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Objective: Circadian dysregulation plays an important role in the etiology of mood disorders. Evening chronotype is frequent in these patients. However, prospective studies about the influence of chronotype on mood symptoms have reached unclear conclusions in patients with bipolar disorder (BD). The objective of this study was to investigate relationship between chronotype and prognostic factors for BD., Methods: At the baseline, 80 euthymic BD patients answered a demographic questionnaire and clinical scales to evaluate anxiety, functioning and chronotype. Circadian preference was measured using the Morningness-Eveningness Questionnaire, in which lower scores indicate eveningness. Mood episodes and hospitalizations were evaluated monthly for 18 months., Results: Among the BD patients, 14 (17.5%) were definitely morning type, 35 (43.8%), moderately morning, 27 (33.7%) intermediate (neither) and 4 (5%) moderately evening. Eveningness was associated with obesity or overweight (p = 0.03), greater anxiety (p = 0.002) and better functioning (p = 0.01), as well as with mood episodes (p = 0.04), but not with psychiatric hospitalizations (p = 0.82). This group tended toward depressive episodes (p = 0.06), but not (hypo)mania (p = 0.56)., Conclusion: This study indicated that evening chronotype predicts a poor prognostic for BD. It reinforces the relevance of treating rhythm disruptions even during euthymia to improve patient quality of life and prevent mood episodes.

Background: Night eating syndrome (NES) is characterized by a delayed pattern of food intake and is clinically defined by the presence of evening hyperphagia, nocturnal ingestion, morning anorexia, and sleep problems. Although most studies report an association of obesity, depressive mood, and NES, very little is known about the impact of bariatric surgery in the course of this syndrome, particularly in patients with depressive symptoms., Objectives: To assess the effects of bariatric surgery on night eating and depressive symptoms., Setting: Tertiary hospital, Brazil., Methods: Sixty patients consecutively submitted to bariatric surgery were included in the study. Baseline depressive symptoms were assessed by the Beck Depression Inventory-Short Form (BDI-SF) and night eating by the Night Eating Questionnaire. Measurements were repeated postoperatively for comparison., Results: Participants were predominantly female (M/F = 9/51). Mean (±SD) age was 34.7±9.2 years and body mass index was 46.04±7.52 kg/m². On average, BDI-SF scores improved after bariatric surgery (9.77±7.01 versus 4.70±4.60; P = .001). Patients with baseline depressive symptoms (BDI-SF>4), in contrast to those without, showed a significant improvement in Night Eating Questionnaire scores (16.03±7.73 versus 12.80±7.76; P = .01), despite a similar postoperative reduction in weight., Conclusion: Bariatric surgery is associated with a reduction in depressive symptoms. After the surgical intervention, improvement of night eating can be observed predominantly in patients with preoperative depressive symptoms. These findings are consistent with the hypothesis of an important role of mood problems in NES., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective:: To evaluate the properties of the Identity-Consequence Fatigue Scale (ICFS) in patients with lung cancer (LC), assessing the intensity of fatigue and associated factors., Methods:: This was a cross-sectional study involving LC patients, treated at a teaching hospital in Brazil, who completed the ICFS. Patients with chronic heart disease (CHD) and healthy controls, matched for age and gender, also completed the scale. Initially, a Brazilian Portuguese-language version of the ICFS was administered to 50 LC patients by two independent interviewers; to test for reproducibility, it was readministered to those same patients. At baseline, the LC patients were submitted to spirometry and the six-minute walk test, as well as completing the Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale (HADS), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), and Fatigue Severity Scale (FSS). Inflammatory status was assessed by blood C-reactive protein (CRP) levels. To validate the ICFS, we assessed the correlations of its scores with those variables., Results:: The sample comprised 50 patients in each group (LC, CHD, and control). In the LC group, the intraclass correlation coefficients for intra-rater and inter-rater reliability regarding ICFS summary variables ranged from 0.94 to 0.76 and from 0.94 to 0.79, respectively. The ICFS presented excellent internal consistency, and Bland-Altman plots showed good test-retest reliability. The ICFS correlated significantly with FSS, HADS, and SF-36 scores, as well as with CRP levels. Mean ICFS scores in the LC group differed significantly from those in the CHD and control groups., Conclusions:: The ICFS is a valid, reliable instrument for evaluating LC patients, in whom depression, quality of life, and CRP levels seem to be significantly associated with fatigue., Objetivo:: Avaliar as propriedades da Escala de Identificação e Consequências da Fadiga (EICF) em pacientes com câncer de pulmão (CP), analisando a intensidade da fadiga e fatores associados., Métodos:: Estudo transversal com pacientes com CP, atendidos em um hospital-escola no Brasil, que preencheram a EICF. Pacientes com doenças cardíacas crônicas (DCC) e controles saudáveis, pareados por idade e sexo, também preencheram a escala. Inicialmente, uma versão brasileira da escala foi aplicada a 50 pacientes com CP por dois entrevistadores independentes; para testar a reprodutibilidade, ela foi reaplicada aos mesmos pacientes. No momento basal, os pacientes com CP realizaram espirometria e teste de caminhada de seis minutos, bem como preencheram a Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale (HADS), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) e Fatigue Severity Scale (FSS). O estado inflamatório foi avaliado pelos níveis de proteína C reativa (PCR) no sangue. Para validar a EICF, avaliamos as correlações entre as pontuações na mesma e essas variáveis., Resultados:: A amostra foi composta por 50 pacientes em cada grupo (CP, DCC e controle). No grupo CP, os coeficientes de correlação intraclasse para confiabilidade intra e interobservador para as variáveis resumidas da EICF variaram de 0,94 a 0,76 e de 0,94 a 0,79, respectivamente. A EICF apresentou excelente consistência interna, e as disposições gráficas de Bland-Altman demonstraram boa confiabilidade teste-reteste. A EICF apresentou correlações significativas com as pontuações na FSS, HADS e SF-36, bem como com os níveis de PCR. As médias das pontuações na EICF do grupo CP diferiram significativamente das dos grupos DCC e controle., Conclusões:: A EICF é um instrumento válido e confiável para a avaliação de pacientes com CP, nos quais depressão, qualidade de vida e níveis de PCR parecem estar significativamente associados à fadiga.

Objective:: Wake-up stroke (WUS) is defined when the exact time of the beginning of the symptoms cannot be determined, for the deficits are perceived upon awakening. Sleep alterations are important risk factors for stroke and cardiovascular diseases. This study evaluates the characteristics of patients with and without WUS, the presence of daytime sleepiness, and associated risk factors., Method:: Patients with ischemic stroke were investigated about the presence of WUS. Clinical and demographic characteristics were evaluated. Stroke severity was studied by the National Institutes of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (MRS), and daytime sleepiness severity was studied by the Epworth Sleepiness Scale (ESS)., Results:: Seventy patients (57.1% men) aged from 32 to 80 years (58.5±13.3) were studied. WUS was observed in 24.3%. Arterial hypertension (67.1%), type 2 diabetes (27.1%), and hyperlipidemia (22.8%) were frequent. Type 2 diabetes and sedentary lifestyle were more common in patients with WUS (p<0.05). Overall, mild, moderate or very few symptoms of stroke (NIHSS<5) were predominant (62.3%). Among all cases, 20% had excessive daytime sleepiness (ESS>10). No differences were found between patients with and without WUS as regards stroke severity or excessive daytime sleepiness. Patients with excessive daytime sleepiness were younger and had more sedentary lifestyle (p<0.05). Individuals with previous history of heavy drinking had more daytime sleepiness (p=0.03)., Conclusion:: Wake-up stroke occurs in approximately 25% of stroke cases. In this study, patients with WUS had more diabetes and sedentary lifestyle. Daytime sleepiness is frequent and is associated with sedentary lifestyle and heavy drinking.

Night eating syndrome (NES) is characterized by caloric intake ≥ 25% of total daily after dinner and/or by two or more weekly nocturnal awakenings accompanied by food ingestion. Causes of NES are not entirely clear and seem to involve a desynchronization between the circadian rhythms of food ingestion and sleep, resulting in a delayed pattern of food intake. Estimates of the prevalence of NES in the general population are around 1.5%, and although much higher frequencies have been described in obese individuals, a causal relationship between NES and obesity is not clearly established. Since the first NES reports, several treatment modalities have been proposed, although, in many cases, the evidence is still insufficient and there is no consensus on the ideal approach. In order to conduct a critical review of proposed treatments for NES since its original description, a systematic search of articles published in journals indexed in Medline/Pubmed database in the period 1955-2015 was performed. Seventeen articles addressing non-pharmacological and pharmacological therapies met the selection criteria. Based on the articles analyzed, we conclude that serotonergic agents and psychological interventions, particularly cognitive behavioral therapy, have been shown to be effective for the treatment of NES. A combination of non-pharmacological and pharmacological therapies must be considered in future studies on the treatment of these patients.

Background: Interventions on adolescents' lifestyle are important, but the main mechanisms that explain the changes (mediating variables) on lifestyle are unclear. This paper presents the rationale and methods of an intervention program focused on promoting active and healthy lifestyles (especially physical activity [PA] practice and reducing screen time) among Brazilian students-the Fortaleça sua Saúde program (Portuguese for "strengthen your health")., Methods/design: This is a school-based cluster-randomized controlled trial. Three intervention and three control (no intervention) full-time public schools were randomly selected in Fortaleza, northeastern Brazil. Students (n = 1,272) from classes in Grades 7-9 were eligible, and 1,085 (548 in the intervention and 537 in control schools) completed the baseline and follow-up measures. The program duration was approximately four months and took place in 2014. Intervention strategies focused on teacher training, activities on health in the curriculum, active opportunities in the school environment (the availability of equipment for PA), and health education (health materials for students and parents). Data collection was undertaken before and immediately after the intervention. The primary variables included the practice of PA (weekly PA volume, PA behavior change stage and preference for PA during leisure-time) and screen time (TV and computer/video games). Potential intrapersonal, interpersonal and environmental mediators of PA and screen time were evaluated by a standardized questionnaire. Other lifestyle components (e.g., eating habits, substance use), psychological (e.g., self-rated health, body satisfaction) and biological (general and abdominal obesity) aspects, as well as academic performance were also evaluated in the total sample. Depressive symptoms, eating disorders, sleep quality, objectively-measured PA, and sedentary time were evaluated in obese students., Discussion: If effective, this program will contribute to the development of public policies for the promotion of active and healthy lifestyles in youth, especially those from low- and middle-income countries. The main intrapersonal, interpersonal and/or environmental mediators of PA and screen time may also be indicated. Finally, we anticipate that the proposed strategies may be adaptable to public schools and may even be extended to the entire school system., Trial Registration: ClinicalTrials.Gov: NCT02439827 . Registration date: May 3, 2015.

Background: Despite its high prevalence and frequent association with multiple comorbidities, including hypertension, heart disease, and stroke, obstructive sleep apnea (OSA) still lacks appropriate tools for cardiovascular risk assessment and stratification. Circulating biomarkers represent a safe, convenient, and inexpensive possibility, and several studies have been performed to define an ideal marker in this context. Additionally, biomarkers can provide insight into the pathological mechanisms of the disease and suggest new therapeutic approaches., Methods: In the present review, the authors critically analyze the biomarkers of cardiovascular risk currently available and other potential markers, including brain natriuretic peptide, C-reactive protein, tumor necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6), cysteine, homocysteine, free fatty acids, 8-isoprostane, gamma-glutamyl transferase, glycated hemoglobin, adipokines, and adhesion molecules., Conclusion: The results clearly demonstrate that the relationship between specific biomarkers and OSA is often influenced by age, gender or ethnicity, which has hindered the identification of a unique marker for the evaluation of all patients with OSA. Moreover, given the frequency of comorbidities in OSA, which, by themselves, increase the cardiovascular risk, all confounding factors must be considered in the evaluation of these biomarkers.

Aim: Parkinson's disease (PD) patients frequently present visual hallucinations (VHs) that have been associated with depression, old age, and cognitive impairment. Sleep abnormalities are also related to these factors. The aim of this study is to evaluate risk factors, particularly sleep alterations, associated with VHs in PD., Methods: This is a cross-sectional evaluation of consecutive patients from a Movement Disorder's clinics. Patients were clinically evaluated, and behavioral questionnaires were applied in a face-to-face interview., Results: Among 100 PD patients (67% male, mean age  =  65.0 ± 10.4), VHs were present in 28% of cases; individuals with VHs had worse sleep quality (Pittsburgh Sleep Questionnaire Index) and more severe sleep disturbances [Parkinson's Disease Sleep Scale (PDSS)]. Logistic regression analysis showed that vivid dreams and Unified Parkinson's Disease Rating Scale (UPDRS) I scores (i.e., mentation, behavior, and mood symptoms) are independently associated with VHs. Our data show that the presence of vivid dreams is associated with VHs in PD and reaffirm that VHs are linked to cognitive impairment., Conclusions: Investigating vivid dreams may help the identification of VHs in PD. Identifying vivid dreams can be hard considering that patients may fail to report symptoms for the fear of the stigma associated with psychosis and dementia.

Sleep has important functions for every organ in the body and sleep deprivation (SD) leads to disorders that cause irreparable damage. The aim of this study was to investigate behavioral and brain structural alterations in mice deprived of paradoxical sleep for 48 and 72 h. Working memory, aversive memory as well as levels of nitric oxide (NO) and thiobarbituric acid reactive substances (TBARS) in the hippocampus, body striatum, and prefrontal cortex were evaluated. Working memory was affected in the 48- and 72-h SD groups while aversive memory was altered only in the 48-h SD group (p ≤ 0.05). Our findings showed that SD reduces NO levels in most brain areas (p < 0.05): NO levels were unaltered in the striatum of animals sleep-deprived for 48 h. Higher levels of TBARS were observed in all areas of the SD groups (p ≤ 0.05). Thus, we confirmed that SD has duration-dependent effects on behavior as well as on NO and TBARS levels in the brain. Preserved striatum NO levels suggest that this structure is less vulnerable to oxidative stress and is only affected by SD of longer duration. Increased TBARS and reduced NO levels in the hippocampus and prefrontal cortex confirm a central role for both these structures in working memory and aversive memory. Contextual fear conditioning was not affected by longer periods of SD. Thus, our findings suggest that shorter SD time may be more beneficial to avoid aversive memory where this may have implications for the management of posttraumatic stress.

Objectives: Excessive daytime sleepiness (EDS) and sudden sleep onset (SOS) episodes are frequent in Parkinson׳s disease (PD). The objectives are to identify clinical characteristics and factors associated with EDS and SOS episodes., Methods: Clinical demographic data were recorded (N=100, mean age=65.0±10.4). EDS was identified by the Epworth Sleepiness Scale (ESS>10) and SOS episodes were registered. Disease severity was evaluated by the Unified Parkinson׳s Disease Rating Scale (UPDRS, I, II, and III), sleep disturbances by the Parkinson׳s Disease Sleep Scale (PDSS<100), depressive symptoms by the Beck Depression Inventory (BDI>10) and rapid eye movement (REM) sleep behavior disorder (RBD) by the REM sleep behavior scale. Levodopa equivalent dose was measured., Results: PD patients with EDS (67%) were predominately male (73.1%) and had worse disease severity (UPDRS II and III p= 0.005); SOS episodes (39%) were associated with disease duration, diabetes, sleep disturbances (PDSS Scale), disease severity (UPDRS I, II, III) and RBD symptoms (p<0.05). Stepwise regression analysis showed that EDS was independently associated with motor-symptoms severity (UPDRS III scale, p=0.003). SOS episodes were independently associated with disease duration (p=0.006) and sleep disturbances (PDSS scale, p=0.03): patients had more uncomfortable immobility at night, tremor on waking and snoring or difficult breathing., Discussion: EDS and or SOS episodes are frequent and manifest a differential pattern in PD. SOS episodes are associated with longer disease duration, diabetes, sleep disturbances and RBD symptoms indicating that these "sleep attacks" are of multifactorial origin and probably influenced by brain structural abnormalities.

To evaluate the relationship between physical activity with co morbidities and health-related quality of life in type 2 diabetic patients with and without restless legs syndrome (RLS). This is an observational study, set at tertiary care diabetic outpatient clinic, where 200 consecutive type 2 diabetic patients and 47 controls participated. Physical activity level was established by the International Physical Activity Questionnaire (IPAQ) and RLS diagnosis and RLS severity were established using the criteria defined by the International Restless Legs Syndrome Study Group; excessive daytime sleepiness was evaluated by the Epworth Sleepiness Scale, quality of sleep by the Pittsburgh Sleep Quality Index and Health-Related Quality of Life by the Short-Form Health Survey (SF-36). Depressive symptoms were investigated by Beck Depression Inventory (BDI- II). Among all diabetic patients (58 % women, mean age 52.7 ± 5.7), disease duration varied from 1 to 30 years (11.7 ± 7.5). Diabetic patients had more hypertension (76 %), peripheral neuropathy (65 %), and depressive symptoms (31 %) than controls; no gender differences were found between cases with and without depressive symptoms. RLS patients (72 % female) had worse quality of sleep. With regards to the quality of life domains, more active RLS diabetic patients had better perception of functional capacity, physical limitation, pain, and general health state (p < 0.05). RLS symptom severity did not vary according to physical activity (IPAQ level). This study shows that the physical activity is associated with a better perception of functional capacity, physical limitation, and pain in diabetic patients with RLS; thus a more active lifestyle should be encouraged.

Purpose: Previously, sleep in chronic obstructive pulmonary disease (COPD) has been objectively investigated only by lab-based polysomnography. The main purpose of this study was to evaluate sleep quality in COPD patients in their home environment using actigraphy. We also investigated the factors associated with sleep impairment and the relationship between objective and subjective sleep quality and daytime somnolence in these patients., Methods: Twenty-six patients with moderate to very severe COPD and 15 controls were studied by actigraphy for at least 5 days. Subjective sleep quality was evaluated by the Pittsburgh Sleep Quality Index and daytime sleepiness by the Epworth Sleepiness Scale (ESS). Dyspnea was quantified by the modified Medical Research Council (MMRC) scale., Results: COPD patients showed increased sleep latency (p = 0.003), mean activity (p = 0.003), and wake after sleep onset (p = 0.003) and reduced total sleep time (TST; p = 0.024) and sleep efficiency (p = 0.001), as compared to controls. In patients, severity of dyspnea was correlated with sleep activity (r = 0.41; p = 0.04) and TST (r = -0.46; p = 0.02) and multiple regression analysis showed that MMRC score was the best predictor of TST (p = 0.02) and sleep efficiency (p = 0.03). Actigraphy measures during daytime were not significantly different between patients and controls. Subjective sleep quality was poorer in patients than controls (p = 0.043). ESS scores were not significantly different between the two groups. Actigraphy measures were not correlated with subjective sleep quality or daytime somnolence in both groups., Conclusions: Nocturnal sleep is markedly impaired in stable COPD patients studied by actigraphy in their home environment and this impairment is related to severity of dyspnea.

Chronic obstructive pulmonary disease (COPD), a major cause of death and disability, is attributed to an abnormal inflammatory response by the lungs to noxious substances, primarily from cigarette smoke. Although oxidative stress is regarded as central to the pathogenesis of COPD, very few studies have examined the effects of antioxidants in this condition. This was a randomized, double-blind, placebo-controlled study on the effects of melatonin in COPD. Thirty-six consecutive patients with clinically stable moderate to very severe COPD (30 men; mean±S.D.=66.6±7.8yr) were randomized to receive 3mg melatonin (N=18) or placebo for 3 months. Oxidative stress was evaluated by 8-isoprostane levels in exhaled breath condensate at baseline (T0) and after one (T1), two (T2), and three months (T3) of treatment. Additionally, exhaled breath condensate levels of IL-8, dyspnea severity (Medical Research Council scale), lung function (spirometry), and functional exercise capacity (six min walk test) were compared at baseline and after treatment. Patients receiving melatonin showed a decrease in 8-isoprostane (T0: mean±S.E.M.=20.41±2.92pg/mL; T1: 18.56±2.68pg/mL; T2: 12.68±2.04pg/mL; T3: 12.70±2.18pg/mL; P=0.04; repeated measures ANOVA) with significant differences from baseline after 2 (P=0.03) and 3months (P=0.01). Dyspnea was improved by melatonin (P=0.01), despite no significant changes in lung function or exercise capacity. Placebo-treated patients, but not those who were given melatonin, showed an increase in IL-8 (P=0.03). In summary, melatonin administration reduced oxidative stress and improved dyspnea in COPD. Further studies are necessary to determine the potential role for melatonin in the long-term management of these patients., (© 2012 John Wiley & Sons A/S.)

Objective: To investigate the frequency of factors associated with restless legs syndrome (RLS) in patients with chronic obstructive pulmonary disease (COPD)., Methods: RLS diagnosis was investigated (International RLS Study Group, IRLSSG) and severity was assessed (IRLS rating scale) in 104 consecutive COPD patients (age 69.1±8). Other measures were dyspnea severity (Modified Medical Research Council, MMRC), sleep quality (Pittsburgh Sleep Quality Index, PSQI), daytime somnolence (Epworth Sleepiness Scale, ESS), depressive symptoms (Beck Depression Inventory, BDI-II), and fatigue (Fatigue Severity Scale, FSS). Laboratory values included hemoglobin, ferritin, creatinine, and fibrinogen., Results: Thirty-two patients (30.8%) were diagnosed with RLS (65.6% women), which was moderate/severe (IRLS >11) in 26 (81.3%). RLS symptoms started after age 40 in most patients (93.3%). RLS patients had poorer sleep quality (PSQI >5=59.6%; p=0.002), worse fatigue (FSS >27=51%; p=0.005), and more depressive symptoms (BDI-II >10=14.4%; p=0.005). Patients with RLS also presented more severe dyspnea (p=0.009) and lower creatinine levels (p=0.005). Overall, fatigue severity was correlated with older age (p=0.001); level of dyspnea was positively correlated with PSQI and FSS (p<0.005) and negatively correlated with ferritin (p=0.03) and creatinine (p=0.005), and PSQI scores correlated positively with FSS (p<0.005) and negatively with ferritin (p=0.005) and creatinine (p=0.02). Quality of sleep was independently predicted by dyspnea severity and creatinine and fatigue by age and depression., Conclusion: RLS is common in COPD. Patients with RLS have low creatinine, poorer quality of sleep, and more fatigue and depressive symptoms. RLS symptom severity is correlated to lower ferritin and severity of dyspnea., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Despite their significant influence on the quality of life, depressive symptoms are not usually included as a clinical parameter in the evaluation of hemodialysis patients. We aimed to identify depressive symptoms and associated risk factors in a large group of individuals with end-stage renal disease (ESRD) on chronic hemodialysis. This was a cross-sectional study of 400 consecutive patients. Cases were analyzed according to the presence/absence of depressive symptoms. All individuals were investigated by interview, and all variables were measured concurrently. Depressive symptoms were evaluated by the Beck Depression Inventory (BDI-II ≥16) and sleep quality by the Pittsburgh Sleep Quality Index (PSQI > 5). Among the 400 patients (59% male), depressive symptoms were present in 77 (19.3%). Depressive symptoms were more common in women and were independently associated with poor sleep quality (P = <0.005), unemployment (P = 0.001), diabetes (P = 0.02), hypoalbuminemia (P = 0.01), low education (P = 0.03), and pruritus (P = 0.04). Women with ESRD on chronic hemodialysis are at increased risk of depression. Furthermore, unemployment and the presence of diabetes, hypoalbuminemia, low education, and pruritus are significantly associated with depressive symptoms. Depressive symptoms are also independently associated with poor quality sleep and studies about the effects of sleep hygiene therapy on depressive symptoms are warranted.

Background and Objectives: Despite a confirmed association between obstructive sleep apnea (OSA) and stroke, the pathogenesis of OSA in stroke has not been hitherto clarified. The aim of this study was to evaluate the relationship between respiratory abnormalities and atherogenic pro-inflammatory markers, interleukin-1beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) in acute ischemic stroke patients., Methods: Nocturnal polygraphy was performed in 50 consecutive patients with acute ischemic stroke in the first week after the event. Levels of inflammatory markers (IL-6, IL-1β and TNF-α) were determined from morning blood samples and comparatively analyzed between cases with and without severe OSA and with age-matched controls., Results: All patients with acute ischemic stroke, 31 men, mean age (64.3 ± 7.7 years), had apnea-hypopnea index (AHI) > 5 and 35 (70%) had severe OSA (AHI ≥ 30). Hypertension was more frequent in patients with severe OSA (85.7%) when compared to controls (40.0%) (P = 0.002). Stroke outcome, assessed by the Barthel index, tended to be more severe (P = 0.06) in cases with severe OSA. Patients with mild/moderate OSA and with severe OSA showed higher levels of IL-6 when compared to controls (P = 0.01 and P = 0.000, respectively). Among cases with acute stroke and severe OSA, IL-6 levels were correlated with lower oxyhemoglobin desaturation (r=-0.30; P = 0.001) and with the desaturation index (r = 0.15; P = 0.02)., Conclusions: IL-6, an atherogenic marker, shows a commensurate increase in stroke patients with OSA. It is correlated with oxyhemoglobin desaturation and with desaturation index and may be a surrogate measure to evaluate continuous positive airway pressure therapy., (© 2011 John Wiley & Sons A/S.)

Objective: Impaired sleep has potential health consequences in chronic hemodialysis patients. To date, this issue has not been examined in studies involving a large number of subjects. This study aimed to identify factors associated with poor sleep quality and excessive day-time sleepiness (EDS) in dialysis patients., Material and Methods: This cross-sectional observational study involved 400 patients (59% male) from three hemodialysis centers (SD-HEMOFOR). Quality of sleep was evaluated by the Pittsburgh Sleep Quality Index (PSQI), EDS by the Epworth Sleepiness Scale (ESS), risk of obstructive sleep apnea (OSA) by the Berlin questionnaire and comorbidity severity by the Charlson Comorbidity Index (CCI)., Results: Poor sleep quality (PSQI >5) was found in 227 individuals (57%) and was associated with older age (p = 0.001), diabetes (p = 0.03), heart failure (p < 0.005), hypoalbuminemia (p = 0.01), low transferrin saturation (TSAT) (p = 0.009), higher CCI score (p = 0.01) and depression (p < 0.005). Independent factors were older age, heart failure, low TSAT and depressive symptoms. Day-time somnolence was present in 108 patients (27%) and was independently associated with stroke [odds ratio (OR) = 2.84, CI 1.03-7.76), lower hemoglobin concentration (OR = 2.45, CI 0.95-3.03) and high risk of OSA (OR = 1.65, CI 1.03-2.63). High risk of OSA (n = 120; 30%), was associated with hypertension (p < 0.001), overweight/obesity (p = 0.001), older age (p = 0.003) and symptoms of depression (p = 0.01)., Conclusions: Poor sleep quality and EDS were prevalent on chronic hemodialysis. Heart failure, low TSAT and depressive symptoms were independently associated with poor sleep quality. Stroke, anemia and high risk of OSA were independently associated with EDS. These results provide new insight into possible treatment strategies.

Objective: The aim of this study was to evaluate clinical/demographic factors, sleep alterations and one year mortality in acute ischemic stroke., Methods: This was a prospective study of 89 consecutive patients (mean age 64.39 ± 8.51 years) with acute ischemic stroke. High risk of obstructive sleep apnea (OSA) was evaluated by the Berlin questionnaire, daytime somnolence by the Epworth Sleepiness Scale (> 10) and subjective sleep quality by the Pittsburgh Sleep Quality Index (> 5). Clinical and anthropometric data including body mass index, hip-waist ratio, neck circumference (NC) were obtained. Increased NC was defined if > 43 cm in men and > 38 cm in women. Stroke severity was estimated by the Barthel Index and the modified Rankin Scale. The end-point was death after 12 months follow-up., Result: One-year mortality was 8.9%. Non-survivors were older (p = 0.006) and had larger NC (p = 0.02). Among all cases, large NC was related to high risk of OSA, diabetes and hypertension (Fisher's exact test). Compared to men, women showed relatively larger NC. Overall, family history of stroke (74.2 %), diabetes (33.7%) and hypertension (78.6%) were frequent; obesity (11.2%) was uncommon. Daytime sleepiness (34.8 %), poor sleep quality (65.2%) and risk of OSA (58.42%) were frequently found., Conclusion: Poor sleep quality, excessive daytime sleepiness and high risk of OSA are frequent in this sample with acute ischemic stroke. One-year mortality was related to older age and large NC. As obesity is uncommon in acute stroke patients, a large NC should be taken as a significant clinical sign related to mortality.

Background and Purpose: the objective was to evaluate the presence of Restless Legs Syndrome (RLS) in acute stroke, its association with sleep disturbances and clinical outcome during long-term follow-up., Methods: this was a longitudinal study (N = 96, 59 men, mean age 64.0 ± 8.9) of cases with acute ischaemic stroke. Patients were asked about the occurrence of RLS symptoms before the cerebrovascular event. RLS was diagnosed using the criteria established by the International RLS Study Group. Stroke outcome was estimated by the Barthel Index and the modified Rankin Scale. Daytime somnolence (Epworth Sleepiness Scale -ESS > 10), poor sleep quality (Pittsburgh Sleep Quality Index -PSQI > 5) and risk of obstructive sleep apnea (OSA) (Berlin questionnaire) were evaluated., Results: twelve patients (12.5%) met the diagnostic criteria for RLS. All cases had symptoms of RLS before stroke. However, none of the cases had a previous medical diagnosis of RLS or were on use of specific medication. In only one case, a family history of RLS was found. In all patients, RLS symptoms started after the age of 40 (mean age 64 ± 6.7). Daytime sleepiness (44.8%) and poor quality sleep (62.8%) were present. Patients with RLS (12.5%) presented greater neck circumference (P = 0.04) and worse sleep quality (P = 0.007). Risk of OSA (56.2%) was associated with hypertension [OR = 0.12; CI=0.03-0.42]. Stroke outcome was significantly worse at three and 12 months (ancova, P < 0.005) in patients with RLS, remaining after adjustment for diabetes and body mass index (P < 0.05)., Conclusions: patients with acute stroke and RLS have worse clinical outcome, at three and 12 months of follow-up.

Background: Despite being frequently described in patients with end-stage renal disease (ESRD), clinical characteristics and comorbidities in association with restless legs syndrome (RLS) are still to be confirmed., Objectives: The aim of this study was to investigate clinical factors associated with RLS in ESRD patients in hemodialysis., Methods: This is a cross-sectional study of 400 patients on hemodialysis, evaluating RLS, clinical features and other sleep abnormalities., Results: Out of 400, 86 patients presented RLS (21.5%; mean age 48.8+/-13.8y), being more frequent in females (p<0.005). Forty-eight individuals (12% mean age 50.7+/-13.1y) had moderate/severe RLS, 14 reported symptoms prior to hemodialysis, 13 described family history of RLS, and eight described symptoms as disturbing during dialysis. RLS cases showed lower hemoglobin (p<0.005), poorer quality of sleep (Pittsburgh Sleep Quality Index >5, p=0.002), higher scores on the Beck Depression Inventory Scale (p<0.005), greater scores on the Charlson Comorbidity Index (p=0.01) and the Epworth Sleepiness Scale (p=0.001) and higher risk of obstructive sleep apnea (OSA; Berlin questionnaire, p=0.01). Hypertension was more frequent in cases with moderate/severe RLS (p=0.01) and remained after controlling for the risk of OSA (p=0.02)., Conclusion: In ESRD patients in hemodialysis, RLS is present in 21.5%; 16% report symptoms prior to hemodialysis and a family history of RLS. Symptoms are disturbing during hemodialysis in 9% of cases. RLS is associated with lower hemoglobin, worse sleep quality, excessive daytime sleepiness, depressive symptoms and higher risk of OSA. Hypertension is associated with moderate/severe RLS., (Copyright 2010 Elsevier B.V. All rights reserved.)

Cognitive and performance impairment is well established in patients with obstructive sleep apnea syndrome (OSAS), having a significant impact on the quality of life and the risk of accidents in these individuals. The severity of the impairment correlates with that of the OSAS, which explains the apparent discrepancy between studies using patients from sleep clinics and population-based studies in terms of the reported frequency and severity of such impairment. Cognitive processing, sustained attention, executive functioning, and memory have all been reported to be impaired in OSAS. However, the causal mechanisms of these deficits have not been entirely clarified, and the relative contribution of intermittent hypoxia and sleep disruption in OSAS is particularly controversial. The potential effect of daytime sleepiness on the performance of these patients on various cognitive tests has yet to be determined, as does that of common comorbidities, such as diabetes, systemic arterial hypertension, cardiovascular disease, and obesity. There is compelling evidence that CPAP treatment can improve performance and cognition, particularly in mild to moderate cases, although further studies on the long-term impact of this type of treatment are still needed.

This study evaluates the diagnostic value of morphometric magnetic resonance imaging (MRI) in the differential diagnosis among Parkinson's disease (PD), progressive supranuclear palsy (PSP) and multiple system atrophy (MSA). We studied 21 PD cases, 11 MSA-c, 8 MSA-p and 20 PSP cases. Midbrain area (Ams), pons area (Apn), middle cerebellar peduncle (MCP) and superior cerebellar peduncle (SCP) were measured using MRI. Comparisons were made between PD, MSA-p, MSA-c and PSP. Apn, MCP and SCP morphometry dimensions presented differences among groups. Ams below 105 mm(2) and SCP smaller than 3 mm were the most predictive measures of PSP (sensitivity 95.0 and 80.0%, respectively). For the group of MSA-c patients, Apn area below 315 mm(2) showed good specificity and positive predictive value (93.8% and 72.7%, respectively). In conclusion, dimensions and cut off values obtained from routine MRI can differentiate between PD, PSP and MSA-c with good sensitivity, specificity and accuracy.

Cystic fibrosis (CF) is a chronic progressive disorder characterized by repeated episodes of respiratory infection. Impaired sleep is common in CF leading to reduced quality of life. Melatonin, a secretory product of the pineal gland, has an important function in the synchronization of circadian rhythms, including the sleep-wake cycle, and has been shown to possess significant anti-oxidant properties. To evaluate the effects of exogenous melatonin on sleep and inflammation and oxidative stress markers in CF, a randomized double-blind, placebo-controlled study initially involving 20 patients with CF was conducted. One individual failed to conclude the study. All subjects were clinically stable when studied and without recent infectious exacerbation or hospitalization in the last 30 days. Groups were randomized for placebo (n = 10; mean age 12.1 +/- 6.0) or 3 mg melatonin (n = 9; mean age 16.6 +/- 8.26) for 21 days. Actigraphy was performed for 6 days before the start of medication and in the third week (days 14-20) of treatment. Isoprostane and nitrite levels were determined in exhaled breath condensate (EBC) at baseline (day 0) and after treatment (day 21). Melatonin improved sleep efficiency (P = 0.01) and tended to improve sleep latency (P = 0.08). Melatonin reduced EBC nitrite (P = 0.01) but not isoprostane. In summary, melatonin administration reduces nitrite levels in EBC and improves sleep measures in clinically stable CF patients. The failure of melatonin to reduce isoprostane levels may have been a result of the low dose of melatonin used as a treatment.

Worldwide, COPD is a major cause of morbidity and mortality. The clinical and functional manifestations of COPD result from lung injury occurring through various mechanisms, including oxidative stress, inflammation, protease-antiprotease imbalance and apoptosis. Oxidative stress is central to the pathogenesis of COPD, since it can directly damage lung structures and exacerbate the other mechanisms involved. The cellular and molecular events involved in such lung injury are believed to occur long before the clinical and functional expression of COPD. Although the use of bronchodilators is currently the principal treatment for COPD, bronchodilators have little or no effect on disease progression. A better understanding of the pathogenesis of COPD, together with renewed efforts in basic and clinical research, will allow the diagnosis of COPD at a pre-clinical stage and provide more appropriate monitoring of disease activity, as well as leading to the development of novel therapeutic agents that will effectively prevent the progression of the disease.

Disrupted sleep and nocturnal hypoxia are common in cystic fibrosis (CF). However, the predictors of nocturnal hypoxia in CF are still controversial. In order to identify the risk factors for nocturnal desaturation and sleep disturbances, we carried out a clinical and polysomnographic investigation of CF patients. We studied 30 clinically stable CF cases with clinical lung disease (mean age = 12.8; mean FEV1 = 65.2), 10 CF cases without significant lung disease (mean age = 13.3; mean FEV1 = 99.8), and 20 controls (mean age = 15.5). Patients were evaluated by spirometry, 6-min walk test, the Shwachman-Kulczycki (S-K) score, and full overnight polysomnography. Cases with clinical lung disease had lower body mass index, forced vital capacity, and S-K scores. During sleep, five CF cases with clinical lung disease (15%) had SaO(2) <90% during more than 30% of total sleep time and 11 cases (36.6%) had a nadir SaO(2) below 85%. FEV1 values for CF cases with clinical lung disease were related to nadir SaO(2) (P < 0.03) and to mean SaO(2) (P = 0.02). A receiver operating characteristic (ROC) analysis determined FEV1 at 64% to be predictive of nocturnal desaturation as defined by minimum SaO(2) <85% (sensitivity = 92.3%; specificity = 77.3%) or SaO(2) <90% for 30% of sleep time (sensitivity = 81.8%; specificity = 85.2%). Frequency of impaired sleep was not different in CF cases with (N = 2) and without significant lung disease (N = 5, P = 0.53). Sleep architecture was not significantly different between the two groups. Sleep apnea was present in three CF cases with clinical lung disease and in one case without significant lung disease. In summary, desaturation during sleep can be predicted by FEV1 <64% with good sensitivity and specificity. There are no significant differences in sleep architecture between clinically stable CF cases with and without significant lung disease.

Disturbed sleep is reportedly common in chronic obstructive pulmonary disease (COPD), but the impact of quality of sleep on health-related quality of life (HRQL) has not been previously investigated in these individuals. The purpose of this study was to assess the impact of quality of sleep on HRQL in patients with COPD. In 30 clinically stable patients with moderate to very severe COPD, we evaluated subjective sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and HRQL using the Saint George's Respiratory Questionnaire. Additionally, lung function was assessed by spirometry, severity of dyspnea by the Modified Medical Research Council scale, and functional exercise capacity by the Six-Minute Walk Test. Twenty-one (70%) patients showed poor quality of sleep (PSQI > 5). HRQL was significantly correlated with quality of sleep (P = 0.02), post-bronchodilator FEV1 (P = 0.04), and severity of dyspnea (P < 0.01). Multiple regression analysis showed that quality of sleep was the best predictor of quality of life in our subjects. Our data suggest that quality of sleep is major determinant of HRQL in COPD. Increased efforts to diagnose and treat sleep problems, including measures to improve factors that adversely affect sleep should receive great attention in the daily management of these patients.

Objectives: To examine the relationship between gastroesophageal reflux (GER) and obstructive sleep apnea syndrome (OSAS) with polysomnographic alterations and symptom severity., Patients and Methods: Eighteen children aged from 6 to 12 years (8.14+/-1.75) with adenotonsillar hypertrophy and OSAS were evaluated with the OSA-18 questionnaire nasofibrolaringoscopy and full overnight polysomnography performed simultaneously with esophageal pH monitoring., Results: OSAS (Apnea-index (AI)>or=1/hour) was present in all cases. Reflux parameters did not correlate to OSAS severity and a temporal relationship between GER and apnea-hypopnea events was not observed. Body mass index was lower than 18 in 9 cases (52.9%) and 7 children (41.1%) presented a history of abnormal behavior during sleep. In most cases oxygen desaturation and reduction of sleep efficiency were mild. Sleep architecture was similar to the young adult pattern. Seven children (41.1%) presented pH monitoring values below 4 during more than 10% of total sleep time. pH monitoring values were correlated to emotional distress (p=0.008) and to daytime problems (p=0.03) as evaluated by the OSA-18., Conclusions: GER is frequent and should be assessed in children from 6 to 12 years with OSAS. Emotional distress and daytime problems are correlated to increased GER severity.

Objective: Depression is a major public health problem. Work stress is associated with depression and workers whose jobs impose high levels of psychological demands, such as truck drivers, may be at increased risk. The aim of this study was to investigate the prevalence and correlates of depression in truck drivers., Method: This was a cross-sectional study of 300 male truck drivers. Presence and severity of depression were assessed by the Mini International Neuropsychiatric Interview followed by the Beck Depression Inventory Short Form. Relevant demographic, clinical and occupational data were collected using a purpose-built questionnaire., Results: The prevalence of depression among truck drivers was 13.6%. Multivariate analysis showed that being 45 years or older had a protective effect (OR=0.19; P=0.02), whereas low educational level (OR=3.03; P=0.01), use of stimulants (OR=5.03; P<0.01) and wage-earning (OR=2.84; P=0.01), as opposed to self-employment, increased the risk for depression., Conclusions: Truck drivers are at increased risk for depression when compared to the general population. Efforts to increase awareness of this problem and to limit the use of stimulants, as well as measures to improve job satisfaction, particularly among the wage-earning drivers, may have a positive impact on mental health in these workers.

Disturbed sleep is common in chronic obstructive pulmonary disease (COPD). Conventional hypnotics worsen nocturnal hypoxemia and, in severe cases, can lead to respiratory failure. Exogenous melatonin has somnogenic properties in normal subjects and can improve sleep in several clinical conditions. This randomized, double-blind, placebo-controlled study was carried out to determine the effects of melatonin on sleep in COPD. Thirty consecutive patients with moderate to very severe COPD were initially recruited for the study. None of the participants had a history of disease exacerbation 4 weeks prior to the study, obstructive sleep apnea, mental disorders, current use of oral steroids, methylxanthines or hypnotic-sedative medication, nocturnal oxygen therapy, and shift work. Patients received 3 mg melatonin (N = 12) or placebo (N = 13), orally in a single dose, 1 h before bedtime for 21 consecutive days. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness was measured by the Epworth Sleepiness Scale. Pulmonary function and functional exercise level were assessed by spirometry and the 6-min walk test, respectively. Twenty-five patients completed the study protocol and were included in the final analysis. Melatonin treatment significantly improved global PSQI scores (P = 0.012), particularly sleep latency (P = 0.008) and sleep duration (P = 0.046). No differences in daytime sleepiness, lung function and functional exercise level were observed. We conclude that melatonin can improve sleep in COPD. Further long-term studies involving larger number of patients are needed before melatonin can be safely recommended for the management of sleep disturbances in these patients.

We have tested the hypothesis that restless leg syndrome (RLS) is related to quality of sleep, fatigue and clinical disability in multiple sclerosis (MS). The diagnosis of RLS used the four minimum criteria defined by the International Restless Legs Syndrome Study Group. Fatigue was assessed by the Fatigue Severity Scale (FSS >27), quality of sleep by the Pittsburgh Sleep Quality Index (PSQI >6), excessive daytime sleepiness by the Epworth Sleepiness Scale (ESS >10) and clinical disability by the Expanded Disability Status Scale (EDSS). Forty-four patients (32 women) aged 14 to 64 years (43 +/- 14) with disease from 0.4 to 23 years (6.7 +/- 5.9) were evaluated. Thirty-five were classified as relapsing-remitting, 5 as primary progressive and 4 as secondary progressive. EDSS varied from 0 to 8.0 (3.6 +/- 2.0). RLS was detected in 12 cases (27%). Patients with RLS presented greater disability (P = 0.01), poorer sleep (P = 0.02) and greater levels of fatigue (P = 0.03). Impaired sleep was present in 23 (52%) and excessive daytime sleepiness in 3 cases (6.8%). Fatigue was present in 32 subjects (73%) and was associated with clinical disability (P = 0.000) and sleep quality (P = 0.002). Age, gender, disease duration, MS pattern, excessive daytime sleepiness and the presence of upper motor neuron signs were not associated with the presence of RLS. Fatigue was best explained by clinical disability and poor sleep quality. Awareness of RLS among health care professionals may contribute to improvement in MS management.

Objectives: Subjective sleep complaints have been reported in up to 80% of patients with end stage renal disease (ESRD). In these patients, sleep disturbances manifesting as insomnia, sleep apnea syndrome, restless leg syndrome (RLS), periodic limb movement disorder and excessive daytime sleepiness (EDS) have been frequently reported. Moreover, studies about the role of dialysis shift on sleep abnormalities, morbidity and mortality are still scarce. The aim of this study was to investigate the influence of dialysis shift on the quality of sleep and sleep abnormalities in patients with ESRD., Methods: We studied one hundred consecutive patients from a dialysis center. Quality of sleep was assessed by the Pittsburgh Sleep Quality Index and subjective EDS by the Epworth Sleepiness Scale. Restless leg syndrome was diagnosed using the four minimum criteria defined by the International Restless Legs Syndrome Study Group. Clinical and laboratory parameters were obtained by interview and chart review. Adequacy of dialysis was evaluated by the Kt/V index., Results: Poor quality sleep (PSQI>6) was found in 75% of cases and was associated with RLS (p=0.004) and with snoring (p=0.016). EDS (ESS>10) was present in 28% of cases. Patients with EDS (1.33+/-0.29) had lower values of the Kt/v index (P=0.01) than those without EDS (1.52+/-0.32). RLS was present in 48% of cases. Irrespective of dialysis shift, poor quality sleep, EDS and RLS were not different among patients., Conclusion: Poor quality sleep, EDS and RLS were common and not related to dialysis shift.

Insomnia, sleep fragmentation and excessive daytime sleepiness are common in Parkinson's disease (PD) and may contribute to the reduction of cognition and alertness in those patients. Melatonin has been shown to improve sleep in several conditions. In experimental models of PD, melatonin can ameliorate motor symptoms. To evaluate the effect of melatonin on sleep and motor dysfuntion in PD, we studied 18 patients (Hoehn & Yahr I to III) from a PD clinic. Prior to treatment, motor dysfunction was assessed by UPDRS II, III and IV. Subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) and daytime somnolence by the Epworth Sleepiness Scale (ESS). Full polysomnography (PSG) was performed in all subjects. Patients were then randomized to receive melatonin (3mg) or placebo one hour before bedtime for four weeks. All measures were repeated at the end of treatment. On initial assessment, 14 patients (70%) showed poor quality sleep (PSQI > 6) and eight (40%) excessive daytime sleepiness (ESS > 10). Increased sleep latency (50%), REM sleep without atonia (66%), and reduced sleep efficiency (72%) were found on PSG. Eight patients had an apnea/ hipopnea index greater than 15 but no severe oxygen desaturation was observed. Sleep fragmentation tended to be more severe in patients on lower doses of levodopa (p = 0.07). Although melatonin significantly improved subjective quality of sleep (p = 0.03) as evaluated by the PSQI index, PSG abnormalities were not changed. Motor dysfunction was not improved by the use of melatonin. Undetected differences in motor scores and PSG findings may have been due to a small sample size and a type II error.

Objective: Pulmonary complications are common after abdominal surgery. Although a variety of risk factors have been described for these complications, studies so far have focused on elective interventions. The aim of this study was to determine the incidence and predictors of pulmonary complications following emergency abdominal surgery., Methods: This was a prospective cohort study. Pre and intra-operative data were collected through interview and chart review and their association with the occurrence of postoperative pulmonary complications (PPC) were analyzed., Results: Two hundred and sixty-six consecutive adult patients were included and seventy-five (28.2%) developed PPC. Age >50 years (adjusted OR=3.86; P<0.001), body mass index (BMI) <21 kg/m(2) or 30 kg/m(2) (adjusted OR=2.43; P=0.007) and upper or upper/lower abdominal incision (adjusted OR=2.57; P=0.027) were independently associated with PPC. Patients submitted to multiple procedures tended to be at a higher risk for PPC (adjusted OR=1.73; P=0.079). The development of PPC was associated with prolonged hospital stay (P<0.001) and increased death rate (P<0.001)., Conclusions: Pulmonary complications are frequent among patients undergoing abdominal emergency surgery and lead to increased length of hospital stay and death rate. Older age, abnormal BMI, upper or upper/lower abdominal incision and multiple procedures are predictors of PPC in this setting.

Medical students are at higher risk for depression, affecting not only their lives but also patient care. This article studied a population of medical students engaged in lecture-based learning regarding the presence of depressive symptoms and its relation to morningness-eveningness. Depressive symptoms were assessed by the Beck Depressive Inventory scale (BDI>10), and diurnal preference was assessed by the Horne & Ostberg Morningness/Eveningness Questionnaire (MEQ). Family history of depression and involvement in regular physical activity were also investigated. A total of 161 students, 77 (47.8%) males, aged 19 to 30 yrs (22.1+/-2.1) living in a city close to the equator were evaluated. Fifty-three individuals (32.9%) had depressive symptoms. Depressive individuals showed a trend to be female (p=0.07). Also, female gender showed a non-significant shift toward morningness. Fifty-eight (36.0%) subjects participated in regular physical activity. In 57 cases (35.4%), there was a history of depression in the family. Fifteen individuals (9.3%) were definitely evening type, 42 (26.1%) were moderately evening type, 44 (27.3%) were indifferent, 42 (26.1%) were moderately morning type, and 18 (11.2%) were definitely morning type. Family history of depression (OR=0.29, 95% CI=1.37-6.12) and sedentary life (OR=0.28, 95% CI=0.12-0.65) were associated with depressive symptoms. Eveningness was associated with depressive symptoms (OR=0.66, 95% CI=0.50-0.88), and this association remained significant after adjusting for the presence of familial depression and physical activity (OR=0.71, 95% CI=0.52-0.95). In conclusion, depressive symptoms are independently associated with "eveningness" in medical students. These results should be confirmed by future studies involving a larger number of subjects.

Truck drivers are more likely to suffer severe injury and death due to certain truck driving characteristics. Identifying and preventing factors associated with accidents in this population is important to minimize damage and improve road safety. Excessive daytime sleepiness is a major public health problem, leading to impaired cognitive function, reduced alertness, and increased risk of motor vehicle crashes. The aim of this cross-sectional study was to determine the prevalence and predictors of hypersomnolence (defined as an Epworth Sleepiness Scale score greater than 10) among truck drivers. Three hundred male truck drivers were studied. Quality of sleep was assessed by the Pittsburgh Sleep Quality Index, and the association between demographic, clinical, and occupational data with excessive sleepiness was analyzed. The mean daily sleep duration was 5.6+/-1.3 h, and poor quality of sleep was found in 46.3% of the individuals. Hypersomnolence was found in 46% of the drivers and was associated with younger age, snoring, and working >10 h without rest. A positive correlation between hypersomnolence and previous accidents was detected (p=0.005). These results show that sleep deprivation and hypersomnolence are frequent among truck drivers. The treatment of sleep-disordered breathing and the implementation of educational programs, particularly targeting younger drivers and promoting increased awareness of the deleterious effects of sleep loss and work overload, may help to reduce hypersomnolence and accidents among truck drivers.

Objective: To investigate the presence of restless legs syndrome (RLS) and the quality of sleep in a population of type 2 diabetic patients., Research Design and Methods: The study population was composed of 100 consecutive patients regularly attending a diabetes clinic at the University Hospital of the Federal University of Ceará. The subjects' quality of sleep was assessed by the Pittsburgh Sleep Quality Index, and excessive daytime sleepiness (EDS) was measured by the Epworth Sleepiness Scale. The RLS was diagnosed using the four minimum criteria defined by the International Restless Legs Syndrome Study Group. Other relevant clinical and laboratory parameters were obtained by interview and chart review., Results: RLS was found in 27% of patients. Poor sleep quality was present in 45% of cases and was associated with age (P = 0.04), peripheral neuropathy (P = 0.001), and RLS (P = 0.000). EDS was found in 26% of patients. Logistic regression analysis revealed an association between RLS and peripheral neuropathy (odds ratio 12.85 [95% CI 2.83-58.40], P = 0.001)., Conclusions: RLS is common in type 2 diabetic patients and can be a major cause of sleep disruption in these patients.

Disturbed sleep is common in asthma. Melatonin has sleep-inducing activity and reportedly affects smooth muscle tone and inflammation. The aim of this study was to evaluate the effect of melatonin on sleep in patients with mild and moderate asthma. This was a randomized, double-blind, placebo-controlled study. Twenty-two consecutive women with asthma were randomized to receive melatonin 3 mg (n = 12) or placebo (n = 10) for 4 weeks. Sleep quality and daytime somnolence were assessed by the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale, respectively. Pulmonary function was assessed by spirometry. Use of relief medication, asthma symptoms, and morning and evening peak expiratory flow rate were recorded daily. Melatonin treatment significantly improved subjective sleep quality, as compared with placebo (p = 0.04). No significant difference in asthma symptoms, use of relief medication and daily peak expiratory flow rate was found between groups. We conclude that melatonin can improve sleep in patients with asthma. Further studies looking into long-term effects of melatonin on airway inflammation and bronchial hyperresponsiveness are needed before melatonin can be recommended in patients with asthma.

Recent recognition of daytime sleepiness in Parkinson's disease (PD) has prompted a search for its causes. Sleepy patients may be more susceptible to sleep attacks after the use of dopamine agonists and the recognition of sleep disturbances in PD may influence important therapeutic decisions. To identify clinical factors influencing excessive daytime sleepiness (EDS) and sleep complaints in PD, we studied 86 consecutive patients with clinical diagnosis of PD using a sleep questionnaire, the Epworth Sleepiness Scale, the Unified Parkinson's Disease Rating Scale and the Montgomery and Asberg Depression Rating Scale. Patients with cognitive dysfunction were not included in the study. We found that 49 patients (53.3%) had insomnia, 45 (49.9%) restless legs syndrome (RLS), 51 (55.4%) vivid dreams, 61 (71.8%) snoring and 29 (31.5%) had EDS. RLS was more frequent in patients with longer duration of illness. Snoring was the most important risk factor associated with EDS (OR=3.64, 95% CI=1.11-11.9, P=0.03) and a marginal association between motor dysfunction and EDS was observed (OR=1.06, 95% CI=1.00-1.12, P=0.05).

Patients with advanced muscular dystrophy frequently develop ventilatory failure. Currently respiratory impairment usually is assessed by measuring vital capacity and the mouth pressure generated during a maximal inspiratory maneuver (PI,max), neither of which directly measures ventilatory capacity. We assessed inspiratory flow reserve in 26 boys [mean (SD) age 12.8 (3.8) years] with Duchenne muscular dystrophy (DMD) without ventilatory failure and in 28 normal boys [mean (SD) age 12.6 (1.9) years] by analyzing the ratio between the largest inspiratory flow during tidal breathing (V'I,max(t)) and during a forced vital capacity maneuver (V'I,max(FVC), (V'I,max(t)/V'I,maxFVC). We have compared this ratio with the forced vital capacity FVC and PI,max measured at functional residual capacity. Mean PI,max was -90(30)cmH2O, average 112% (range 57-179%) of predicted values in control boys and -31(11)cmH2O, average 40% predicted values in DMD boys (control vs DMD, P < 0.001). FVC was reduced in DMD boys [59(20)% predicted values vs 86(10)% predicted values in controls, P < 0.01]. Absolute V'I,max(FVC) was strongly related to FVC in both control and DMD boys; V'I,max(FVC) (expressed as FVC. s(-1)) was not related to PI,max in either group. The mean V'I,max(t)/V'I,max(FVC); ratio was higher in DMD 0.22 (0.08) than in controls 0.12 (0.03) (P < 0.001) indicating a reduction in inspiratory flow reserve in DMD. Inspiratory flow reserve was within the normal range in 8 of 19 DMD patients with PI,max less than 50% of predicted values. We conclude that measurement of inspiratory flow reserve (V'I,max(t)/V'I,maxFVC ratio) provides a simple and direct assessment of dynamic inspiratory muscle function which is not replicated by static measurement of PI,max or vital capacity and might be useful in assessment of respiratory impairment in boys with Duchenne muscular dystrophy. Follow-up studies are required to establish whether measures of inspiratory flow reserve are of clinical value in predicting subsequent ventilatory failure.

Background: There is little information on the morphometric characteristics of the diaphragm in patients with Duchenne muscular dystrophy., Methods: The thickness of the diaphragm was measured at the zone of apposition using B mode ultrasonography in 10 boys with Duchenne muscular dystrophy of mean (SD) age 10.3 (1.3) years and 12 normal controls of mean (SD) age 11.3 (2.0) years during relaxation (DiTrelax) and during maximum effort inspiratory manoeuvres (DiTPimax) at functional residual capacity., Results: DiTrelax was greater in the patients with Duchenne muscular dystrophy (1.74 (0.21) mm) than in controls (1.48 (0.20) mm), mean difference (95% CI) 0.26 (0.08 to 0.44), despite considerable impairment of maximum effort inspiratory mouth pressure (Pimax) (patients with Duchenne muscular dystrophy -37 (8) cm H2O, controls -80 (33) cm H2O), mean difference (95% CI) 43 (65 to 20). During a Pimax manoeuvre, compared with measurements taken during relaxation, the diaphragm thickened 1.6 times in patients with Duchenne muscular dystrophy and 2.3 times in controls (DiTPimax 2.62 (0.7) mm and 3.5 (0.85) mm, respectively), mean difference (95% CI) -0.88 (-1.58 to -0.18)., Conclusions: Resting diaphragm thickness is increased in young patients with Duchenne muscular dystrophy with impaired respiratory muscle force. This finding could be analogous to the pseudo-hypertrophy that is observed in some limb muscle groups.

Background: Ultrasound allows observation of the thickness of the diaphragm in the zone of apposition in vivo during relaxation and maximum inspiratory efforts., Methods: Changes of diaphragm thickness were studied by B mode (two dimensional) ultrasound in 13 healthy men aged 29-54 years in the seated position. A high resolution 7.5 MHz ultrasound transducer was held perpendicular to the chest wall in the line of a right intercostal space between the anteroaxillary and mid-axillary lines to observe the diaphragm in the zone of apposition 0.5-2 cm below the costophrenic angle. The changes of thickness were observed while breath holding at total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV). At FRC the thickness while relaxing against a closed mouthpiece and during a maximum inspiratory mouth pressure (PImax) manoeuvre was recorded. The thickening ratio (TR) was calculated as TR = thickness during PImax manoeuvre/thickness while relaxing., Results: Mean (SD) thickness was 4.5 (0.9) mm at TLC, 1.7 (0.2) mm at FRC, and 1.6 (0.2) mm at RV. During the PImax manoeuvre at FRC mean thickness increased from 1.7 (0.2) mm during relaxation to 4.4 (1.4) mm, while mean PImax and TR were -104 (33) cm H2O and 2.6 (0.7), respectively. There was a high degree of correlation between TR and the pressure achieved during the maximum inspiratory manoeuvre (r = -0.82)., Conclusions: Ultrasound provides a non-invasive assessment of diaphragm thickness with change of lung volume and during the PImax manoeuvre which should prove useful in assessing diaphragm mass and contraction in respiratory and muscle disease.

To investigate how treatment can affect airway dynamics and respiratory muscle strength in Parkinson's disease (PD), we assessed maximum effort inspiratory and expiratory mouth pressures (MIP and MEP), oscillatory impedance, and maximum expiratory and inspiratory flow-volume curves (MEFV and MIFV) in 10 patients (8 male and 2 female; mean age 51 +/- 5.3 yr, SD) after temporary interruption of antiparkinsonian therapy (off) and during continuous subcutaneous infusion of a direct stimulant of dopamine receptors, apomorphine (on). Treatment improved neurologic scores (off 25 +/- 5, on 9 +/- 5, modified Webster scale, p < 0.001), MEP (off 45 +/- 25, on 63 +/- 29 cm H2O, p = 0.003), and peak inspiratory flow (PIF; off 3.83 +/- 1.6, on 4.37 +/- 1.7 L/s, p = 0.028). Maximum inspiratory pressure was very low off treatment (-25 +/- 16 cm H2O) and improved moderately with apomorphine (-33 +/- 17 cm H2O) (p = 0.064). Total respiratory resistance during tidal breathing was normal in 9 patients both off and on treatment despite, in some cases, dramatic changes in MEFV and MIFV curves. These results suggest that abnormalities of the flow-volume curves may be due to problems in the rapid activation and coordination of contraction of upper airways and chest wall muscles during forced maneuvers, which is improved by apomorphine treatment.