Health-related quality of life effects of modafinil for treatment of narcolepsy

OBJECTIVE

To evaluate the burden of illness of narcolepsy and assess the health-related quality-of-life (HQL) effects of oral modafinil, a wake-promoting therapy for excessive daytime sleepiness associated with narcolepsy.

METHODS

Subjects with narcolepsy enrolled in a nine-week, placebo-controlled, double-blind study and were randomized to placebo, modafinil 200 mg, or modafinil 400 mg. After the study, consenting subjects received modafinil in a 40-week open-label extension. A self-administered HQL questionnaire consisting of the 36-Item Short Form Health Survey (SF-36) and supplemental narcolepsy-specific scales was given to subjects at baseline, study endpoint, and several open-label timepoints.

RESULTS

481 subjects completed a baseline and double-blind endpoint HQL assessment. Compared to population norms, baseline HQL scores reflected substantial burden in vitality, social functioning, and performing usual activities. At study endpoint, subjects in the 400 mg modafinil group had significantly higher scores than placebo for 10 of the 17 HQL scales. The 400 mg modafinil group had more energy, fewer difficulties performing usual activities, fewer interferences with social activities, improved psychological well-being and higher productivity, attention and self-esteem compared to placebo subjects (p<.05). The positive treatment effects were sustained over the open-label extension.

CONCLUSION

Modafinil significantly improves health-related quality of life in narcolepsy.

Effect of Oral JZP-110 (ADX-N05) on Wakefulness and Sleepiness in Adults with Narcolepsy: A Phase 2b Study

STUDY OBJECTIVES

To evaluate the efficacy and safety of oral JZP-110, a second-generation wake-promoting agent with dopaminergic and noradrenergic activity, for treatment of impaired wakefulness and excessive sleepiness in adults with narcolepsy.

METHODS

This was a phase 2b, randomized, double-blind, placebo-controlled, parallel-group trial conducted at 28 centers in the United States. Patients were adults with narcolepsy who had baseline scores ≥ 10 on the Epworth Sleepiness Scale (ESS) and baseline sleep latency ≤ 10 min on the Maintenance of Wakefulness Test (MWT). Patients received a daily placebo (n = 49) or JZP-110 (n = 44) 150 mg/day weeks 1-4 and 300 mg/day weeks 5-12. Primary efficacy endpoints were change from baseline in average MWT sleep latency, and the Clinical Global Impression-Change (CGI-C); secondary endpoints were change from baseline in ESS score and Patient Global Impression-Change.

RESULTS

Improvements were significantly greater with JZP-110 versus placebo on mean MWT sleep latency (4 w, 9.5 versus 1.4 min, P < 0.0001; 12 w, 12.8 versus 2.1 min, P < 0.0001), percentage of patients with CGI-C improvement (4 w, 80% versus 51%, P = 0.0066; 12 w, 86% versus 38%, P < 0.0001), and mean change in ESS (4 w, -5.6 versus -2.4, P = 0.0038; 12 w, -8.5 versus -2.5, P < 0.0001). Three JZP-110-treated patients (6.8%) discontinued due to adverse events (AEs). The most common AEs with JZP-110 versus placebo were insomnia (23% versus 8%), headache (16% versus 10%), nausea (14% versus 6%), diarrhea (11% versus 6%), decreased appetite (14% versus 0%), and anxiety (11% versus 0%).

CONCLUSIONS

At doses of 150-300 mg/day, JZP-110 was well tolerated and significantly improved the ability to stay awake and subjective symptoms of excessive sleepiness in adults with narcolepsy.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov identifier NCT01681121.

Verification of sleep apnea using a portable sleep apnea screening device

Sixty-seven patients referred to a sleep laboratory with a tentative diagnosis of obstructive sleep apnea were examined with a device designed for home use as an apnea screening system. Direct comparison was made between data obtained by the portable device and by data acquired simultaneously with standard polysomnographic techniques. The portable recorder measured nasal/oral airflow, chest wall movement, cardiac rhythm, and blood oxygen saturation. There was no significant difference in the number of disordered breathing events (apneas and hypopneas) recorded by the two systems. The portable device was found to have a sensitivity of 95% and a specificity of 96%. Indications and limitations for use of the portable home apnea screening test are reviewed and guidelines for normalcy suggested.

Effect of oral JZP-110 (ADX-N05) treatment on wakefulness and sleepiness in adults with narcolepsy

BACKGROUND

JZP-110 is a wake-promoting agent with dopaminergic and noradrenergic activity.

METHODS

This double-blind, crossover study, randomized adults with narcolepsy with or without cataplexy (N = 33) to placebo or JZP-110 at 150 mg/day (weeks 1 and 3) increased to 300 mg/day (weeks 2 and 4). Patients had to have baseline Epworth Sleepiness Scale (ESS) scores ≥10 and mean sleep latencies ≤10 min on the Maintenance of Wakefulness Test (MWT). Efficacy end points included MWT sleep latency and ESS, and the percentage of patients improved on the Clinical Global Impression of Change.

RESULTS

Patients were primarily male (57.6%) and white (69.7%), with a mean (standard deviation) age of 37.1 (12.4) years. At two weeks, the change in the mean MWT sleep latency was 11.8 min longer with JZP-110 than with placebo (P = 0.0002); JZP-110 resulted in greater changes in sleep latency on each MWT trial (P <0.001). For ESS, JZP-110 was more efficacious relative to placebo after 1 (P <0.0001) and two weeks (P = 0.0002); final ESS scores were 10.8 with JZP-110 and 15.2 with placebo, changes of -6.7 and -2.4, respectively. JZP-110 was generally well tolerated; the most common adverse events with JZP-110 were nausea (12%), noncardiac chest discomfort (9.1%), and headache (9.1%).

CONCLUSIONS

The efficacy of JZP-110 for impaired wakefulness and excessive sleepiness was observed at 150-300 mg/day and as early as one week after initiating treatment (Clinicaltrials.gov identifier NCT01485770).

NightBalance Sleep Position Treatment Device Versus Auto-Adjusting Positive Airway Pressure for Treatment of Positional Obstructive Sleep Apnea

STUDY OBJECTIVES

Compare treatment efficacy and objective adherence between the NightBalance sleep position treatment (SPT) device and auto-adjusting positive airway pressure (APAP) in patients with exclusive positional obstructive sleep apnea (ePOSA) defined as a supine apnea-hypopnea index (sAHI) ≥ 2 times the nonsupine AHI (nsAHI) and a nsAHI < 10 events/h.

METHODS

This prospective multicenter randomized crossover trial enrolled treatment naive participants with ePOSA (AHI ≥ 15 events/h and nsAHI < 10 events/h) or (AHI > 10 and < 15 events/h with daytime sleepiness and nsAH < 5 events/h). Polysomnography and objective adherence determination (device data) were performed at the end of each 6-week treatment. Patient device preference was determined at the end of the study.

RESULTS

A total of 117 participants were randomized (58 SPT first, 59 APAP first). Of these, 112 started treatment with the second device (adherence cohort) and 110 completed the study (AHI cohort). The AHI on SPT was higher (mean ± standard deviation, 7.29 ± 6.8 versus 3.71 ± 5.1 events/h, P < .001). The mean AHI difference (SPT-APAP) was 3.58 events/h with a one sided 95% confidence interval upper bound of 4.96 events/h (< the prestudy noninferiority margin of 5 events/h). The average nightly adherence (all nights) was greater on SPT (345.3 ± 111.22 versus 286.98 ± 128.9 minutes, P < .0001). Participants found the SPT to be more comfortable and easier to use and 53% reported a preference for SPT assuming both devices were equally effective.

CONCLUSIONS

Treatment with SPT resulted in non-inferior treatment efficacy and greater adherence compared to APAP in ePOSA suggesting that SPT is an effective treatment for this group.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: The POSAtive Study: Study for the Treatment of Positional Obstructive Sleep Apnea; Identifier: NCT03061071; URL: https://clinicaltrials.gov/ct2/show/NCT03061071.

Efficacy of atomoxetine plus oxybutynin in the treatment of obstructive sleep apnea with moderate pharyngeal collapsibility

Purpose

Preliminary studies have shown a significant decrease in severity of obstructive sleep apnea (OSA) with the use of a combination of atomoxetine and oxybutynin, with patients having moderate pharyngeal collapsibility during sleep more likely to respond. This study evaluated the efficacy and safety of AD036 (atomoxetine 80 mg and oxybutynin 5 mg) in the treatment of OSA.

Methods

This trial was a phase 2, randomized, placebo-controlled crossover study comparing AD036, atomoxetine 80 mg alone, and placebo during three home sleep studies, each separated by about 1 week. The trial included patients with OSA and moderate pharyngeal collapsibility as defined by a higher proportion of hypopneas to apneas and mild oxygen desaturation.

Results

Of 62 patients who were randomized, 60 were included in efficacy analyses. The apnea–hypopnea index (AHI) from a median (interquartile range) of 14.2 (5.4 to 22.3) events/h on placebo to 6.2 (2.8 to 13.6) with AD036 and 4.8 (1.4 to 11.6) with atomoxetine alone (p < .0001). Both drugs also decreased the oxygen desaturation index (ODI) and the hypoxic burden (p < .0001). AD036, but not atomoxetine alone, reduced the respiratory arousal index and improved ventilation at the respiratory arousal threshold (greater V_active). There was a trend for total sleep time to be decreased more with atomoxetine alone than with AD036. The most common adverse event was insomnia (12% with AD036, 18% with atomoxetine).

Conclusion

AD036 significantly improved OSA severity in patients with moderate pharyngeal collapsibility. Atomoxetine may account for the majority of improvement in OSA severity, while the addition of oxybutynin may mitigate the disruptive effect of atomoxetine on sleep and further improve ventilation.

Trial registration

Clinical trial registered with www.clinicaltrials.gov (NCT04445688).

Sleep Apnea and Sports Performance

Obstructive sleep apnea is a significant medical disorder that is increasingly recognized for its wide-ranging effects on physical and mental health. It can have a profound negative impact on sleep quality, daytime alertness, mood, and cardiovascular health, and effects on metabolic and endocrinologic parameters. There is little known about the prevalence and presentation of apnea in athletes and its potential effect on athletic performance. A high index of suspicion for apnea should exist, particularly in those who have anatomic features and symptoms consistent with the disorder. This article reviews pathophysiology, diagnostic modalities, and treatment interventions.

Electroencephalographic abnormalities in monozygotic twins with Tourette's syndrome

The association of attentional, neuropsychological, and behavioural abnormalities with Tourette's syndrome (TS) suggests that the abnormal function of the disorder extends beyond the motor circuits of the basal ganglia. To explore this possibility we studied, with conventional 18-channel electroencephalography, monozygotic twins ranging from 8 to 26 years of age, where at least one member of the twin pair suffered from TS. In nine out of the 11 twin pairs that differed in clinical severity of the tic disorder, the twin with the more severe course of illness had a significantly more abnormal electroencephalogram (EEG) by qualitative visual analysis. Most of the differences were due to excessive frontocentral theta activity, suggesting dysfunction outside the basal ganglia. There was also a significant relationship between a lower global neuropsychological testing score and a worse overall EEG. In eight of nine twin sets with different global neuropsychological testing scores, the twin with the lower score had a worse EEG. A similar relationship was found between birth weight and overall EEG quality. In the nine sets that differed in birth weight, the twin with a lower birth weight had a worse EEG in seven of the sets. The EEG findings are unlikely to be unlikely to be a medication effect because the same result was seen in the six twin pairs who had been medication-free for at least six months before entry into the study. The origin of this slowing may relate to the interaction between environmental insults to the central nervous system and the genetic component of TS, an interaction producing damage to the cortex, thalamus, or both.

Absence of the septum pellucidum. Overlapping clinical syndromes

A patient with absence of the septum pellucidum, optic hypoplasia, congenital nystagmus, hemiatrophy, and seizures fulfilled clinical and radiological criteria for diagnosis of both septo-optic dysplasia and the syndrome of absent septum pellucidum with porencephalies. The anatomical and clinical similarities between these two syndromes suggest a common embryological basis. Their simultaneous presence in this case further supports this explanation. Clinically mild forms of both septo-optic dysplasia and the syndrome of absent septum pellucidum with porencephalies are now detected with the aid of computed tomographic scanning in patients with unexplained hemiatrophy, congenital nystagmus, seizures, and short stature.

Candida albicans meningitis in a parenteral drug abuser

We have described a patient with meningitis due to Candida albicans, in whom the only identifiable risk factor was a history of intravenous amphetamine abuse. Despite intravenous therapy with 2 gm of amphotericin B and concurrent 5-fluorocytosine, symptoms, CSF pleocytosis, and hypoglycorrhachia persisted. After a brief course of intrathecal amphotericin B therapy, the patient improved clinically and the CSF returned to normal.

Noninvasive assessment of impotence

The examinations described provide quantitative data on hemodynamics of the erectile process. Comprehensive study cannot be totally noninvasive because it does require measurements of intracavernous pressure. Patients selected for invasive study should exhibit normal neurologic function. These tests generally do not display anatomy underlying the physiologic disorder, although ultrasound has great promise in this regard. Angiography is needed for rational planning of operative procedures. Angiographic examination that includes arteriography of large and small arteries and delineation of cavernosal venous drainage or cavernosography defines both the location and the nature of defects causing erectile failure. It is our belief that both noninvasive and invasive tests (physiologic measurements to assess penile blood flow and cavernosal competence and comprehensive angiography using artificial erection) must be obtained prior to operation.

Metastatic disease of the spine: diagnosis and management

This paper reviews the pathophysiology, clinical presentation, work-up, and management of epidural spinal cord compression by metastatic tumor. Included are descriptions detailing clinical syndromes of cervical, thoracic, cauda equina, and conus medullaris compressions. Indications for plain x-ray films, myelography, and CT scanning as well as a discussion of radiation, steroid, and surgical therapy are presented.

Truncal seizures: an unusual presentation of cerebral cysticercosis

We present the case of a 24-year-old woman who developed repetitive partial simple seizures confined to her right rib cage. Computed tomography scan of the head was consistent with the diagnosis of cerebral cysticercosis. The patient was started on a regimen of anticonvulsants, steroids, and praziquantel with full resolution of symptoms.

An unusual case of proctalgia

We report the case of a 21-year-old man with the sudden onset of severe proctalgia followed by headaches and fever. The patient had a lumbar puncture consistent with subarachnoid hemorrhage. After a normal four-vessel cerebral arteriogram, a myelogram and computed tomography scan of the spine were performed and revealed a mass lesion of the L1 level. Pathologic evaluation after resection of the mass resulted in a diagnosis of hemorrhage from a myxopapillary ependymoma. These relatively benign tumors of the cauda equina-filum terminale respond well to treatment. The differential diagnosis of proctalgia is reviewed, and the need for emergency physicians to consider spinal subarachnoid hemorrhage when a patient presents with the acute onset of rectal pain is emphasized.

Sleep Dysfunction and Gastrointestinal Diseases

Sleep deprivation and impaired sleep quality have been associated with poor health outcomes. Many patients experience sleep disturbances, which can increase the risk of medical conditions such as hypertension, obesity, stroke, and heart disease as well as increase overall mortality. Recent studies have suggested that there is a strong association between sleep disturbances and gastrointestinal diseases. Proinflammatory cytokines, such as tumor necrosis factor, interleukin-1, and interleukin-6, have been associated with sleep dysfunction. Alterations in these cytokines have been seen in certain gastrointestinal diseases, such as gastroesophageal reflux disease, inflammatory bowel disease, liver disorders, and colorectal cancer. It is important for gastroenterologists to be aware of the relationship between sleep disorders and gastrointestinal illnesses to ensure good care for patients. This article reviews the current research on the interplay between sleep disorders, immune function, and gastrointestinal diseases.

Corrigendum: Case report: A patient with Delayed Sleep-Wake Phase Disorder and Optic Nerve Hypoplasia treated with tasimelteon: a case study

[This corrects the article DOI: 10.3389/fnins.2023.1287514.].

Case report: A patient with Delayed Sleep-Wake Phase Disorder and Optic Nerve Hypoplasia treated with tasimelteon: a case study

We present a case of an adult female diagnosed with Delayed Sleep-Wake Phase Disorder (DSWPD) and Optic Nerve Hypoplasia (ONH), with a confirmed delayed Dim Light Melatonin Onset (DLMO), who reports the inability to fall asleep at their desired bedtime and obtain adequate sleep nightly, despite the ability to have a full night's sleep when not required to be up at a specific time for societal requirements. The participant was enrolled in an 11-month Open-Label Extension (OLE) following the randomized portion of a clinical study and was successfully treated with tasimelteon. DSWPD symptoms were resolved, and their previously delayed sleep-wake cycle was advanced.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT04652882, identifier NCT04652882.

A screening sequence for vasculogenic impotence

Delineation of neural, arterial, and venous components contributing to penile erectile failure is critical to proper patient selection for surgical interventions, particularly for a subset of men with impotence as the sole manifestation of pelvic arterial disease. In addition to obtaining a history and physical examination specific for disordered erectile function and vascular risk factors, we developed a sequence of testing to include noninvasive estimates of penile perfusion, pulse volume recording (PVR), and penile/brachial blood pressure indices (PBPI); somatosensory evoked potentials from dorsal penile (PEP) and posterior tibial nerve stimulation (SEP) and bulbocavernosus reflex time (BCR); stimulation of artificial erection with injection of papaverine (AE); and selective hypogastric-pudendal arteriography with patients under epidural anesthesia, and corpus cavernosography with AE. Three hundred fifty-three men complaining of impotence were screened by PVR and PBPI; among these 42 impotent men and 20 additional concurrent potent control subjects had evoked potentials and BCR measurements, and 55 men received one or more AE injections. On the basis of these results, angiographic investigation was recommended. Age and risk factors were similar in the two groups. Abnormal penile blood perfusion was associated significantly only with cigarette smoking (p less than 0.0001) or overt large vessel disease. Impotent men with (138) or without perfusion abnormalities (215) averaged 54 and 56 years of age, respectively; impotent men with normal flow patterns most commonly had treated hypertension or diabetes (79 of 215 men). Covert neurologic abnormalities were detected in 28 of 42 impotent men. Abnormal penile perfusion plus failure of AE predicted isolated ischiopudendal trunk or pudendal artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Fatigue is distinct from sleepiness and negatively impacts individuals living with obstructive sleep apnea (OSA): results from qualitative research of individuals with OSA

BACKGROUND

We sought to identify important issues regarding symptoms and impacts of obstructive sleep apnea (OSA), to explore fatigue and sleepiness, and evaluate the content, clarity, and relevance of specific patient reported outcome (PRO) measures.

METHODS

Participants in the US with OSA and at least mild fatigue were studied. Individuals with positive airway pressure (PAP) therapy intolerance or current PAP refusal (non-PAP users) and those who initiated PAP within the past 12 months (PAP users) were identified and interviewed. Interviews included concept elicitation questions about symptoms and impacts of OSA. Participants then completed several PRO measures (the PRO Measurement Information System [PROMIS] Fatigue-8a, PROMIS Sleep-Related Impairment-8a, Epworth Sleepiness Scale [ESS], Patient-Global Impression of Severity of Fatigue [PGI-S Fatigue], and Patient Global Impression of Change in Fatigue [PGI-C Fatigue]) and were cognitively debriefed to evaluate their content, clarity, and relevance.

RESULTS

A total of 30 individuals with OSA (20 non-PAP and 10 PAP) were enrolled. In addition to fatigue (reported by 100%), sleepiness (75%), difficulty concentrating (85%), dry mouth/throat (60%), headaches (50%) and interrupted sleep (50%) were the most common symptoms reported by non-PAP users. Fifty-eight percent of non-PAP users rated fatigue as the most bothersome symptom; 5% rated sleepiness as the most bothersome. Among PAP users, the most common symptoms (prior to PAP use) in addition to fatigue (100%) were sleepiness (90%), difficulty concentrating (60%), dry mouth/throat (60%), headaches (50%), and interrupted sleep (50%). Fatigue was rated as most bothersome by 56% of PAP users; sleepiness was rated as the most bothersome by 22%. All participants mentioned fatigue and sleepiness separately, indicating they are considered distinct symptoms. In general, participants found the PRO measures to be relevant and clear, and results supported their content validity, clarity, and relevance.

CONCLUSIONS

Fatigue was the most bothersome symptom reported by non-PAP and PAP users. Participants described fatigue as a distinct and different concept from excessive daytime sleepiness. Participants reported that their OSA symptoms negatively impact daily activities, functioning, work, and relationships. The PRO measures are clear and relevant for individuals with OSA and appropriate for use in both clinical and research settings.

Experience in diagnosis and treatment of impotence caused by cavernosal leak syndrome

To delineate neural, arterial, and venous components contributing to impotence, we used a previously described noninvasive screening sequence combined with stimulation of artificial erection with papaverine injection, selective pudendal arteriography (SPA), and dynamic cavernosography (DC). Among 572 men with impotence, age range 17 to 78 years (average age 54.8 years), 26 men with potential cavernosal leaks in absence of other factors were identified; 16 underwent DC; among these five had normal cavernous venous drainage. Eight men with abnormal cavernosal venous drainage required cavernous infusion flow rates higher than 120 ml/min to obtain erection and higher than 40 ml/min to maintain erection. Radiographic studies showed cavernosal leakage in all eight patients. Eight men, ages 39 to 61 years, underwent surgical ablation of abnormal cavernosal venous drainage. Among these, five men have had excellent results for up to 3 years. One failure was related to unrecognized penile arterial disease later shown by SPA. In two men small doses of papaverine now induce erection. We now recommend SPA before DC to rule out an arterial abnormality. Accurate identification of factors contributing to erectile failure is critical for successful treatment; in this experience candidates for correction of cavernosal leak syndrome were uncommon.