with early occurrence of rapid eye movement sleep, sleep-related hallucinations, sleep paralysis, rapid eye movement parasomnia), as possible dysregulation of rapid eye movement sleep, and cataplexy resembling an intrusion of rapid eye movement atonia during wake. The relevance of non-sleep-related symptoms, such as obesity, precocious puberty, psychiatric and cardiovascular morbidities, has subsequently been recognized. The diagnostic tools have been improved, but sleep-onset rapid eye movement periods on polysomnography and Multiple Sleep Latency Test remain key criteria. The pathogenic mechanisms of narcolepsy type 1 have been partly elucidated after the discovery of strong HLA class II association and orexin/hypocretin deficiency, a neurotransmitter that is involved in altered rapid eye movement sleep regulation. Conversely, the causes of narcolepsy type 2, where cataplexy and orexin deficiency are absent, remain unknown. Symptomatic medications to treat patients with narcolepsy have been developed, and management has been codified with guidelines, until the recent promising orexin-receptor agonists. The present review retraces the steps of the research on narcolepsy that linked the features of the disease with rapid eye movement sleep abnormality, and those that do not appear associated with rapid eye movement sleep.
Collapse
Affiliation(s)
- Francesco Biscarini
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
- National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France
- Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| |
Collapse
|
3
|
Barateau L, Pizza F, Chenini S, Peter-Derex L, Dauvilliers Y. Narcolepsies, update in 2023. Rev Neurol (Paris) 2023; 179:727-740. [PMID: 37634997 DOI: 10.1016/j.neurol.2023.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023]
Abstract
Narcolepsy type 1 (NT1) and type 2 (NT2), also known as narcolepsy with and without cataplexy, are sleep disorders that benefited from major scientific advances over the last two decades. NT1 is caused by the loss of hypothalamic neurons producing orexin/hypocretin, a neurotransmitter regulating sleep and wake, which can be measured in the cerebrospinal fluid (CSF). A low CSF level of hypocretin-1/orexin-A is a highly specific and sensitive biomarker, sufficient to diagnose NT1. Orexin-deficiency is responsible for the main NT1 symptoms: sleepiness, cataplexy, disrupted nocturnal sleep, sleep-related hallucinations, and sleep paralysis. In the absence of a lumbar puncture, the diagnosis is based on neurophysiological tests (nocturnal and diurnal) and the presence of the pathognomonic symptom cataplexy. In the revised version of the International Classification of sleep Disorders, 3rd edition (ICSD-3-TR), a sleep onset rapid eye movement sleep (REM) period (SOREMP) (i.e. rapid occurrence of REM sleep) during the previous polysomnography may replace the diurnal multiple sleep latency test, when clear-cut cataplexy is present. A nocturnal SOREMP is very specific but not sensitive enough, and the diagnosis of cataplexy is usually based on clinical interview. It is thus of crucial importance to define typical versus atypical cataplectic attacks, and a list of clinical features and related degrees of certainty is proposed in this paper (expert opinion). The time frame of at least three months of evolution of sleepiness to diagnose NT1 was removed in the ICSD-3-TR, when clear-cut cataplexy or orexin-deficiency are established. However, it was kept for NT2 diagnosis, a less well-characterized disorder with unknown clinical course and absence of biolo biomarkers; sleep deprivation, shift working and substances intake being major differential diagnoses. Treatment of narcolepsy is nowadays only symptomatic, but the upcoming arrival of non-peptide orexin receptor-2 agonists should be a revolution in the management of these rare sleep diseases.
Collapse
Affiliation(s)
- L Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France.
| | - F Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - S Chenini
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France
| | - L Peter-Derex
- Center for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 1 University, Lyon, France; Lyon Neuroscience Research Center, PAM Team, Inserm U1028, CNRS UMR 5292, Lyon, France
| | - Y Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU de Montpellier, Montpellier, France; National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France; Institute of Neurosciences of Montpellier, University of Montpellier, Inserm, Montpellier, France.
| |
Collapse
|
4
|
Shelton AR. Sleep Disorders in Childhood. Continuum (Minneap Minn) 2023; 29:1205-1233. [PMID: 37590830 DOI: 10.1212/con.0000000000001285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing, insomnia, parasomnias, restless sleep disorder, restless legs syndrome, narcolepsy in childhood, and Kleine-Levin syndrome. LATEST DEVELOPMENTS Our understanding of pediatric sleep pathophysiology continues to evolve, and diagnostic and treatment modalities have expanded. A low-sodium oxybate formulation was approved in July 2020 in the United States to treat cataplexy and excessive daytime sleepiness in patients 7 years old and older with narcolepsy. A validated pediatric hypersomnolence survey for pediatric narcolepsy and idiopathic hypersomnia with high sensitivity, specificity, and interrater reliability is now available. ESSENTIAL POINTS The clinical presentation, diagnostics, and treatment of children with sleep disorders differ from those of adults. Untreated sleep disorders in childhood can lead to adverse physical and psychological consequences in adults. Correctly diagnosing and treating sleep disorders in youth can prevent a significant burden of disease in adulthood.
Collapse
|
5
|
Abad VC. Pharmacological options for narcolepsy: are they the way forward? Expert Rev Neurother 2023; 23:819-834. [PMID: 37585269 DOI: 10.1080/14737175.2023.2249234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Narcolepsy is an under-recognized, rare neurologic disorder of hypersomnolence that is associated with increased mortality and medical and psychiatric co-morbidities. Narcolepsy exerts a substantial economic burden on patients and society. There is currently no cure, and life-long symptomatic therapy is needed. Available drugs do not modify the disease course. AREAS COVERED This manuscript provides an overview of narcolepsy symptoms, diagnosis, pathophysiology, current pharmacotherapies, and emerging treatments. Gaps and unresolved issues in diagnosis and management of narcolepsy are discussed to answer whether pharmacological options are the way forward. EXPERT OPINION Diagnostic criteria for narcolepsy (ICSD-3) need revision and greater clarity. Improved recognition of cataplexy and other symptoms through educational outreach, new biomarkers, improved test scoring through artificial intelligence algorithms, and use of machine learning may facilitate earlier diagnosis and treatment. Pharmacological options need improved symptomatic therapy in addition to targeted therapies that address the loss of hypocretin signaling. Optimal narcolepsy care also needs a better understanding of the pathophysiology, recognition of the different phenotypes in narcolepsy, identification of at-risk individuals and early recognition of symptoms, better diagnostic tools, and a database for research and disease monitoring of treatment, side-effects, and comorbidities.
Collapse
Affiliation(s)
- Vivien C Abad
- Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences Stanford University, Redwood, CA, USA
| |
Collapse
|
6
|
Kotagal S. Update on Central Hypersomnia Disorders in Children. CURRENT SLEEP MEDICINE REPORTS 2022. [DOI: 10.1007/s40675-022-00237-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
7
|
Barateau L, Pizza F, Plazzi G, Dauvilliers Y. 50th anniversary of the ESRS in 2022-JSR special issue. J Sleep Res 2022; 31:e13631. [PMID: 35624073 DOI: 10.1111/jsr.13631] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 01/21/2023]
Abstract
This article addresses the clinical presentation, diagnosis, pathophysiology and management of narcolepsy type 1 and 2, with a focus on recent findings. A low level of hypocretin-1/orexin-A in the cerebrospinal fluid is sufficient to diagnose narcolepsy type 1, being a highly specific and sensitive biomarker, and the irreversible loss of hypocretin neurons is responsible for the main symptoms of the disease: sleepiness, cataplexy, sleep-related hallucinations and paralysis, and disrupted nocturnal sleep. The process responsible for the destruction of hypocretin neurons is highly suspected to be autoimmune, or dysimmune. Over the last two decades, remarkable progress has been made for the understanding of these mechanisms that were made possible with the development of new techniques. Conversely, narcolepsy type 2 is a less well-defined disorder, with a variable phenotype and evolution, and few reliable biomarkers discovered so far. There is a dearth of knowledge about this disorder, and its aetiology remains unclear and needs to be further explored. Treatment of narcolepsy is still nowadays only symptomatic, targeting sleepiness, cataplexy and disrupted nocturnal sleep. However, new psychostimulants have been recently developed, and the upcoming arrival of non-peptide hypocretin receptor-2 agonists should be a revolution in the management of this rare sleep disease, and maybe also for disorders beyond narcolepsy.
Collapse
Affiliation(s)
- Lucie Barateau
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Yves Dauvilliers
- Sleep-Wake Disorders Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.,National Reference Centre for Orphan Diseases, Narcolepsy, Idiopathic Hypersomnia, and Kleine-Levin Syndrome, Montpellier, France.,Institute for Neurosciences of Montpellier, University of Montpellier, INSERM, Montpellier, France
| |
Collapse
|
8
|
Latorre D, Federica S, Bassetti CLA, Kallweit U. Narcolepsy: a model interaction between immune system, nervous system, and sleep-wake regulation. Semin Immunopathol 2022; 44:611-623. [PMID: 35445831 PMCID: PMC9519713 DOI: 10.1007/s00281-022-00933-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/22/2022] [Indexed: 12/21/2022]
Abstract
Narcolepsy is a rare chronic neurological disorder characterized by an irresistible excessive daytime sleepiness and cataplexy. The disease is considered to be the result of the selective disruption of neuronal cells in the lateral hypothalamus expressing the neuropeptide hypocretin, which controls the sleep-wake cycle. Diagnosis and management of narcolepsy represent still a substantial medical challenge due to the large heterogeneity in the clinical manifestation of the disease as well as to the lack of understanding of the underlying pathophysiological mechanisms. However, significant advances have been made in the last years, thus opening new perspective in the field. This review describes the current knowledge of clinical presentation and pathology of narcolepsy as well as the existing diagnostic criteria and therapeutic intervention for the disease management. Recent evidence on the potential immune-mediated mechanisms that may underpin the disease establishment and progression are also highlighted.
Collapse
Affiliation(s)
| | - Sallusto Federica
- Institute of Microbiology, ETH Zurich, Zurich, Switzerland.,Center of Medical Immunology, Institute for Research in Biomedicine, Università della Svizzera italiana, Bellinzona, Switzerland
| | | | - Ulf Kallweit
- Clinical Sleep and Neuroimmunology, Institute of Immunology, University Witten/Herdecke, Witten, Germany.,Center for Biomedical Education and Research (ZBAF), University Witten/Herdecke, Witten, Germany
| |
Collapse
|
9
|
Frohnhofen H, Popp R. [Sleep and sleep disorders in old age]. Dtsch Med Wochenschr 2022; 147:258-268. [PMID: 35226925 DOI: 10.1055/a-1495-3348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The increasing interruptions of night sleep with normal ageing must be distinguished from sleep disorders. Somatic and psychiatric morbidity as well as medication have a huge impact on sleep. Furthermore, the relationship between sleep and morbidity is mutual. Disturbed sleep modifies the clinical appearance of diseases and morbidity affects the ability to sleep. Especially in geriatric medicine, geriatric syndromes such as falls, depression or dementia are modified by sleep disorders. Therefore, treatment for sleep disorders offers the chance to improve geriatric syndromes.When treating, it is important to identify the individual sleep disorders. Coincidences of different sleep disorders are common in the elderly. The history of a patient in connection with a sleeping diary is the basic diagnostic procedure. Sleep medicine provides further technical methods for further examination. Older people should also be examined in a sleep laboratory if the results have consequences that will be accepted by the patient. However, this should be clarified in advance.
Collapse
|
10
|
Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
Collapse
Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
11
|
Lividini A, Pizza F, Filardi M, Vandi S, Ingravallo F, Antelmi E, Bruni O, Cosentino FII, Ferri R, Guarnieri B, Marelli S, Ferini-Strambi L, Romigi A, Bonanni E, Maestri M, Terzaghi M, Manni R, Plazzi G. Narcolepsy type 1 features across the life span: age impact on clinical and polysomnographic phenotype. J Clin Sleep Med 2021; 17:1363-1370. [PMID: 33666167 DOI: 10.5664/jcsm.9198] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVES Narcolepsy type 1 (NT1) is a chronic neurological disorder typically arising during adolescence and young adulthood. Recent studies demonstrated that NT1 presents with age-specific features, especially in children. With this study we aimed to describe and to compare the clinical pictures of NT1 in different age groups. METHODS In this cross-sectional, multicenter study, 106 untreated patients with NT1 enrolled at the time of diagnosis underwent clinical evaluation, a semistructured interview (including the Epworth Sleepiness Scale), nocturnal video-polysomnography, and the Multiple Sleep Latency Test. Patients were enrolled in order to establish 5 age-balanced groups (childhood, adolescence, adulthood, middle age, and senior). RESULTS The Epworth Sleepiness Scale score showed a significant increase with age, while self-reported diurnal total sleep time was lower in older and young adults, with the latter also complaining of automatic behaviors in more than 90% of patients. Children reported the cataplexy attacks to be more frequent (> 1/d in 95% of patients). "Recalling an emotional event," "meeting someone unexpectedly," "stress," and "anger" were more frequently reported in adult and older adult patients as possible triggers of cataplexy. Neurophysiological data showed a higher number of sleep-onset rapid eye movement periods on the Multiple Sleep Latency Test in adolescent compared to senior patients and an age-progressive decline in sleep efficiency. CONCLUSIONS Daytime sleepiness, cataplexy features and triggers, and nocturnal sleep structure showed age-related difference in patients with NT1; this variability may contribute to diagnostic delay and misdiagnosis.
Collapse
Affiliation(s)
- Althea Lividini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Marco Filardi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Stefano Vandi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Francesca Ingravallo
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Elena Antelmi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University of Rome, Italy
| | | | - Raffaele Ferri
- Sleep Research Center, Department of Neurology IC, Oasi Research Institute-IRCCS, Troina, Italy
| | - Biancamaria Guarnieri
- Center of Sleep Medicine, Department of Neurology, Villa Serena Hospital and Villa Serena Foundation for Research, Città S. Angelo, Pescara, Italy
| | - Sara Marelli
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Neurology-Sleep Disorders Centre, Milan, Italy
| | - Luigi Ferini-Strambi
- Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Neurology-Sleep Disorders Centre, Milan, Italy
| | - Andrea Romigi
- IRCCS Neuromed Istituto Neurologico Mediterraneo Sleep Medicine Centre, Pozzilli, Italy
| | - Enrica Bonanni
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - Michelangelo Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Italy
| | - Michele Terzaghi
- Unit of Sleep Medicine and Epilepsy, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Raffaele Manni
- Unit of Sleep Medicine and Epilepsy, IRCCS Mondino Foundation, Pavia, Italy
| | - Giuseppe Plazzi
- IRCCS, Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
12
|
Abstract
Narcolepsy with cataplexy is a severe lifelong disorder characterized, among others, by sudden loss of bilateral face muscle tone triggered by emotions (cataplexy). A recent approach for the diagnosis of the disease is based on a completely manual analysis of video recordings of patients undergoing emotional stimulation made on-site by medical specialists, looking for specific facial behavior motor phenomena. We present here the CAT-CAD tool for automatic detection of cataplexy symptoms, with the double aim of (1) supporting neurologists in the diagnosis/monitoring of the disease and (2) facilitating the experience of patients, allowing them to conduct video recordings at home. CAT-CAD includes a front-end medical interface (for the playback/inspection of patient recordings and the retrieval of videos relevant to the one currently played) and a back-end AI-based video analyzer (able to automatically detect the presence of disease symptoms in the patient recording). Analysis of patients’ videos for discovering disease symptoms is based on the detection of facial landmarks, and an alternative implementation of the video analyzer, exploiting deep-learning techniques, is introduced. Performance of both approaches is experimentally evaluated using a benchmark of real patients’ recordings, demonstrating the effectiveness of the proposed solutions.
Collapse
|
13
|
Quaedackers L, Pillen S, Overeem S. Recognizing the Symptom Spectrum of Narcolepsy to Improve Timely Diagnosis: A Narrative Review. Nat Sci Sleep 2021; 13:1083-1096. [PMID: 34262379 PMCID: PMC8273742 DOI: 10.2147/nss.s278046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/23/2021] [Indexed: 11/23/2022] Open
Abstract
Narcolepsy is a chronic sleep disorder with a strong negative impact on quality of life, especially when untreated. Diagnostic delay is a persistent problem, with obvious detrimental effects on patients. A diagnosis of narcolepsy may be delayed because of its broad symptom presentation which is much more encompassing than the classical "tetrad" of sleepiness, cataplexy, hallucinations, and sleep paralysis. Furthermore, symptoms can vary over time. Presentation of symptoms can also be markedly different between children and adults. Finally, common sleep-related comorbidities increase the risk of narcolepsy being masked by overlapping symptoms or treatment. In this review, we provide a detailed description of the broad and dynamic symptom spectrum of narcolepsy, with specific attention to the different manifestations in both adults and children. The overarching goal is to help not only sleep specialists, but general practitioners, pediatricians, and other caregivers with early recognition and prompt diagnosis of this severe but treatable disorder.
Collapse
Affiliation(s)
| | - Sigrid Pillen
- Sleep Medicine Center Kempenhaeghe, Heeze, the Netherlands
| | - Sebastiaan Overeem
- Biomedical Diagnostics Laboratory, Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| |
Collapse
|
14
|
Lammers GJ, Bassetti CL, Dolenc-Groselj L, Jennum PJ, Kallweit U, Khatami R, Lecendreux M, Manconi M, Mayer G, Partinen M, Plazzi G, Reading PJ, Santamaria J, Sonka K, Dauvilliers Y. Diagnosis of central disorders of hypersomnolence: A reappraisal by European experts. Sleep Med Rev 2020; 52:101306. [DOI: 10.1016/j.smrv.2020.101306] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 02/13/2020] [Accepted: 02/13/2020] [Indexed: 01/22/2023]
|
15
|
Abstract
PURPOSE OF REVIEW Narcolepsy is a central disorder of hypersomnolence with symptoms of excessive daytime sleepiness, sleep paralysis, and cataplexy. Cataplexy is the sudden loss of muscle tone in either the face, neck, trunk, and/or limbs, leading to a loss of voluntary muscle control. This article reviews recent research on the clinical characteristics of cataplexy. RECENT FINDINGS Longitudinal research in adults suggests that there may be a remission of cataplectic severity after symptom stabilization. First-line treatment options for cataplexy include sodium oxybate and pitolisant, with many drugs such as AXS-12, FT218, and JZP258 under investigation. Patients with cataplexy reported greater limitations of daily activities such as driving and exercise compared to patients without cataplexy. Cataplexy remains a challenge for children and adults with narcolepsy and can interfere with daily activities. There is no cure for narcolepsy, but cataplexy can be well-managed with current and promising new treatment options on the horizon.
Collapse
|
16
|
Therapy for Cataplexy. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-0619-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Purpose of the review
Cataplexy, an involuntary loss of muscle activity triggered by strong emotions is the most impressive symptom in narcolepsy. This review gives an overview of the current understanding of cataplexy and its available treatment options.
Recent findings
With the discovery of hypocretin/orexin, the understanding of the pathophysiology of cataplexy advanced in the past decades. In the recent years, with the development of new anticataplectic agents (e.g., Pitolisant) symptomatic treatment of cataplexy has further improved. Abrupt cessation of anticataplectic medication especially antidepressants increase the risk of status cataplecticus, a virtually continuous series of long-lasting cataplectic attacks.
Summary
Cataplexies still remain an under-recognized phenomenon due to missing diagnostic measures. Treatment for cataplexy still remains symptomatic but new agents with better tolerability and usability are continuously developed. New therapeutic actions either targeting the autoimmune mechanisms underlying orexin cell death or substituting orexin action are promising treatments for the near future.
Collapse
|
17
|
Schneider L, Ellenbogen J. Images: Facial cataplexy with demonstration of persistent eye movements. J Clin Sleep Med 2020; 16:157-159. [PMID: 31957646 DOI: 10.5664/jcsm.8148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
None A patient was transferred for management of "medication-refractory seizures" after failure of levetiracetam and valproate dual therapy. She had a life-long history of two types of events: periods in which she would rapidly and uncontrollably lapse into unconsciousness, and spells in which she would "pass out" but maintain consciousness, the latter happening with increasing frequency in association with laughing, as of late. She also reported hypnogogic/hypnopompic hallucinations, sleep paralysis, and disrupted nocturnal sleep. A clinical diagnosis of narcolepsy was made. The prevailing pathophysiological concept of narcolepsy details "partial intrusions of REM" sleep into wakefulness. Healthy REM sleep includes generalized atonia, but with preservation of eye movements, respiratory function, and sphincter tone. Cataplexy recapitulates this pattern, and is often induced by extreme emotions, laughter in this case. Despite generalized and severe weakness and areflexia during this patient's cataplectic events, she was able to volitionally move her eyes, which is consistent with the physiology of REM sleep. The diagnosis of cataplexy is often missed, due to clinicians being unfamiliar with the findings and the lack of ability to induce sufficient emotional responses to trigger an episode. This example of cataplexy is also quite characteristic of the "cataplectic facies." The ability to observe the infrequently observed phenomenon of cataplexy serves as a reminder that consciousness is preserved, as are extra-ocular muscle movements.
Collapse
Affiliation(s)
- Logan Schneider
- Stanford/VA Alzheimer's Center, Palo Alto, California.,Sierra Pacific VA (VISN 21) Mental Illness Research, Education and Clinical Centers, Palo Alto, California.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
| | - Jeffrey Ellenbogen
- The Sound Sleep Project, Baltimore, Maryland.,Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Walter Reed Army Institute of Research, Silver Spring, Maryland
| |
Collapse
|
18
|
Narcolepsy — clinical spectrum, aetiopathophysiology, diagnosis and treatment. Nat Rev Neurol 2019; 15:519-539. [DOI: 10.1038/s41582-019-0226-9] [Citation(s) in RCA: 204] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2019] [Indexed: 12/15/2022]
|
19
|
Huang B, Xu T, Wang Z, Chen K, Zhang J, Zhao Z, Zhuang J, Wu H. The clinical characteristics of cataplectic attack in narcolepsy type 1. Sleep Med 2019; 77:261-269. [PMID: 31607435 DOI: 10.1016/j.sleep.2019.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Cataplexy is a pathognomonic symptom of narcolepsy type 1. This study was conducted to clarify the clinical characteristics of cataplexy by staging, and to further analyse the correlations of clinical features and cataplectic stages in patients with narcolepsy type 1 (NT1). METHODS We experimentally triggered patients with NT1 into cataplexy while under video-polysomnography (v-PSG) monitoring in the sleep lab. The most serious cataplectic attack from each patient was analysed. Each cataplectic episode was segmented into four stages according to the v-PSG. Correlations were analysed between cataplectic stages in pairs, and between cataplectic stages and other clinical features. RESULTS We observed 81 cataplectic episodes in 21 patients with diverse triggers, including humorous or exciting videos, tickling, recalling horrible memories and exercising. Nine patients (43%) went through complete cataplectic attacks while the others experienced partial attacks. Four cataplectic stages (ie, triggering, resisting, atonic, and recovering) were identified according to clinical and electromyograms characteristics. Resisting stage is predominant (56.4%) in cataplexy, while atonic stage is most related with the total duration of cataplexy. The Epworth Sleepiness Scale score (ESS) has a positive correlation with the total duration of cataplexy. Both duration of cataplexy and ESS score are negatively correlated with disease course. However, medication history seems have no influence on either cataplexy duration or ESS score. CONCLUSION Four-stage segmentation shows the dynamic process of the cataplectic attack, which is different from the traditional classification of complete or partial cataplexy. Resisting stage is necessary for every cataplexy and might reflect the compensation mechanism, while atonic stage may be omitted in some patients. The severity of narcolepsy reduces with the extension of natural course regardless of medication history.
Collapse
Affiliation(s)
- Bei Huang
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China; Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region of China
| | - Tao Xu
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China
| | - Zongwen Wang
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China
| | - Kun Chen
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China
| | - Jihui Zhang
- Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region of China
| | - Zhongxin Zhao
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China
| | - Jianhua Zhuang
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China.
| | - Huijuan Wu
- Department of Neurology, Changzheng Hospital, The Second Medical University of Chinese PLA, Shanghai, China.
| |
Collapse
|
20
|
Tics and stereotypies: A comparative clinical review. Parkinsonism Relat Disord 2019; 59:117-124. [DOI: 10.1016/j.parkreldis.2019.02.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 12/28/2018] [Accepted: 02/03/2019] [Indexed: 01/07/2023]
|
21
|
Baumann CR. Clinical Sleep-Wake Disorders I: Focus on Hypersomnias and Movement Disorders During Sleep. Handb Exp Pharmacol 2019; 253:245-259. [PMID: 30341725 DOI: 10.1007/164_2018_126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Central disorders of hypersomnolence are characterized by daily periods of irrepressible need to sleep or daytime lapses into sleep, as defined in the current version of the International Criteria of Sleep Disorders. Thus, the unifying symptom is excessive daytime sleepiness which is not caused by any other sleep-wake disorder. Relevant disorders including narcolepsy type 1 and 2, idiopathic hypersomnia, Kleine-Levin syndrome, and insufficient sleep syndrome will be discussed. Other central disorders of hypersomnolence include hypersomnias due to medical or psychiatric disorders or because of medication or substance use.In sleep-related movement disorders, the cardinal symptom consists of simple, often stereotyped movements occurring during sleep. The most frequent disorder in this category of sleep-wake disorders is restless legs syndrome, which is often associated with period limb movements during sleep.
Collapse
Affiliation(s)
- Christian R Baumann
- Department of Neurology, University Hospital Zurich, University of Zurich, Zürich, Switzerland.
| |
Collapse
|
22
|
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.
Collapse
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.
| |
Collapse
|
23
|
Bartolini I, Pizza F, Di Luzio A, Neccia G, Antelmi E, Vandi S, Plazzi G. Automatic detection of cataplexy. Sleep Med 2018; 52:7-13. [PMID: 30195199 DOI: 10.1016/j.sleep.2018.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Although being the most specific symptom of narcolepsy type 1 (NT1), cataplexy is currently investigated by clinical interview only, with potential diagnostic pitfalls. Our study aimed at testing the accuracy of an automatic video detection of cataplexy in NT1 patients vs. non-cataplectic subjects undergoing a standardized test with emotional stimulation. METHODS Fifteen drug-naive NT1 patients and 15 age- and sex-balanced non-cataplectic subjects underwent a standardized video recording procedure including emotional stimulation causing laughter. Video recordings were visually inspected by human scorers to detect three typical cataplexy facial motor patterns (ptosis, mouth opening and head drop), and then analysed by SHIATSU (Semantic-based HIearchical Automatic Tagging of videos by Segmentation using cUts). Expert-based and automatic attack detection was compared in NT1 patients and non-cataplectic subjects. RESULTS All NT1 patients and none of the non-cataplectic subjects displayed cataplexy during emotional stimulation. Automatic detection correlated well with experts' assessments in NT1 with an overall accuracy of 81%. In non-cataplectic subjects, automatic detection falsely identified cataplexy in two out of 15 (13.3%) subjects who showed active eyes closure during intense laughter as a confounder with ptosis. CONCLUSIONS Automatic cataplexy detection by applying SHIATSU to a standardized test for video documentation of cataplexy is feasible, with an overall accuracy of 81% compared to human examiners. Further studies are warranted to enlarge the range of elementary motor patterns detected, analyse their temporal/spatial relations and quantify cataplexy for diagnostic purposes.
Collapse
Affiliation(s)
- Ilaria Bartolini
- Department of Computer Science and Engineering, University of Bologna, Bologna, Italy
| | - Fabio Pizza
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Andrea Di Luzio
- Department of Computer Science and Engineering, University of Bologna, Bologna, Italy; Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Giulia Neccia
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Elena Antelmi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Stefano Vandi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Plazzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
| |
Collapse
|