WITHDRAWN: Treatments for adults with prominent lower front teeth

BACKGROUND

Prominent lower front teeth may be associated with a large or prognathic lower jaw (mandible) or a small or retrusive upper jaw (maxilla). Edward Angle, who may be considered the father of modern orthodontics, classified the malocclusion in this situation as Class III. The individual is described as having a negative or reverse overjet as the lower front teeth are more prominent than the upper front teeth.

OBJECTIVES

The purpose of this systematic review was to evaluate different treatments of Angle Class III malocclusion in adults.

SEARCH METHODS

The following databases were searched: Cochrane Oral Health Group Trials Register (to 22 March 2012); CENTRAL (The Cochrane Library 2012, Issue 1); MEDLINE via OVID (1950 to 22 March 2012); EMBASE via OVID (1980 to 22 March 2012); LILACs (1982 to 22 March 2012); BBO (1986 to 22 March 2012); and SciELO (1997 to 22 March 2012).

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials of treatments for adults with an Angle Class III malocclusion were included.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the eligibility of the identified reports. Two review authors independently extracted data and assessed the risk of bias in the included studies. The mean differences with 95% confidence intervals were calculated for continuous data.

MAIN RESULTS

Two randomized controlled trials were included in this review. There are different types of surgery for this type of malocclusion but only trials of mandible reduction surgery were identified. One trial compared intraoral vertical ramus osteotomy (IVRO) with sagittal split ramus osteotomy (SSRO) and the other trial compared vertical ramus osteotomy (VRO) with and without osteosynthesis. Neither trial found any difference between the two treatments. The trials did not provide adequate data for assessing effectiveness of the techniques described.

AUTHORS' CONCLUSIONS

There is insufficient evidence from the two included trials, to conclude that one procedure is better or worse than another. The included trials compared different interventions and were at high risk of bias and therefore no implications for practice can be given. Further high quality randomized controlled trials with long term follow-up are required.

Benzodiazepines for restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a common disease affecting about 5% to 15% of the population. Symptoms of RLS can be severe in a minority of and can have a major impact on sleep, mostly sleep initiation, and quality of life. Benzodiazepines are drugs that can induce and maintain sleep and, hence, intuitively are thought to be beneficial to people with RLS. Altough benzodiazepines, particularly clonazepam, are used to treat RLS symptoms, a systematic review done by the American Academy of Sleep Medicine stated that benzodiazepines should not be used as a first-line treatment, although could be used as a coadjuvant therapy.

OBJECTIVES

To evaluate the efficacy and safety of benzodiazepine compared to placebo or other treatment for idiopathic RLS, including unconfounded trials comparing benzodiazepines versus open control.

SEARCH METHODS

In March 2016 we searched CENTRAL, MEDLINE, Embase and LILACS We checked the references of each study and contacted study authors to identify any additional studies. We considered studies published in any language.

SELECTION CRITERIA

Randomised clinical trials of benzodiazepine treatment in idiopathic RLS.

DATA COLLECTION AND ANALYSIS

We did not perform data collection and analysis, since we did not include any studies, MAIN RESULTS: We did not identify any studies that met the inclusion criteria of the review. Two cross-over studies are awaiting classification because the cross-over trials did not give data at the end of the first cross-over period.

AUTHORS' CONCLUSIONS

The effectiveness of benzodiazepines for RLS treatment is currently unknown.

Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children

BACKGROUND

Apnoea is a breathing disorder marked by the absence of airflow at the nose or mouth. In children, risk factors include adenotonsillar hypertrophy, obesity, neuromuscular disorders and craniofacial anomalies. The most common treatment for obstructive sleep apnoea syndrome (OSAS) in childhood is adeno-tonsillectomy. This approach is limited by its surgical risks, mostly in children with comorbidities and, in some patients, by recurrence that can be associated with craniofacial problems. Oral appliances and functional orthopaedic appliances have been used for patients who have OSAS and craniofacial anomalies because they hold the lower jaw (mandible) forwards which potentially enlarges the upper airway and increases the upper airspace, improving the respiratory function.

OBJECTIVES

To assess the effects of oral appliances or functional orthopaedic appliances for obstructive sleep apnoea in children.

SEARCH METHODS

We searched the following electronic databases: Cochrane Oral Health's Trials Register (to 7 April 2016); Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3) in the Cochrane Library (searched 7 April 2016); MEDLINE Ovid (1946 to 7 April 2016); Embase Ovid (1980 to 7 April 2016); LILACS BIREME (from 1982 to 7 April 2016); BBO BIREME (from 1986 to 7 April 2016) and SciELO Web of Science (from 1997 to 7 April 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials on 7 April 2016. We placed no restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing all types of oral and functional orthopaedic appliances with placebo or no treatment, in children 15 years old or younger.

PRIMARY OUTCOME

reduction of apnoea to less than one episode per hour.

SECONDARY OUTCOMES

dental and skeletal relationship, sleep parameters improvement, cognitive and phonoaudiological function, behavioural problems, quality of life, side effects (tolerability) and economic evaluation.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies and extracted data independently. Authors were contacted for additional information. We calculated risk ratios with 95% confidence intervals for all important dichotomous outcomes. We assessed the quality of the evidence of included studies using GRADEpro software.

MAIN RESULTS

The initial search identified 686 trials. Only one trial, reporting the results from a total of 23 children and comparing an oral appliance to no treatment, was suitable for inclusion in the review. The trial assessed apnoea-hypopnoea, daytime symptoms (sleepiness, irritability, tiredness, school problems, morning headache, thirstiness in the morning, oral breathing and nasal stuffiness) and night-time symptoms (habitual snoring, restless sleep and nightmares measured by questionnaire). Results were inconsistent across outcomes measures and time points. The evidence was considered very low quality.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support or refute the effectiveness of oral appliances and functional orthopaedic appliances for the treatment of obstructive sleep apnoea in children. Oral appliances or functional orthopaedic appliances may be considered in specified cases as an auxiliary in the treatment of children who have craniofacial anomalies which are risk factors for apnoea.

Opioids for restless legs syndrome

BACKGROUND

Restless legs syndrome (RLS) is a distressing and common neurological disorder that may have a huge impact in the quality of life of those with frequent and intense symptoms. Patients complain of unpleasant sensations in the legs, at or before bedtime, and feel an urge to move the legs, which improves with movement, such as walking. Symptoms start with the patient at rest (e.g. sitting or lying down), and follow a circadian pattern, increasing during the evening or at night. Many pharmacological intervention are available for RLS, including drugs used to treat Parkinson's disease (L-Dopa and dopaminergic agonists), epilepsy (anticonvulsants), anxiety (benzodiazepines), and pain (opioids). Dopaminergic drugs are those most frequently used for treatment of RLS, but some patients do not respond effectively and require other medication. Opioids, a class of medications used to treat severe pain, seem to be effective in treating RLS symptoms, and are recommended for patients with severe symptoms, because RLS and pain appear to share the same mechanism in the central nervous system. All available drugs are associated to some degree with side effects, which can impede treatment. Opioids are associated with adverse events such as constipation, tolerance, and dependence. This justifies the conduct of a systematic review to ascertain whether opioids are safe and effective for treatment of RLS.

OBJECTIVES

To asses the effects of opioids compared to placebo treatment for restless legs syndrome in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled trials, CENTRAL 2016, issue 4 and MEDLINE, EMBASE, and LILACS up to April 2016, using a search strategy adapted by Cochraneto identify randomised clinical trials. We checked the references of each study and established personal communication with other authors to identify any additional studies. We considered publications in all languages.

SELECTION CRITERIA

Randomised controlled clinical trials of opioid treatment in adults with idiopathic RLS.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened articles, independently extracted data into a standard form, and assessed for risk of bias. If necessary, they discussed discrepancies with a third researcher to resolve any doubts.

MAIN RESULTS

We included one randomised clinical trial (N = 304 randomised; 204 completed; 276 analysed) that evaluated opioids (prolonged release oxycodone/naloxone) versus placebo. After 12 weeks, RSL symptoms had improved more in the drug group than in the placebo group (using the IRLSSS: MD -7.0; 95% CI -9.69 to -4.31 and the CGI: MD -1.11; 95% CI -1.49 to -0.73). More patients in the drug group than in the placebo group were drug responders (using the IRLSSS: RR 1.82; 95% CI 1.37 to 2.42 and the CGI: RR1.92; 95% ICI 1.49 to 2.48). The proportion of remitters was greater in the drug group than in the placebo group (using the IRLSSS: RR 2.14; 95% CI 1.45 to 3.16). Quality of life scores also improved more in the drug group than in the placebo group (MD -0.73; 95% CI -1.1 to -0.36). Quality of sleep was improved more in the drug group measured by sleep adequacy (MD -0.74; 95% CI -1.15 to -0.33), and sleep quantity (MD 0.89; 95% CI 0.52 to 1.26).There was no difference between groups for daytime somnolence, trouble staying awake during the day, or naps during the day. More adverse events were reported in the drug group (RR 1.22; 95% CI 1.07 to 1.39). The major adverse events were gastrointestinal problems, fatigue, and headache.

AUTHORS' CONCLUSIONS

Opioids seem to be effective for treating RLS symptoms, but there are no definitive data regarding the important problem of safety. This conclusion is based on only one study with a high dropout rate (moderate quality evidence).

Pharmacological treatment for Kleine-Levin syndrome

BACKGROUND

This is an updated version of the original Cochrane review, published in 2009, Issue 2.Kleine-Levin syndrome (KLS) is a rare disorder that mainly affects adolescent men. It is characterised by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behaviour, such as hypersexuality, and signs of dysautonomia.In 1990, the diagnostic criteria for Kleine-Levin syndrome were modified in the International Classification of Sleep Disorders, where KLS was defined as a syndrome comprised of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behaviour. According to the International Classification of Sleepiness Disorders, 3rd version (ICSD-3), revised in 2014, the Kleine-Levin syndrome is a disorder characterized by recurrent episodes of hypersomnia that last from two days to four weeks, with at least annual recurrence, and hyperphagia (rapid consumption of a large amount of food), usually with onset in early adolescence in males but occasionally in later life and in women. A monosymptomatic form of the disorder with hypersomnia only can occur without binge eating or hypersexuality.The cause of Kleine-Levin syndrome remains unknown, and several treatment strategies have been used. Some medications have been reported to provide benefit in the treatment of patients with KLS, but because of the rarity of the condition, no long-term follow-up therapies have yet been described.

OBJECTIVES

This review aimed to evaluate:1. whether pharmacological treatment for Kleine Levin syndrome was effective and safe.2. which drug or category of drugs was effective and safe.

SEARCH METHODS

For the latest update, we searched the following sources: the Cochrane Epilepsy Group Specialized Register (7 April 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies Online CRSO (7 April 2016); MEDLINE (1946 to April 2016); LILACS (7 April 2016); ClinicalTrials.gov (7 April 2016); WHO International Clinical Trials Registry Platform ICTRP (7 April 2016); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-randomised controlled trials looking at pharmacological interventions for Kleine-Levin syndrome were eligible. We had planned to include both parallel-group and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors (MMO and CC) had planned to extract the data reported in the original articles.

MAIN RESULTS

No studies met the inclusion criteria for this systematic review.

AUTHORS' CONCLUSIONS

Therapeutic trials of pharmacological treatment for Kleine-Levin syndrome with a double-blind, placebo-controlled design are needed.

Intake of stimulant foods is associated with development of parasomnias in children

OBJECTIVE

To verify if nighttime feeding habits can influence parasomnia in children.

METHOD

Seven private and four public Elementary Schools took part in the study. A total of 595 Sleep Disturbance Scale for Children were distributed to the parents of children aged from 7 to 8 years. Data of dietary recall, starting time to school, physical activity, and nutritional status were studied.

RESULTS

Of the 226 questionnaires completed, 92 (41%) reported parasomnia. Girls had 2.3 times more the chance to parasomnia than boys. Children who consumed stimulant foods had 2.6 times more chance to have parasomnia than those of children who consumed non-stimulant foods. There were no difference between parasomnia and no-parasomnia groups in food type (p = 0.78) or timing of last meal before bedtime (p = 0.50).

CONCLUSION

Our findings suggest that intake of stimulant foods is associated with development of parasomnia in children.

Willis-Ekbom Disease or Restless Legs Syndrome?

BACKGROUND

Restless Legs Syndrome (RLS) or Willis-Ekbom Disease (WED) is highly prevalent, but patients and healthcare providers alike know little about it. Furthermore, controversy persists as to the best way of diagnosing this nosological entity.

OBJECTIVE

To verify whether the term used to refer to this disease entity (Restless Legs Syndrome or Willis-Ekbom Disease) affects the prevalence of self-diagnosed RLS/WED in a sample of newly graduated physicians.

METHODS

Newly graduated physicians were asked to self-evaluate for the presence of RLS/WED. Briefly, participants were allocated randomly across two groups. One was asked to self-assess for RLS, while the other was asked to self-assess for WED. The evaluation form given to one group asked 'Do you have Restless Legs Syndrome?' whereas the form given to participants in the other group asked 'Do you have Willis-Ekbom Disease?'. Both forms also contained the four criteria for diagnosing RLS proposed by the International Restless Legs Syndrome Study Group (IRLSSG) and instructions for self-diagnosis according to these criteria.

RESULTS

The study sample comprised 1413 newly graduated physicians. Of the 708 participants who were given the form that used the term RLS, 87 (12.28%) diagnosed themselves with the condition. Conversely, of 705 physicians given the form with the term WED, 13 (1.84%) diagnosed themselves with the condition (p <0.0001).

CONCLUSION

A greater proportion of newly graduated physicians diagnosed themselves with RLS/WED when presented with the term Restless Legs Syndrome than when presented with the term Willis-Ekbom Disease. This suggests that the term Restless Legs Syndrome may not be the most appropriate term to denote this nosological entity.

Pharmacotherapy for sleep bruxism

BACKGROUND

Sleep bruxism is an oral activity characterized by involuntary teeth grinding or clenching during sleep. Several forms of treatment have been proposed for this disorder, including behavioural, dental and pharmacological strategies.

OBJECTIVES

To evaluate the effectiveness and safety of pharmacological therapy for the treatment of sleep bruxism compared with other drugs, no treatment or placebo.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 8, 2014), MEDLINE (1966 to August 2014), EMBASE (1980 to August 2013) and LILACS (1982 to August 2014). We identified additional reports from the reference lists of retrieved reports and from reviews on treatment of sleep bruxism. We applied no language restrictions.

SELECTION CRITERIA

We selected randomized controlled trials (RCTs) or quasi-RCTs that compared drugs with other drugs, no treatment or placebo in people with sleep bruxism.

DATA COLLECTION AND ANALYSIS

Review authors carried out data extraction and quality assessment of the included trials independently and in duplicate. We discussed discrepancies until we reached consensus. We consulted a third review author in cases of persistent disagreement. We contacted authors of primary studies when necessary.

MAIN RESULTS

We identified 18 potentially relevant RCTs, but only seven met the inclusion criteria. All studies had a small number of participants, ranging from seven to 16 people per study and had a cross-over design. Three studies were of low risk of bias, while four were of uncertain risk. Amitriptyline (three studies), bromocriptine (one study), clonidine (one study), propranolol (one study), levodopa (Prolopa®) (one study) and tryptophan (one study) were compared with placebo. Studies evaluating bromocriptine, clonidine, propranolol and levodopa reported our primary outcome of indices of bruxism motor activity.Results were imprecise and consistent with benefit, no difference or harm. These were the specific findings for each of the drugs according to specific outcomes: 1. Amitriptyline versus placebo for masseteric electromyography (EMG) activity per minute: standardized mean difference (SMD) -0.28 (95% confidence interval (CI) -0.91 to 0.34; P value = 0.37), 2. bromocriptine versus placebo for bruxism episodes per hour: mean difference (MD) 0.60 (95% CI -2.93 to 4.13), bruxism bursts per hour: MD -2.00 (95% CI -53.47 to 49.47), bruxism bursts per episode: MD 0.50 (95% CI -1.85 to 2.85) or number of episodes with grinding noise: MD 2.40 (95% CI -24.00 to 28.80), 3. clonidine versus placebo for number of bruxism episodes per hour: MD -2.41 (95% CI -4.84 to 0.02), 4. propranolol versus placebo for the number of bruxism episodes per hour: MD 1.16 (95% CI -1.89 to 4.21), 5. L-tryptophan versus placebo for masseteric EMG activity per second: SMD 0.08 (95% CI -0.90 to 1.06) and 6. levodopa versus placebo for bruxism episodes per hour of sleep: MD -1.47 (95% CI -3.64 to 0.70), for bruxism bursts per episode: MD 0.06 (95% CI -2.47 to 2.59).We combined several secondary outcomes (sleep duration, masseteric EMG activity per minute and pain intensity) in a meta-analysis for comparison of amitriptyline with placebo. The results for most comparisons were uncertain because of statistical imprecision. One study reported that clonidine reduced rapid eye movement (REM) sleep stage and increased the second stage of sleep. However, results for other sleep-related outcomes with clonidine were uncertain. Adverse effects were frequent in people who took amitriptyline (5/10 had drowsiness, difficulty awakening in the morning, insomnia or xerostomia compared with 0/10 in the placebo group), as well as in people who received propranolol (7/16 had moderate-to-severe xerostomia compare with 2/16 in the placebo group). Clonidine was associated with prolonged morning hypotension in three of 16 participants. The use of preventive medication avoided any adverse effects in people treated with levodopa and bromocriptine.

AUTHORS' CONCLUSIONS

There was insufficient evidence on the effectiveness of pharmacotherapy for the treatment of sleep bruxism. This systematic review points to the need for more, well-designed, RCTs with larger sample sizes and adequate methods of allocation, outcome assessment and duration of follow-up. Ideally, parallel RCTs should be used in future studies to avoid the bias associated with cross-over studies. There is a need to standardize the outcomes of RCTs on treatments for sleep bruxism.

Orthodontic and orthopaedic treatment for anterior open bite in children

BACKGROUND

Anterior open bite occurs when there is a lack of vertical overlap of the upper and lower incisors. The aetiology is multifactorial including: oral habits, unfavourable growth patterns, enlarged lymphatic tissue with mouth breathing. Several treatments have been proposed to correct this malocclusion, but interventions are not supported by strong scientific evidence.

OBJECTIVES

The aim of this systematic review was to evaluate orthodontic and orthopaedic treatments to correct anterior open bite in children.

SEARCH METHODS

The following databases were searched: the Cochrane Oral Health Group's Trials Register (to 14 February 2014); the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library 2014, Issue 1); MEDLINE via OVID (1946 to 14 February 2014); EMBASE via OVID (1980 to 14 February 2014); LILACS via BIREME Virtual Health Library (1982 to 14 February 2014); BBO via BIREME Virtual Health Library (1980 to 14 February 2014); and SciELO (1997 to 14 February 2014). We searched for ongoing trials via ClinicalTrials.gov (to 14 February 2014). Chinese journals were handsearched and the bibliographies of papers were retrieved.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of orthodontic or orthopaedic treatments or both to correct anterior open bite in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of all reports identified. Risk ratios (RRs) and corresponding 95% confidence intervals (CIs) were calculated for dichotomous data. The continuous data were expressed as described by the author.

MAIN RESULTS

Three randomised controlled trials were included comparing: effects of Frankel's function regulator-4 (FR-4) with lip-seal training versus no treatment; repelling-magnet splints versus bite-blocks; and palatal crib associated with high-pull chincup versus no treatment.The study comparing repelling-magnet splints versus bite-blocks could not be analysed because the authors interrupted the treatment earlier than planned due to side effects in four of ten patients.FR-4 associated with lip-seal training (RR = 0.02 (95% CI 0.00 to 0.38)) and removable palatal crib associated with high-pull chincup (RR = 0.23 (95% CI 0.11 to 0.48)) were able to correct anterior open bite.No study described: randomisation process, sample size calculation, there was not blinding in the cephalometric analysis and the two studies evaluated two interventions at the same time. These results should be therefore viewed with caution.

AUTHORS' CONCLUSIONS

There is weak evidence that the interventions FR-4 with lip-seal training and palatal crib associated with high-pull chincup are able to correct anterior open bite. Given that the trials included have potential bias, these results must be viewed with caution. Recommendations for clinical practice cannot be made based only on the results of these trials. More randomised controlled trials are needed to elucidate the interventions for treating anterior open bite.

Pharmacological treatment for Kleine-Levin syndrome

BACKGROUND

This is an updated version of the original Cochrane review, published in Issue 2, 2009.Kleine-Levin syndrome (KLS) is a rare disorder that mainly affects adolescent men. It is characterised by recurrent episodes of hypersomnia, usually accompanied by hyperphagia, cognitive and mood disturbances, abnormal behavior such as hypersexuality and signs of dysautonomia.In 1990 the diagnostic criteria for Kleine-Levin syndrome were modified in the International Classification of Sleep Disorders, where KLS was defined as a syndrome composed of recurring episodes of undue sleepiness lasting some days, which may or may not be associated with hyperphagia and abnormal behavior.The cause of Kleine-Levin syndrome remains unknown, and several treatment strategies have been used. Some medications have been reported to provide benefit in the treatment of patients with KLS, but because of the rarity of the condition, no long-term follow-up therapies have yet been described.

OBJECTIVES

This review aimed to evaluate:1. whether pharmacological treatment for Kleine Levin syndrome is effective and safe.2. which drug or category of drugs is effective and safe.

SEARCH METHODS

We obtained relevant trials from the following sources: the Cochrane Epilepsy Group Specialized Register (2 May 2013); the Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, The Cochrane Library, April 2013); MEDLINE (1946 to 2 May 2013); SCOPUS (2 May 2013); LILACS (2 May 2013); ClinicalTrials.gov (2 May 2013); WHO International Clinical Trials Registry Platform ICTRP (2 May 2013); reference lists of sleep medicine textbooks; review articles and reference lists of articles identified by the search strategies.

SELECTION CRITERIA

All randomised controlled trials (RCTs) and quasi-randomised controlled trials looking at pharmacological interventions for Kleine-Levin syndrome were selected. We included both parallel-group and cross-over studies.

DATA COLLECTION AND ANALYSIS

Two review authors (MMO and CC) extracted the data reported in the original articles.

MAIN RESULTS

No studies met the inclusion criteria for this systematic review.

AUTHORS' CONCLUSIONS

Therapeutic trials of pharmacological treatment for Kleine-Levin syndrome with a double-blind, placebo-controlled design are needed.

Treatments for adults with prominent lower front teeth

BACKGROUND

Prominent lower front teeth may be associated with a large or prognathic lower jaw (mandible) or a small or retrusive upper jaw (maxilla). Edward Angle, who may be considered the father of modern orthodontics, classified the malocclusion in this situation as Class III. The individual is described as having a negative or reverse overjet as the lower front teeth are more prominent than the upper front teeth.

OBJECTIVES

The purpose of this systematic review was to evaluate different treatments of Angle Class III malocclusion in adults.

SEARCH METHODS

The following databases were searched: Cochrane Oral Health Group Trials Register (to 22 March 2012); CENTRAL (The Cochrane Library 2012, Issue 1); MEDLINE via OVID (1950 to 22 March 2012); EMBASE via OVID (1980 to 22 March 2012); LILACs (1982 to 22 March 2012); BBO (1986 to 22 March 2012); and SciELO (1997 to 22 March 2012).

SELECTION CRITERIA

All randomized or quasi-randomized controlled trials of treatments for adults with an Angle Class III malocclusion were included.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the eligibility of the identified reports. Two review authors independently extracted data and assessed the risk of bias in the included studies. The mean differences with 95% confidence intervals were calculated for continuous data.

MAIN RESULTS

Two randomized controlled trials were included in this review. There are different types of surgery for this type of malocclusion but only trials of mandible reduction surgery were identified. One trial compared intraoral vertical ramus osteotomy (IVRO) with sagittal split ramus osteotomy (SSRO) and the other trial compared vertical ramus osteotomy (VRO) with and without osteosynthesis. Neither trial found any difference between the two treatments. The trials did not provide adequate data for assessing effectiveness of the techniques described.

AUTHORS' CONCLUSIONS

There is insufficient evidence from the two included trials, to conclude that one procedure is better or worse than another. The included trials compared different interventions and were at high risk of bias and therefore no implications for practice can be given. Further high quality randomized controlled trials with long term follow-up are required.

Physical therapy for Bell's palsy (idiopathic facial paralysis)

BACKGROUND

Bell's palsy (idiopathic facial paralysis) is commonly treated by various physical therapy strategies and devices, but there are many questions about their efficacy.

OBJECTIVES

To evaluate physical therapies for Bell's palsy (idiopathic facial palsy).

SEARCH METHODS

We searched the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2011), MEDLINE (January 1966 to February 2011), EMBASE (January 1946 to February 2011), LILACS (January 1982 to February 2011), PEDro (from 1929 to February 2011), and CINAHL (January 1982 to February 2011). We included searches in clinical trials register databases until February 2011.

SELECTION CRITERIA

We selected randomised or quasi-randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently scrutinised titles and abstracts identified from the search results. Two authors independently carried out risk of bias assessments, which , took into account secure methods of randomisation, allocation concealment, observer blinding, patient blinding, incomplete outcome data, selective outcome reporting and other bias. Two authors independently extracted data using a specially constructed data extraction form. We undertook separate subgroup analyses of participants with more and less severe disability.

MAIN RESULTS

For this update to the original review, the search identified 65 potentially relevant articles. Twelve studies met the inclusion criteria (872 participants). Four trials studied the efficacy of electrical stimulation (313 participants), three trials studied exercises (199 participants), and five studies compared or combined some form of physical therapy with acupuncture (360 participants). For most outcomes we were unable to perform meta-analysis because the interventions and outcomes were not comparable.For the primary outcome of incomplete recovery after six months, electrostimulation produced no benefit over placebo (moderate quality evidence from one study with 86 participants). Low quality comparisons of electrostimulation with prednisolone (an active treatment)(149 participants), or the addition of electrostimulation to hot packs, massage and facial exercises (22 participants), reported no significant differences. Similarly a meta-analysis from two studies, one of three months and the other of six months duration, (142 participants) found no statistically significant difference in synkinesis, a complication of Bell's palsy, between participants receiving electrostimulation and controls. A single low quality study (56 participants), which reported at three months, found worse functional recovery with electrostimulation (mean difference (MD) 12.00 points (scale of 0 to 100) 95% confidence interval (CI) 1.26 to 22.74).Two trials of facial exercises, both at high risk of bias, found no difference in incomplete recovery at six months when exercises were compared to waiting list controls or conventional therapy. There is evidence from a single small study (34 participants) of moderate quality that exercises are beneficial on measures of facial disability to people with chronic facial palsy when compared with controls (MD 20.40 points (scale of 0 to 100), 95% CI 8.76 to 32.04) and from another single low quality study with 145 people with acute cases treated for three months where significantly fewer participants developed facial motor synkinesis after exercise (risk ratio 0.24, 95% CI 0.08 to 0.69). The same study showed statistically significant reduction in time for complete recovery, mainly in more severe cases (47 participants, MD -2.10 weeks, 95% CI -3.15 to -1.05) but this was not a prespecified outcome in this meta analysis.Acupuncture studies did not provide useful data as all were short and at high risk of bias. None of the studies included adverse events as an outcome.

AUTHORS' CONCLUSIONS

There is no high quality evidence to support significant benefit or harm from any physical therapy for idiopathic facial paralysis. There is low quality evidence that tailored facial exercises can help to improve facial function, mainly for people with moderate paralysis and chronic cases. There is low quality evidence that facial exercise reduces sequelae in acute cases. The suggested effects of tailored facial exercises need to be confirmed with good quality randomised controlled trials.

Cooling for cerebral protection during brain surgery

BACKGROUND

The brain is at risk of ischaemia during a variety of neurosurgical procedures, and this can lead to devastating results. Induced hypothermia is the controlled lowering of core body temperature for therapeutic purposes. This remains the current practice during neurosurgery for the prevention or minimization of ischaemic brain injury. Brain surgery may lead to severe complications due to factors such as requirement for brain retraction, vessel occlusion, and intraoperative haemorrhage. Many anaesthesiologists believe that induced hypothermia is indicated to protect the central nervous system during surgery. Although hypothermia is often used during brain surgery, clinical efficacy has not yet been established.

OBJECTIVES

To evaluate the effectiveness and safety of induced hypothermia versus normothermia for neuroprotection in patients undergoing brain surgery.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 10), MEDLINE, LILACS, EMBASE and Current Controlled Trials (from inception to November 2010), reference lists of identified trials, and bibliographies of published reviews. We also contacted researchers in the field. There were no language restrictions.

SELECTION CRITERIA

We included randomized controlled trials and quasi-randomized controlled trials of induced hypothermia versus normothermia for neuroprotection in patients undergoing brain surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included four trials of cooling for cerebral protection during brain surgery, involving a total of 1219 patients. We did not find any evidence that hypothermia for neuroprotection in patients undergoing brain surgery is either effective or unsafe when compared to normothermia.

AUTHORS' CONCLUSIONS

Although there is some evidence that mild hypothermia is safe, its effectiveness is not clear when compared with normothermia. We need to perform more clinical trials in order to establish the benefit, if any, of hypothermia for cerebral protection during brain surgery before making firm recommendations for the routine use of this intervention.

Translation and validation into the Brazilian Portuguese of the restless legs syndrome rating scale of the International Restless Legs Syndrome Study Group

BACKGROUND: Restless legs syndrome (RLS) is a chronic sensory-motor disorder characterized by unpleasant limb sensations and an irresistible urge to move. The International Restless Legs Syndrome Study Group developed the Restless Legs Syndrome Rating Scale (IRLS) to assess the severity of RLS symptoms. The objective of this study was to translate and validate the IRLS into Brazilian Portuguese. METHOD: The IRLS was translated into Brazilian Portuguese, analyzed, back translated to English, and compared to the original version. It was applied to 10 patients for cultural verification. The language was adjusted and the final version was administered to 30 patients (13 male, mean age 58.88±14.82). RESULTS: There was correlation among the IRLS evaluation of three experts. Many linguistic adaptations were required to achieve cultural adequacy and the Cronbach's alpha coefficient showed reliability of 80%. CONCLUSION: IRLS was translated, adapted, and validated to Brazilian Portuguese language, showing good reliability and validity.

Sleep disturbance scale for children: translation, cultural adaptation, and validation

INTRODUCTION

The Sleep Disturbance Scale for Children (SDSC) is a 26-item instrument for evaluating sleep among children aged 3-18 years. It differentiates among conditions such as disorders of initiating and maintaining sleep, sleep breathing disorders, disorders of arousal, sleep-wake transition disorders, excessive somnolence, and sleep hyperhydrosis. The aim of this study was to translate, culturally adapt, and validate it for Brazilian Portuguese.

METHOD

The study was carried out in two phases: (1) forward translation, back translation, pretesting, and calculation of sample size; (2) validation: reliability (Chronbach's alpha), convergent analysis (Pearson correlation), and discriminatory validity (comparing the scores of the test with the results of polysomnography). One hundred children, aged 3-18 years, accompanied by their parents and/or guardians participated in the phases. PSG studies have been done to calculate the sample size and validation.

RESULTS

The scale instructions and items were adapted regarding semantic, experiential, conceptual, and cultural equivalence validation. The scale structure related to visual communication was also adapted to Brazilian population preference and habits, and this resulted in a chart with clear instructions and easy recognition of the statements and possible responses. Reliability analysis showed values greater than 0.55. There has been reasonable convergent validity. Discriminatory validity using the PSG study for positive sleep-disordered breathing (SDB) was 8.9, attesting discriminatory validity only for SDB. The three questions of the scale can screen SDB.

CONCLUSION

The SDSC was translated, adapted and validated for Brazilian Portuguese, and it presented internal consistency and convergent and discriminatory validity. It can be used in population-based studies in order to screen for sleep-disordered breathing in children.

Physical therapy for Bell s palsy (idiopathic facial paralysis)

BACKGROUND

Bell's palsy (idiopathic facial paralysis) is commonly treated by physical therapy services with various therapeutic strategies and devices. There are many questions about their efficacy and effectiveness.

OBJECTIVES

To evaluate the efficacy of physical therapies on the outcome of Bell's palsy.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (February 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2007), MEDLINE (January 1966 to February 2008), EMBASE (January 1980 to February 2008), LILACS (January 1982 to February 2008), PEDro (from 1929 to February 2008), and CINAHL (January 1982 to February 2008).

SELECTION CRITERIA

We selected randomised or quasi-randomised controlled trials involving any physical therapy. We included participants of any age with a diagnosis of Bell's palsy and all degrees of severity. The outcome measures were: incomplete recovery six months after randomisation, motor synkinesis, crocodile tears or facial spasm six months after onset, incomplete recovery after one year and adverse effects attributable to the intervention.

DATA COLLECTION AND ANALYSIS

Titles and abstracts identified from the register were scrutinized. The assessment of methodological quality took into account secure method of randomisation, allocation concealment, observer blinding, patient blinding, differences at baseline of the experimental groups, and completeness of follow-up. Data were extracted using a specially constructed data extraction form. Separate subgroup analyses of participants with more and less severe disability were undertaken.

MAIN RESULTS

The search identified 45 potentially relevant articles. Six studies met the inclusion criteria. Three trials studied the efficacy of electrostimulation (294 participants) and three exercises (253 participants). Neither treatment produced significantly more improvement than the control treatment or no treatment. There was limited evidence that improvement began earlier in the exercise group.

AUTHORS' CONCLUSIONS

There is no evidence of significant benefit or harm from any physical therapy for idiopathic facial paralysis. The possibility that facial exercise reduces time to recover and sequelae needs confirming with good quality randomised controlled trials.

Occlusal splints for treating sleep bruxism (tooth grinding)

BACKGROUND

Sleep bruxism is an oral activity characterised by teeth grinding or clenching during sleep. Several treatments for sleep bruxism have been proposed such as pharmacological, psychological, and dental.

OBJECTIVES

To evaluate the effectiveness of occlusal splints for the treatment of sleep bruxism with alternative interventions, placebo or no treatment.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (to May 2007); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1); MEDLINE (1966 to May 2007); EMBASE (1980 to May 2007); LILACS (1982 to May 2007); Biblioteca Brasileira de Odontologia (1982 to May 2007); Dissertation, Theses and Abstracts (1981 to May 2007); and handsearched abstracts of particular importance to this review. Additional reports were identified from the reference lists of retrieved reports and from article reviews about treating sleep bruxism. There were no language restrictions.

SELECTION CRITERIA

We selected randomised or quasi-randomised controlled trials (RCTs), in which splint therapy was compared concurrently to no treatment, other occlusal appliances, or any other intervention in participants with sleep bruxism.

DATA COLLECTION AND ANALYSIS

Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction. Discrepancies were discussed and a third review author consulted. The author of the primary study was contacted when necessary.

MAIN RESULTS

Thirty-two potentially relevant RCTs were identified. Twenty-four trials were excluded. Five RCTs were included. Occlusal splint was compared to: palatal splint, mandibular advancement device, transcutaneous electric nerve stimulation, and no treatment. There was just one common outcome (arousal index) which was combined in a meta-analysis. No statistically significant differences between the occlusal splint and control groups were found in the meta-analyses.

AUTHORS' CONCLUSIONS

There is not sufficient evidence to state that the occlusal splint is effective for treating sleep bruxism. Indication of its use is questionable with regard to sleep outcomes, but it may be that there is some benefit with regard to tooth wear. This systematic review suggests the need for further investigation in more controlled RCTs that pay attention to method of allocation, outcome assessment, large sample size, and sufficient duration of follow up. The study design must be parallel, in order to eliminate the bias provided by studies of cross-over type. A standardisation of the outcomes of the treatment of sleep bruxism should be established in the RCTs.

Mannitol for acute stroke

BACKGROUND

Mannitol is an osmotic agent and a free radical scavenger which might decrease oedema and tissue damage in stroke.

OBJECTIVES

To test whether treatment with mannitol reduces short and long-term case fatality and dependency after acute ischaemic stroke or intracerebral haemorrhage (ICH).

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (searched December 2006), MEDLINE (1966 to January 2007), the Chinese Stroke Trials Register (searched November 2006), the China Biological Medicine Database (searched December 2006) and the Latin-American database LILACS (1982 to December 2006). We also searched the database of Masters and PhD degree theses at Sao Paulo University (searched January 2007), and neurology and neurosurgery conference proceedings in Brazil from 1965 to 2006. In an effort to identify further published, ongoing and unpublished studies we searched reference lists and contacted authors of published trials.

SELECTION CRITERIA

We included randomised controlled trials comparing mannitol with placebo or open control in patients with acute ischaemic stroke or non-traumatic intracerebral haemorrhage.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed quality, extracted data, and performed the data analysis.

MAIN RESULTS

Three small trials, involving 226 participants, were included. One trial included patients with presumed ischaemic stroke without computerised tomography (CT) verification, and the other two trials included patients with CT-verified ICH. Data on the primary outcome measure (death and dependency) were not available in any of the trials. Death and disability could be calculated in the larger ICH trial without differences between the mannitol and control groups. Case fatality was not reported in the trial of ischaemic stroke. Case fatality did not differ between the mannitol and control groups in the ICH trials. Adverse events were either not found or not reported. The change in clinical condition was reported in two trials, and the proportion of those with worsening or not improving condition did not differ significantly between mannitol-treated patients and controls. Based on these three trials neither beneficial nor harmful effects of mannitol could be proved. Although no statistically significant differences were found between the mannitol-treated and control groups, the confidence intervals for the treatment effect estimates were wide and included both clinically significant benefits and clinically significant harms as possibilities.

AUTHORS' CONCLUSIONS

There is currently not enough evidence to support the routine use of mannitol in acute stroke patients. Further trials are needed to confirm or refute whether mannitol is beneficial in acute stroke.

Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children

BACKGROUND

Apnoea is a breathing disorder marked by the absence of airflow at the nose or mouth. In children, risk factors include adenotonsillar hypertrophy, obesity, neuromuscular disorders and craniofacial anomalies. The most common treatment for obstructive sleep apnoea syndrome (OSAS) in childhood is adenotonsillectomy. This approach is limited by its surgical risks, mostly in children with comorbities and, in some patients, by recurrence that can be associated with craniofacial problems. Oral appliances and functional orthopaedic appliances have been used for patients who have OSAS and craniofacial anomalies because they change the mandible posture forwards and potentially enlarge the upper airway and increase the upper airspace, improving the respiratory function.

OBJECTIVES

To assess the effectiveness of oral appliances or functional orthopaedic appliances for OSAS in children.

SEARCH STRATEGY

A sensitive search was developed for the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 3); PubMed (January 1966 to September 2005); EMBASE (1980 to September 2005); Lilacs (1982 to September 2005); BBO-Bibliografia Brasileira de Odontologia (1986 to September 2005); and SciELO (1997 to September 2005). There was no restriction of language or source of information.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials comparing all types of oral and functional orthopaedic appliances with placebo or no treatment, in children 15 years old or younger.

PRIMARY OUTCOME

reduction of apnoea to less than one episode per hour.

SECONDARY OUTCOMES

dental and skeletal relationship, sleep parameters improvement, cognitive and phonoaudiologic function, behavioural problems, drop outs and withdrawals, quality of life, side effects (tolerability), economic evaluation.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two review authors. Authors were contacted for additional information. Risk ratios with 95% confidence intervals were calculated for all important dichotomous outcomes.

MAIN RESULTS

The initial search identified 384 trials. One of them, reporting results from a total of 23 patients, was suitable for inclusion in the review. Data provided in the published report did not answer all the questions from this review, but some of them were, and the presented results favour treatment.

AUTHORS' CONCLUSIONS

At present there is no sufficient evidence to state that oral appliances or functional orthopaedic appliances are effective in the treatment of OSAS in children. Oral appliances or functional orthopaedic appliances may be helpful in the treatment of children with craniofacial anomalies which are risk factors for apnoea.

Orthodontic and orthopaedic treatment for anterior open bite in children

BACKGROUND

Anterior open bite occurs when there is a lack of vertical overlap of the upper and lower incisors. The aetiology is multifactorial including: oral habits, unfavourable growth patterns, enlarged lymphatic tissue with mouth breathing. Several treatments have been proposed to correct this malocclusion, but interventions are not supported by strong scientific evidence.

OBJECTIVES

The aim of this systematic review was to evaluate orthodontic and orthopaedic treatments to correct anterior open bite in children.

SEARCH STRATEGY

Search strategies were developed for MEDLINE and revised appropriately for the following databases: Cochrane Oral Health Group Trials Register; CENTRAL (The Cochrane Library 2005, Issue 4); PubMed (1966 to December 2005); EMBASE (1980 to February 2006); Lilacs (1982 to December 2005); Brazilian Bibliography of Odontology (BBO) (1986 to December 2005); and SciELO (1997 to December 2005). Chinese journals were handsearched and the bibliographies of papers were retrieved.

SELECTION CRITERIA

All randomised or quasi-randomised controlled trials of orthodontic or orthopaedic treatments or both to correct anterior open bite in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of all reports identified. Risk ratios (RRs) and corresponding 95% confidence intervals (CIs) were calculated for dichotomous data. The continuous data were expressed as described by the author.

MAIN RESULTS

Twenty-eight trials were potentially eligible, but only three randomised controlled trials were included comparing: effects of Frankel's function regulator-4 (FR-4) with lip-seal training versus no treatment; repelling-magnet splints versus bite-blocks; and palatal crib associated with high-pull chincup versus no treatment. The study comparing repelling-magnet splints versus bite-blocks could not be analysed because the authors interrupted the treatment earlier than planned due to side effects in four of ten patients.FR-4 associated with lip-seal training (RR = 0.02 (95% CI 0.00 to 0.38)) and removable palatal crib associated with high-pull chincup (RR = 0.23 (95% CI 0.11 to 0.48)) were able to correct anterior open bite.No study described: randomisation process, sample size calculation, there was not blinding in the cephalometric analysis and the two studies evaluated two interventions at the same time. These results should be therefore viewed with caution.

AUTHORS' CONCLUSIONS

:There is weak evidence that the interventions FR-4 with lip-seal training and palatal crib associated with high-pull chincup are able to correct anterior open bite. Given that the trials included have potential bias, these results must be viewed with caution. Recommendations for clinical practice cannot be made based only on the results of these trials. More randomised controlled trials are needed to elucidate the interventions for treating anterior open bite.

Andersen syndrome: an association of periodic paralysis, cardiac arrhythmia and dysmorphic abnormalities

Andersen syndrome (AS) is a rare disease characterized by the presence of periodic paralysis (PP), cardiac arrhythmia and dysmorphic abnormalities. We report herein the first Brazilian patient presenting AS who also had obesity, obstructive sleep apnea (OSA) and daytime sleepiness. Clinical and genetic evaluation of six family members demonstrated that four had dysmorphic abnormalities but none had PP or cardiac arrhythmia. Sequencing of KCNJ2 revealed the R218W mutation in the index patient and her 6-year-old daughter, who presented dysmorphic abnormalities (micrognathia, clinodactyly of fourth and fifth fingers, short stature) and OSA. Three relatives had clinodactyly as the only manifestation but the R218W mutation was absent, suggesting that this characteristic may be influenced by another gene. OSA accompanied by dysmorphic features may be related to AS.

The oral glucose tolerance test is frequently abnormal in patients with uncontrolled epilepsy

PURPOSE

The clinical efficacy of the ketogenic diet as therapy for patients with difficult-to-treat epilepsy prompted us to investigate the glucose metabolism of these patients under an oral overload of glucose, that is, in the oral glucose tolerance test (OGTT).

METHODS

Thirty patients (12 males, 18 females; age range: 17-59, mean: 35.1) with difficult-to-treat epilepsy, 23 patients with controlled epilepsy (11 males, 12 females; age range: 14-66, mean: 36.9), and 39 control subjects (18 males, 21 females; age range: 16-58, mean: 33.3) were evaluated with the OGTT. For patients with epilepsy, we also measured C-peptide and glycosylated hemoglobin in the fasting state. Glucose levels lower than 70 mg/dL at any point of the curve were considered to be abnormal.

RESULTS

All subjects in the control group and the group with controlled epilepsy had a normal OGTT. In contrast, all 30 patients with difficult-to-treat epilepsy had at least one point on the OGTT curve below the normal range (P<0.001), most often 180 and 240 minutes after the oral glucose load (P<0.001). C-peptide levels were significantly lower in the group with difficult-to-treat epilepsy as compared with the group with controlled epilepsy. Fasting glycohemoglobin and insulin levels did not differ between the two patient groups.

CONCLUSIONS

We suggest that undiagnosed metabolic disturbances in patients with difficult-to-treat epilepsy may somehow contribute to their refractoriness to conventional pharmacological therapy. We propose the hypothesis that calorie-restricted diets aimed at correcting OGTT curves may prove beneficial in treating patients with difficult-to-treat epilepsy. Our hypothesis generates a clear endpoint for the diet, and its demonstration would provide new standards for diet-based antiepileptic regimens. Accordingly, our results may help in understanding the positive consequences of ketogenic or calorie-restricted diets in persons with seizures.

A functional electric orthesis on the paretic leg improves quality of life of stroke patients

CONTEXT: Hemiparesia changes quality of life of patients with stroke making difficult a normal life. OBJECTIVE: To evaluate the effect of Functional Eletric Orthesis (FEO) applied over the paretic leg in the quality of life of stroke patients. METHOD: The quality of life of 50 stroke patients of Associacao de Assistencia a Crianca Deficiente (AACD) was evaluated with SF-36 questionnaire before and after the treatment with a FEO for rehabilitation of walking. We analyzed data according to gender and affected hemisphere. RESULTS: The average values from all domains of SF-36 improved significantly (p<0.001). Female patients improved more than male in Emotional Domain (p=0.04) and presented a trend to be better regarding Bodily Pain and Social Functioning. Patients with right hemiparesia improved more than those with left hemiparesia (p=0.02). CONCLUSION: FEO over a paretic leg is efficient to improve quality of life of stroke patients, mainly Physical Functioning.

Sleep disorders are associated with impulsivity in school children aged 8 to 10 years

CONTEXT: Sleep has an important function in the physical and emotional development of children. Some studies suggest an association between impulsivity and sleep disorders. However, little is known about this association in schoolchildren aged 8 to 10 years. METHOD: We studied 1180 children, 547 with sleep disorders (SD) and 633 without SD (control group), classified with SD questionnaires. Within the SD group, 53 children with sleep-related respiratory disorders (SRRD) and 521 children with non-respiratory sleep disorders (NRSD) were analyzed. We acessed emotional indicators of impulsivity with Bender test. RESULTS: More SD children presented impulsivity than control group (p<0.05). More NRSD and 10 years old children presented impulsivity than control group of the same age (p=0.001). Impulsivity and SRRD were associated with 8 years old children (p<0.05). CONCLUSION: Children with SD, 8 years old children with SRRD, and 10 years old children with NRSD presented higher proportion of impulsivity than control children.

Sleep disorders and starting time to school impair balance in 5-year-old children

OBJECTIVE: To verify if sleep disorders and differents starting time to school have impaired motor skills in 5-year-old children. METHOD: Cross-sectional design consisting of 132 children with sleep disorders and 136 normal controls of the public school in the city of São Paulo. The group with sleep disorders was identified based on a questionnaire, and motor tests for global motor coordination, fine motor coordination, perceptual-motor coordination, and static and dynamic balance were applied in all children. RESULTS: In the static balance test, more specifically in the sharpened Romberg (Tandem) test, 34% of boys from the study group, who studied in the morning, failed the test (p < 0.05). In the single leg stance test, 62% of boys from the study group who studied in the morning failed (p< 0.05). CONCLUSION: This study suggests that sleep disorders may interact with the school period and alter motor performance, especially in boys studying in the morning.

Sleep habits and starting time to school in Brazilian children

OBJECTIVE: This study investigated the sleep habits in Brazilian children according to age, gender and starting time to school. METHOD: We investigated 2,482 scholars aged 7 to 10 years. We compared sleep habits, gender, and starting time to school (morning and afternoon). RESULTS: Sixty-one per cent of the children presented sleep rituals before sleep. Milk drinking before sleep was more frequent among seven years old children. We found a progressive reduction with age in keeping the lights on. Girls used to leave an object to bed more than boys did. Children that studied in the morning presented reduced total sleep time, sleep earlier, and nap more frequently than children that studied in the afternoon. CONCLUSION: Starting time to school deeply influences sleep habits in Brazilian children from São Paulo City, in whom bed-time rituals are highly prevalent.

Cognitive dysfunction in children with sleep-disordered breathing

Two daily school periods are mandatory in Brazil owing to a shortage of academic facilities, which can decrease cognitive performance, especially in children with sleep-disordered breathing. This study aimed to verify the influence of starting time to school on cognition, comparing children with sleep disorders and normal children. Cognition was assessed in 79 children with sleep-disordered breathing, 468 children with nonrespiratory sleep disorders, and 633 normal control children. We analyzed total sleep time, starting time to school (morning or afternoon), and grades. First grade morning students with sleep-disordered breathing had 8.04 higher odds for cognitive dysfunction than normal children. For children with sleep-disordered breathing, second and third grade morning students had higher odds for cognitive dysfunction than those who studied in the afternoon (3.69 and 4.07). Fourth grade morning students had 8.27 higher odds for cognitive dysfunction than first grade children. In conclusion, sleep-disordered breathing, grades, and starting time to school interact to affect cognition in Brazilian children.

Sleep disruption in systemic sclerosis (scleroderma) patients: clinical and polysomnographic findings

BACKGROUND

Progressive systemic sclerosis (SSc) is a connective tissue disease characterized by endothelial lesions and fibrosis of the skin and other organs. Patients' quality of life and life expectancy are determined by the intensity of pulmonary, esophageal, cardiac, and renal involvement. Neurological involvement was considered to be rare, but increasing evidence indicates that peripheral and autonomic neuropathies commonly occur. Conditions seen with SSc, such as pulmonary fibrosis and gastro-esophageal reflux, have the potential to affect sleep. No systematic assessment of sleep-related problems associated with this disorder has been performed.

MATERIAL AND METHODS

An all-night polysomnogram and a clinical interview blinded to sleep status were obtained for 27 consecutive SSc patients. Sleep data were compared to age adjusted published normative values. Correlations were determined for sleep and clinical data.

RESULTS

Patients with SSc had a reduced sleep efficiency (SE) (mean+/-SD: 82+/-12.3%) and rapid eye movement sleep (13.1+/-5.6%) and increased arousal index (26.1+/-13.0) and slow wave sleep (25.7+/-9.7%). The periodic leg movement index (PLMI) exceeded 5/h in 13 patients (48%) and 25/h in seven patients. Six patients had restless legs syndrome (RLS). Significant disordered breathing was absent. The RLS patients showed a greater arousal index than all other patients. PLMI was correlated with SE for RLS but not for non-RLS patients. Esophageal dyskinesia, dyspnea, and RLS were significantly associated with poor sleep.

CONCLUSION

Patients with SSc have significant disturbance of their sleep. Esophageal dyskinesia and dyspnea, which are common complications of SSc, were commonly associated with indices of sleep disruption. RLS but not sleep apnea appears to have an increased prevalence in SSc.

Clinical impact of transesophageal echocardiography in patients with stroke without clinical evidence of cardiovascular sources of emboli

OBJECTIVE

The purpose of this study is to evaluate the impact of transeophageal echocardiography on management of patients at low-risk for cardiogenic embolism to prevent new potential cardiovascular sources of emboli.

METHODS

We studied 69 patients with ischemic stroke at low-risk for cardiogenic embolism. Transeophageal echocardiography was performed to access: left atrium enlargement; communication or aneurysm of the interatrial septum; patent foramen ovale; spontaneous echo contrast or intracavitary thrombi; the presence of intraaortic atherosclerotic plaques or thrombi; significant valvar morphologic alteration or dysfunction; left ventricle enlargement, hypertrophy, or contractile abnormality. Transesophageal echocardiography altered clinical management, and we adopted anticoagulant therapy or another procedure apart from the use of acetylsalicylic acid.

RESULTS

Transeophageal echocardiography detected at least one abnormality in 40 cases (58%). Clinical conduct was adjusted after the performance of transesophageal echocardiography in 11 patients (15.9%); anticoagulation was added in 10 cases and surgical correction in one patient.

CONCLUSION

Transeophageal echocardiography was a very useful tool in the secondary prevention for stroke in patients at low risk for cardiogenic embolism.

Cochrane report: A systematic review of mannitol therapy for acute ischemic stroke and cerebral parenchymal hemorrhage

BACKGROUND

Mannitol was reported to decrease cerebral edema associated with tissue damage and is used to treat acute stroke in many countries.

SUMMARY OF REVIEW

We tested whether there is any evidence from unconfounded randomized clinical trials that treatment with mannitol reduces short- and long-term case fatality and dependency if administered after ischemic stroke or cerebral parenchymal hemorrhage. Trials were identified by the standard search strategy of the Cochrane Collaboration Stroke Review Group. A supplementary MEDLINE search was performed, and the Chinese Stroke Trials Register and the Latin-American databank LILACS were checked. A search was performed of master's and PhD degree theses in the databank of Sao Paulo University and in abstracts of medical congresses on neurology and neurosurgery during 1965-1997 in Brazil. Investigators were contacted for unpublished information. Only truly randomized unconfounded clinical trials were eligible for inclusion. Two of the reviewers independently extracted data from the trials. Data synthesis and analysis was performed with the use of the Cochrane Review Manager software (RevMan version 4.0.4).

CONCLUSIONS

Only 1 trial fulfilled the inclusion criteria. The number of included patients was small, and the follow-up was short. Case fatality, the proportion of dependent patients, and side effects were not reported and were not available from the investigators. As a result of lack of appropriate randomized trials, currently no conclusion can be drawn on the effects of mannitol in acute stroke. The routine use of mannitol in all patients with acute stroke is not supported by evidence from randomized controlled clinical trials.

[Cerebrospinal fluid in the diagnosis of cerebro-meningeal metastasis from malignant melanoma arising from giant congenital melanocytic nevus: case report]

We describe the case of a 28-year-old man with a giant congenital melanocytic nevus (GCMN) with malignant transformation to melanoma and metastasis on the central nervous system (CNS). We also make a summary of the pathological features from both lesions (GCMN and Melanoma), the occurrence of malignancy of GCMN, the organs more frequently involved with metastatic melanoma--with emphasis to involvement of CNS--just as the factors that cause malignant transformation of GCMN; the methods to diagnose metastases in CNS--emphasizing the importance of cerebrospinal fluid--and some therapeutical modalities for the metastatic melanoma in CNS.