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Idiopathic REM sleep behavior disorder is a parasomnia characterized by dream enactment and is commonly a prediagnostic sign of parkinsonism and dementia. Since risk factors have not been defined, we initiated a multicenter case-control study to assess environmental and lifestyle risk factors for REM sleep behavior disorder.

Objectivesthe aim of the present study was to apply a rational plan for simultaneous cardiac and carotid surgery in high-risk patients. Materials and methodsa consecutive series of 89 patients with coexisting severe cardiac and carotid disease were operated on during a 5-year period with routinary carotid shunting, moderate hypothermia and balanced anaesthesia. The combined surgical procedures were coronary artery by-pass grafts (CABG) + carotid endarterectomy (CEA) in 81 patients, CABG + CEA + aortic valve replacement (AVR) in four patients, and four cases of CEA + AVR.Resultstwo deaths (2%), three acute myocardial infarctions (3%) and one (1%) major stroke occurred in five patients during the perioperative (30 days) period for a combined rate of death and/or disabling stroke of 3%. There were five reversible neurological deficits. Carotid and aortic mean clamping times were 9 and 60 min respectively. Patients were discharged after a mean length of stay in Intensive Care Unit (ICU) of 131 h and 7 days of hospitalisation post-ICU.Conclusionsbased on our results, combined interventions of CEA and CABG can be performed with an acceptable morbidity and mortality when severe carotid stenosis is associated with advanced, symptomatic cardiac disease. The management of these patients needs careful and appropriate pre-intra and post-operative assessment and timing aimed to reduce the ischaemic injuries, both cardiac and cerebral, especially during CBP time.

Endocrine changes have been reported in treated epileptic subjects, who often exhibit sexual dysfunctions, but the endocrine effects of single antiepileptic drugs have not been completely elucidated. In this study we have investigated the influence of phenobarbital (PB) on adenopituitary function and on peripheral sexual steroid pattern in 8 epileptic males. Chronic PB treatment does not modify luteinizing hormone (LH) pulsatile secretion. In the same subjects, LH and follicle stimulating hormone (FSH) response to Gonadotropin Releasing Hormone was blunted with respect to healthy controls both in terms of absolute values and of secretion areas. No difference was; found in prolactin (PRL) response to Thyrotropin Releasing Hormone. In the epileptic group a significant increase in the levels of sex hormone binding globulin and a consequent decrease of the percent free testosterone have been observed. PB treatment also significantly lowers 17-β-estradiol mean levels. These data suggest that PB independently affects both gonadotropin secretion and peripheral steroid pattern.

A clinical and polygraphic study of nocturnal sleep was performed in 8 (4 males, 4 females; age range 10–37 years) patients with spinal muscular atrophy, whose baseline respiratory function assessment during wakefulness showed restrictive ventilatory syndrome but blood-gas tension within normal limits. No patient reported any significant sleep complaint suggestive of sleepdisordered breathing. However, in 4 patients HbSaO2 desaturations below 90% (HbSaO2 nadir 68%) were detected during nocturnal polysomnography. The HbSaO2 desaturations occurred during brief central apneas or hypopneas, mainly during REM sleep, the apnoea hypopnea index being within normal limits in all cases. The data suggest that nocturnal polysomnography can detect otherwise clinically silent hypoxemia in SMA patients without any predisposing factor to sleep-disordered breathing other than their illness and still showing normal blood-gas tensions during wakefulness. Further studies are needed to determine the long-term evolution and the prognostic significance of nocturnal hypoxemia in these patients. Sono illustrati i risultati di una indagine clinica e polisonnografica sugli aspetti del sonno notturno e della respirazione durante sonno in 8 pazienti affetti da Amiotrofia Spinale (4 maschi, 4 femmine, di età compresa tra 10 e 37 anni) e che mostravano in veglia una sindrome restrittiva toracica ma valori emogasanalitici ancora nei limiti della norma. Nessun paziente riportava disturbi soggettivi del sonno tra quelli suggestivi di un sottostante disordine respiratorio sonno-relato. In 4 pazienti sono state documentate ricorrenti desaturazioni emoglobiniche di O2 sotto il 90% (valore minimo osservato 68%) nel corso della polisonnografia notturna, in relazione ad apnee o ipopnee non ostruttive, principalmente durante sonno REM. L'Indice di Apnea/Ipopnea è risultato essere nei limiti in tutti i pazienti. I dati suggeriscono che una iniziale tendenza alla desaturazione di O2 sonno relata può essere presente in pazienti con Amiotrofia Spinale senza apparenti disturbi clinici del sonno e che mostrano ancora un quadro di compenso emogasanalitico in veglia. L'evoluzione, la rilevanza clinica e dunque il significato prognostico di tali patterns di ipossiemia notturna andranno verificati in studi clinici e polisonnografici più estesi e con sviluppo longitudinale.

We report a case of hypnogenic paroxysmal dystonia (HPD), diagnosed on the basis of typical clinical and neurophysiological criteria. Dose dependent and long-lasting well-being of the patient was obtained with carbamazepine (CBZ) treatment.

A retrospective study of the electroencephalographic patterns in 26 adults with chronic progressive external ophthalmoplegia. 12 of them presented EEG anomalies, all slight and aspecific. Of the various parameters considered (age, age at onset, duration of disease, CT, CSF findings, abnormalities of muscle mitochondria) the only two that seem to correlate are altered EEG patterns and severity of mitochondrial anomalies in skeletal muscle tissue.

The effects of topiramate in 15 patients with drug refractory partial epilepsy or Lennox-Gastaut syndrome were assessed in an open, add-on prospective study. After a follow-up of 14–21 months, six patients are still on topiramate (mean dosage 583 mg/day, range 400–800 mg/day), and nine have discontinued treatment because of adverse events (n=6), inefficacy (n=2) or poor compliance (n=1). Nine patients (69%) continued to have a ≥50% reduction in seizure frequency during the last two months of treatment, and one has been seizure-free for the last 19 months. The most common adverse events were somnolence, weight loss, mental slowing, fatigue, ataxia and irritability. Most of these events were reversible, but withdrawal of treatment was required in six cases as a result of ataxia (two patients), somnolence, metabolic acidosis, irritability or psychotic symptoms (one patient each). It is concluded that topiramate is a valuable agent for the long-term management of refractory epilepsy.

The aim of this study was to assess breathing patterns during sleep in patients with generalized mild myasthenia gravis. Fourteen patients (13 F; 1M, age range 20–40 years) in a stable clinical and functional state underwent a sleep questionnaire, baseline respiratory function tests and standard nocturnal polysomnography.

We describe a 43-year-old neurologically intact patient who reported episodes of diplopia and oscillopsia associated with a right-beating nystagmus and a skew deviation. These symptoms and signs were related to a left posterior epileptic EEG discharge. We suggest that these ocular motor signs derived from an ictal activation of the vestibular cortex, which in turn activated descending projections to the vestibular nuclei, leading to both a dynamic (right-bearing nystagmus) and a static (skew deviation) vestibular imbalance.

Impaired reproductive function is thought to frequently affect women with epilepsy, mainly when seizures originate in the temporal lobe. In this study, we evaluated menstrual cycle features and assessed ovulation by determining luteal progesterone (Pg) levels in 101 consecutive women with epilepsy (36 with idiopathic generalized epilepsy -IGE; 65 with partial epilepsy -PE), aged between 16 and 50 years, treated with various antiepileptic drugs (AED). PE originated in the temporal lobe (TLE) in 40 subjects, in the frontal lobe in 13, in the parietal lobe in 2, while the origin of focal seizures remained undetermined in 10 patients. In all patients, menstrual and reproductive history, body mass index, hair distribution and hormonal pattern were assessed. Suprapubic ovary ultrasound (US) examination was carried out in 83 patients (28 with IGE, 55 with PE). Three patients with IGE and one with PE were amenorrheic. Oligomenorrhea occurred in 16 patients, polymenorrhea in 2. Changes in menstrual cyclicity were independent from epilepsy type (19.4% in IGE; 23.1% in PE) and from origin of focal discharges (22.5% of patients with TLE; 20.0% with origin in other brain areas). Luteal Pg levels remained below 2 ng/ml in 30 patients independently of epilepsy type. Corpus luteum dysfunction was combined with hyperandrogenism in 15 of these patients. In the other cases different alterations of hypothalamus-pituitary-ovary axis were observed. Valproic acid blunted luteal Pg surge more frequently than other AED. Polycystic ovaries (PCO) were observed in 14 (16.9%) patients (21.0% with IGE; 14.5% with PE). These prevalences are not higher than those reported in the general population. Among PE patients, PCO was found in 1 case with undertemined focal origin and in 7 TLE cases, who also had ovary volume significantly larger than patients with seizures originating from the frontal or parietal lobe. Epileptic women exhibited an increased occurrence of multifollicular ovaries (MFO) found in 12 cases (14.4% vs5% in the general population). However, no defined hormonal or clinical pictures were associated with this US alteration in most patients. These findings reappraise the impact of ovary alterations in women mainly affected by mild to moderate epilepsy, on differing AED regimens, with the exception of more frequent ovulatory dysfunction and PCO occurrence in patients taking VPA.

A night-time polygraphic sleep recording with continuous HbSaO2 monitoring was performed in 11 chair-bound Duchenne muscular dystrophy patients with severe restrictive lung disease but with blood gas values within normal limits when awake. No abnormalities of sleep pattern were detected. Nocturnal sleep did not have significant adverse effects on respiration. However, in 6 patients, infrequent central apnoeas or hypopnoeas occurred which were associated with falls in HbSaO2 greater than those that have been reported to be in normal subjects. The magnitude of HbSaO2 falls appeared to be significantly correlated with functional residual capacity values. Overall, the findings revealed a relatively preserved, although unstable, blood O2 balance during nocturnal NREM and REM sleep in patients with Duchenne muscular dystrophy, even in an advanced stage of their illness.

Pathologic nocturnal eating can be associated with a heterogeneous group of medical and psychiatric disorders. The current study was designed to evaluate the prevalence and clinical features of nocturnal eating syndrome (NES), a major subtype of pathological nocturnal eating. Conducted prospectively over an 18-month period (January 1994-June 1995), the study consisted of clinical, psychological, and polysomnographic assessments of 120 adult subjects (51 males, 69 females; mean age 42.6 years, range 18-86 years) who were either self-referrals (58%) or physician referrals (42%) to our Sleep Disorders Center for insomnia complaints. Nocturnal eating with features that are typical of NES, namely compulsive feeding shortly after a mid-non-rapid eye movement (NREM) sleep awakening, in the absence of daytime eating disorders, occurred in seven subjects (five females, two males; mean age 50.8 +/- 9.5 years; mean age at onset of NES 42 years, range 18-61 years), or 5.8% of the sample. NES accounted for 44.4% of all the nocturnal eating cases observed. The data suggest that an adult, late-onset variety of NES is not infrequent. Several of the clinical features of our NES patient series correspond closely to most of those observed in other descriptions of NES in the literature. Overall, the data reinforce the idea that NES is a distinct syndrome, even though some of its features overlap with sleep-related eating disorders (e.g. associated with sleepwalking, restless legs syndrome, obstructive sleep apnea, etc.) and with eating disorders such as daytime binge eating.

Planning of the electric generating and interconnecting system in Italy is performed by means of a coordinated set of computer programs.

Over the past few years, for defining its operational programs, ENEL Planning Department has been using a procedure (PASEMM procedure) which is based on Markov processes.

A multiparametric investigation of daytime sleepiness was performed in 18 healthy young university students. After undergoing a standard polysomnographic recording at home the night before, all subjects were evaluated by Multiple sleep latency test (MSLT) at 10.00, 12.00, 14.00, 16.00, 18.00. Subjective sleepiness (by using Visual Analogue Rating Scale) and performance tasks (Cancellation Test, Digit Symbol Substitution, Choice Reaction Time, Critical Flicker Fusion Threshold) were also assessed at the same times. Mean daily sleep latency was found to be about 10 minutes, with several individual values in the borderline range (>5 >10 minutes). Subjects did not rate themselves as excessively sleepy and there was no correlation between subjective and objective estimates of sleepiness. No consistent correlation was found between subjective-objective sleepiness and results of performance tests. Anxiety trait (Spielberg State Anxiety Trait) did not correlate with sleepiness, but higher anxiety scores were significantly associated with poor performance. These results confirm the occurrence of fairly marked objective drowsiness in healthy young subjects which, however, was not associated with subjective sleepiness and did not adversely affect performance on a variety of tests of CNS function.

The relationship between the serum concentration of phenobarbital and its pharmacodynamic effects was assessed in a double-blind controlled study in eight normal volunteers who were given single oral doses of phenobarbital (200 mg) and placebo according to a randomized cross-over design. Compared with the placebo session, phenobarbital was found to induce CNS-depressing effects as assessed by visual analogue rating scales (VARS) and critical flicker fusion tests (CFF), whereas no significant effects were detected on choice reaction times, tappings, and digit symbol substitutions. There was a clear-cut dissociation between the time course of serum phenobarbital levels, which remained at a plateau throughout most of the period of observation (up to 72 h) and its subjective (VARS) and objective (CFF) effects, which could be documented only for up to 9 h after administration. These data suggest that pharmacodynamic tolerance develops rapidly even after a single oral dose of the drug. Multiple Sleep Latency Tests (MSLTs) were also performed in the same subjects and showed that phenobarbital increases diurnal drowsiness and attenuates the circadian variation in drowsy state that is seen under control conditions. MSLTs appeared to be superior to other tests in documenting the sedative effects of the barbiturate.

Subjective sleep quality and its related factors were investigated in 869 (530 F, 339 M) 17‐year‐old adolescents, who were selected from the pupils of state‐run secondary schools in the city of Pavia in the north west of Italy. The study was conducted cross sectionally, and it consisted of a questionnaire based survey. One hundred and forty‐two subjects (16.5% of the whole sample, 19% of the females and 11.7% of the males) met the criteria chosen for definition as poor sleepers (namely, a complaint of «non restorative nocturnal sleep», «often» or «always» over the previous 12 mo). A significant association was found between chronic poor sleep and (1) gender (female) (2) emotional factors, such as worries, anxiety and depression (3) poor sleep hygiene (4) arousal related parasomnia. Only 4% of poor sleepers took sleep promoting drugs (including benzodiazepines, homeopathic products and other medications), generally without seeking medical advice.

A nocturnal polysomnographic study with infrared video-monitoring was performed in ten patients with multisystem atrophy with autonomic failure (MSA-AF) (seven males, three females; median age: 54 years), selected irrespective of the presence of sleep complaints. The MSA-AF patients showed disrupted sleep patterns. Quantitative and qualitative alterations of REM sleep were found, some of which resembled those seen in patients with REM sleep behaviour syndrome. However, only one patient reported episodes of REM behaviour. Six patients showed arterial oxyhaemoglobin (HbSaO2) drops below 90% during sleep in relation to recurrent apnoeas or hypopnoeas (HbSaO2 nadir 70%). The apnoea hypopnoea index was above the upper limit of the normal range in three of these patients in the absence of obesity or bronchopulmonary diseases. Among patients with sleep-related breathing impairment, laryngeal stridor (three cases) or snoring (one case) were observed. Patients with sleep-related breathing disorders (SBD) exhibited a higher degree of autonomic dysfunction than patients without SBD.

Hypnic headache (HH) occurs exclusively during sleep. Six attacks were recorded during nocturnal polysomnographic (PSG) monitoring of 10 HH patients. The PSG data obtained indicate that the attacks arose directly from sleep four from non-REM and two from REM sleep. In no patient were the HH attacks found to show any close temporal relationship with sleep-related breathing abnormalities.

Twenty-four-hour ambulatory polysomnography was performed in 20 patients with PD who were having visual hallucinations (12 men and 8 women, mean age 70 ± 6 years). Visual hallucinations were clearly related to daytime NREM sleep or nocturnal REM sleep in 33 of the instances. The data reinforce the hypothesis that neural mechanisms implicated in generating sleep and, in particular, in dream imagery play a role in the occurrence of visual hallucinations in PD.

A report of 3 cases of sodium valproate “encephalopathy”. The addition of valproate to the treatment in 3 subjects, two adults and one child, all with generalised epilepsy, induced a worsening of the clinical and EEG pattern and in one case disturbances of vigilance as well. The occurrence of this complication in generalised epilepsy and the possibility that EEG alterations are its only manifestation are emphasised.

A clinical, EEG and CT study was carried out on 21 patients with chronic stable respiratory failure. The neurological disturbances and mental deterioration observed were of a mild degree, and no severe alterations were detected at EEG. CT showed cerebral atrophy, but the type and prevalence did not differ substantially between patients studied and normal sex- and age-matched control subjects. The data gave evidence that in chronic stable repiratory failure cerebral function is only slightly affected.

In a case of acute intoxication produced by carbamazepine overdose ataxia and cyclic coma were the salient features. The mechanisms underlying these symptoms are discussed. Some peculiarities such as breathing irregularities and microhematuria are also described.