Diurnal Symptoms Research Articles

Association of Nocturnal Enuresis With Vesicoureteral Reflux and Renal Cortical Damage

BackgroundThe prevalence of vesicoureteral reflux (VUR) is higher in enuretic children than in non-enuretic children. Recent studies have reported VUR in 6–23% of children with enuresis.ObjectivesTo clarify the association of nocturnal enuresis with vesicoureteral reflux (VUR) and to identify children who are at risk for VUR.Patients and MethodsDuring 2007–2009, neurologically normal children who were referred with a chief complaint of nocturnal enuresis and had abnormal renal ultrasonography (US) results, daytime incontinence, abnormal results in urodynamic studies, urinary tract infection, or a history of VUR in their siblings were prospectively evaluated for VUR by voiding cystourethrography (VCUG).ResultsA total of 60 children (26 boys and 34 girls) aged 5–17 (mean ± SD: 8.46 ± 2.45) years met the inclusion criteria and were enrolled in the study. Twenty-eight (46.7%) patients had mono-symptomatic nocturnal enuresis (MNE), and 32 (53.3%) had non-mono symptomatic nocturnal enuresis (NMNE). VUR was reported in 10 (16.7%) patients and posterior urethral valve (PUV) was found in 1 (1.7%) patient. The prevalence of VUR was significantly higher in patients with daytime incontinence and in girls (P = 0.016 and 0.003 respectively). We did not find any significant correlations between VUR and the form of enuresis (primary versus secondary), urinary tract infection, or any diurnal urinary symptoms other than daytime incontinence (P > 0.05 for all). of 10 renal scintigrams, 5 (50%) showed renal cortical defects.ConclusionsVUR is uncommon in children with MNE and in those with NMNE who do not wet themselves during the day; however, it is a relatively common finding in enuretic children who have daytime incontinence. We recommend VCUG in all enuretic children who have daytime incontinence.

Consistencia interna y validez de la versión española del cuestionario de calidad de vida específico para el síndrome de apneas-hipopneas del sueño Quebec Sleep Questionnaire

IntroductionThere is no specific health-related quality of life (HRQL) questionnaire that has been validated in Spanish for its use in patients with sleep apnea-hypopnea syndrome (SAHS). The objective of the present study was to validate the Spanish version of the Quebec Sleep Questionnaire (QSQ). Patients and methodsA multi-center study including a group of patients with SAHS (AHI≥5) referred to the Sleep Unit. All patients completed the following questionnaires: SF-36, FOSQ, QSQ and Epworth scale. Internal consistency, construct validity, concurrent validity, predictive validity, repeatability and responsiveness to change of the QSQ (32 items in five domains: daytime sleepiness, diurnal symptoms, nocturnal symptoms, emotions, and social interactions) were assessed. ResultsA hundred twenty one patients were included in the study (mean age: 57±13; mean Epworth: 9±4; mean Body Mass Index (BMI): 28±3kg·m−2 and mean AHI: 36±20hour−1). The factorial analysis showed a construct of five factors with similar distribution to the original questionnaire domains. Internal consistency (Cranach's alpha between 0.78 and 0.93 for the different domains), concurrent validity (compared to SF-36, Epworth scale and FOSQ), predictive validity of SAHS severity and test-retest reliability were appropriate. The test showed good responsiveness to change in diurnal (P=.003) and nocturnal symptoms domains (P=.02). ConclusionsThe Spanish version of the QSQ is a valid HRQL measure with appropriate psychometric properties for use in patients with SAHS and is responsive to change in symptoms domains.

The burden of diurnal and nocturnal gastroesophageal reflux disease symptoms

Aims: To quantify the relationship between the timing of gastroesophageal reflux disease (GERD) symptoms and the burden of illness. Patients & methods: Data from the 2010 National Health and Wellness Survey were used. Regression analyses compared non-GERD controls with GERD patients with diurnal symptoms, nocturnal symptoms, and both diurnal and nocturnal symptoms, controlling for potential confounders. Outcome measures included the Work Productivity and Activity Impairment and Short Form-12 questionnaires and reported healthcare resource use. Results: All GERD groups demonstrated a substantial burden of illness compared with controls, estimated at US$1435 in direct costs and US$3143 in lost productivity. Experiencing GERD both day and night was associated with higher costs and lower quality of life than experiencing diurnal-only or nocturnal-only symptoms. Conclusion: Experiencing GERD symptoms both day and night is associated with higher costs than experiencing diurnal or nocturnal symptoms alone.

A simplified Chinese version of the Quebec sleep questionnaire was evaluated for reliability and validity

To develop a simplified Chinese version of the 32-item Quebec sleep questionnaire (QSQ) and to examine the reliability and validity. A cross-sectional sample of 141 patients [22 simple snorers and 119 obstructive sleep apnea hypopnea syndrome (OSAHS)] and a longitudinal sample of 55 patients [35 in uvulopalatopharyngoplasty (UPPP) group and 20 in control group] completed the simplified Chinese version of QSQ for assessment of its feasibility, reliability, validity and responsiveness. QSQ had good feasibility. All internal consistency coefficients exceeded 0.65. Intraclass correlation coefficients of five domains for test-retest reliability ranged from 0.82 - 0.91. There were significant differences in four domains (daytime sleepiness, diurnal symptoms, nocturnal symptoms and social interactions) among patients with different severity of apnea hypopnea index (AHI) and lowest saturation of arterial oxygen (LSaO2, P < 0.01 or < 0.05). Correlations between QSQ scores and five domains and Epworth sleepiness scale (ESS) were statistically significant (P < 0.01). Correlations between QSQ scores and three domains (daytime sleepiness, nocturnal symptoms and social interactions) and polysomnography (PSG) indices (AHI and LSaO2) were statistically significant (P < 0.05). There were significant differences in scores of five domains of patients between at baseline and after UPPP. There were significant differences in change scores of five domains between patients who were treated and those who were not. The simplified Chinese version of QSQ offers good reliability, validity and responsiveness and can be used as a OSAHS-specific instrument to assess impact of illness and treatment effectiveness in OSAHS patients.

Once‐daily administration of trospium chloride extended release provides 24‐hr coverage of nocturnal and diurnal symptoms of overactive bladder: An integrated analysis of two phase III trials

Once-daily extended release (XR) trospium chloride, which provides therapeutic trospium plasma concentrations over 24 hours, has demonstrated efficacy in treating overactive bladder (OAB) symptoms as evaluated over a 24-hr period. This analysis examined the effects of trospium XR on diurnal and nocturnal OAB symptoms. Pooled data were analyzed from two identically designed Phase III trials in which patients with OAB were randomized to receive trospium XR 60 mg or placebo once daily in the morning for 12 weeks. Efficacy was assessed using 3-day urinary diaries. Diurnal events were those occurring from arising from bed in the morning until retiring in the evening; nocturnal events were those occurring from retiring until arising. In total, 1,165 patients received trospium XR (N = 578) or placebo (N = 587). At Week 12 comparison of trospium XR versus placebo, a significantly greater mean reduction from baseline in nocturnal voids (-0.8 vs. -0.6; P = 0.006) and diurnal voids (-1.9 vs. -1.4; P < 0.0001) was noted. At Week 12, the mean percent reduction from baseline with trospium XR versus placebo in nocturnal urge urinary incontinence (UUI) episodes (-60.2% vs. -48.3%; P = 0.003) and mean absolute reduction in diurnal UUI episodes (-2.0 vs. -1.5; P < 0.0001) was significantly greater. Predictors of nocturnal response were duration (weeks) and type of therapy (trospium XR vs. placebo). Reductions in nocturnal toilet voids were accompanied by significant improvements in sleep-related quality of life (QoL) domains. Trospium XR significantly improved both nocturnal and diurnal OAB symptoms. Nocturnal improvements were associated with sleep-related QoL benefits. These results indicate that the XR formulation of trospium chloride provides effective 24-hr coverage of OAB symptoms.

Características cardiovasculares y clínicas de los pacientes con apneas obstructivas del sueño sin somnolencia diurna excesiva

Objectives To investigate whether patients with obstructive sleep apnoea (OSA) without excessive daytime sleepiness (EDS) have cardiovascular problems and different clinical characteristics from OSA with EDS. Methods Two groups of patients were compared retrospectively, one without EDS (Epworth <11) and another control group with EDS (Epworth>10), adjusted for sex, age, body mass index (BMI) and apnoea-hypopnoea index (AHI). The diurnal and nocturnal symptoms of OSA were analysed along with, polysomnography variables, prevalence of hypertension, diabetes mellitus, hyperlipaemia and history of previous cardiovascular events. A logistic regression was performed adjusted for multiple confounding factors to identify the variables associated with OSA without EDS. Results A total of 166 patients without EDS were studied (Epworth 7.2±2.4) and 295 with EDS (Epworth 14.5±2.5). In the adjusted multivariate logistic regression, OSA without EDS is independently associated with a feeling of restful sleep (95% CI: 1.70 to 3.93), less intellectual deterioration (95% CI: 0.30 to 0.95) and less effective sleep (95% CI: 0.96 to 0.99). No differences were found as regards prevalence of cardiovascular comorbidity, previous cardiovascular events, sleep structure or nocturnal clinical symptoms of OSA. When the patients who were in the extreme quartiles of the Epworth scale were analysed, the results obtained were equivalent to those of the whole series, with only intellectual deterioration disappearing from the final model. Conclusions After adjusting for confounding variables, OSA without EDS has a similar prevalence of cardiovascular comorbidities and less diurnal symptoms than OSA with EDS.

‘Eye-of-the-Tiger’ Sign and Classic Pantothenate Kinase Associated Neurodegeneration

A five-year-old girl presented with one-year history of gradual onset repeated falls while walking, dysarthria, increasing stiffness, toe walking and abnormal posturing of limbs. There was no diurnal variation and symptoms progressively worsened. On examination, she had masklike facies with horizontal smile and generalized dystonia. Ocular examination revealed waxy pallor of the disc, arteriolar attenuation and alteration in retinal pigmentation with normal foveal reflex suggesting retinitis pigmentosasine-pigmento (Fig. 1). Magnetic resonance imaging (MRI) of brain revealed bilateral symmetrical hypointensity in the globus-pallidus with central hyperintensity, giving an ‘eyeof-tiger’ appearance on T2 weighted and FLAIR images (Fig. 2). Retinitis pigmentosa in eyes and characteristic MRI findings gave the diagnosis of Pantothenate kinase associated neurodegeneration (PKAN). PKAN, formerly known as Hallovorden-Spatz syndrome is an autosomal recessive disorder caused by mutation of the pantothenate kinase-2 gene [1]. The MRI finding, ‘eye-of-the-tiger’sign is pathognomonic of classic PKAN [2]. The hypointensity on T2 weighted image is because of iron deposition and the central hyperintensity is due to the glioses and spongioses due to cell death [3]. There is an absolute correlation between the presence of a mutation in PANK2 and the eye-of-the-tiger sign; that is, all patients with the PANK2 mutation have this MR imaging pattern, which also is not seen in any mutation-negative patients [4]. Eye-of-tiger-sign can sometimes be seen in few cases of neuroferritinopathy, but in these cases careful scurtinization will reveal involvement of other basal ganglia nuclei (caudate and putamen), thalamus and cerebral cortex which is not seen in PKAN [1]. Another condition, where the ‘eye of tiger’ like appearance is seen is dihydropteridine reductase deficiency in which there will be associated features like cortical calcifications and cysts. Even the clinical presentation varies with microcephaly, parkinsonism, oculogyric crisis and disturbed psychomotor development [5]. The eye-of-the-tiger sign can also be seen in non-NBIA conditions such as corticobasal ganglia degeneration and progressive supranuclear palsy [1]. However the clinical features like age of onset differentiate these from PKAN. In conclusion, though important neuroimaging finding like ‘eye-of-the-tiger’ sign can be seen in other conditions, the presence of this finding along with other clinical clues Fig. 1 Ophthalmoscopic findings of right fundus: Retinal examination shows waxy pallor of the disc, arteriolar attenuation and alteration in retinal pigmentation. Macula is normal with normal foveal reflex. Features are consistent with retinitis pigmentosa sine pigmento

Prevalence and Risk Factors of Habitual Snoring in Primary School Children

Our study aimed to determine the prevalence of habitual snoring (HS) in primary school children and to evaluate the diurnal symptoms and conditions that may be associated with it. A validated questionnaire completed by parents was used to assess the sleep and daytime behaviors of Chinese children aged 5 to 14 years. Thirteen primary schools in two representative districts were randomly selected. A total of 6,349 out of 9,172 questionnaires (response rate 69.2%) with complete answers were returned. The prevalence rate of HS was 7.2%. Male sex (odds ratio [OR] [95% CI]: 2.5 [1.7-3.6]), BMI z score (OR [95% CI]: 1.4 [1.1-1.6]), maternal HS (OR [95% CI]: 3.4 [2.0-5.7]), paternal HS (OR [95% CI]: 3.8 [2.7-5.5]), allergic rhinitis (OR [95% CI]: 2.9 [2.0-4.2]), asthma (OR [95% CI]: 2.4 [1.2-5.2]), nasosinusitis (OR [95% CI]: 4.0 [1.5-10.6]), and tonsillitis (OR [95% CI]: 3.1 [1.9-5.1]) in the past 12 months were identified to be independent risk factors associated with HS. HS was also associated with daytime, nocturnal, parasomniac, and sleep-related breathing symptoms. HS was demonstrated to be an independent risk factor for parent-reported poor temper (OR [95% CI]: 1.9 [1.4-2.5]), hyperactivity (OR [95%CI]: 1.7 [1.2-2.5]), and poor school performance (OR [95% CI]: 1.7 [1.2-2.5]). HS was a significant and prevalent problem in primary school children. Male sex, obesity, parental HS, atopic symptoms, and history of upper respiratory infections were significant risk factors. HS was also associated with sleep-disordered breathing symptoms and adverse neurobehavioral outcomes.

Paroxysmal activity and seizures associated with sleep breathing disorder in children: A possible overlap between diurnal and nocturnal symptoms

Sleep breathing disorders (SBD) can trigger paroxysmal events. We recently found a higher percentage of paroxysmal activity (PA) in a sample of Italian children with obstructive sleep apnea syndrome (OSAS) and no history of epilepsy. The signs of nocturnal seizures can overlap with sleep respiratory events. The aim of this study was to confirm the high frequency of PA or interictal epileptiform discharges (IEDs) during sleep in a cohort of Spanish children who underwent polysomonography (PSG) for suspected SBD and to ascertain the eventual presence of seizures by means of a video-PSG with an extended electroencephalogram (EEG). PSG was performed in a population of children with no previous history of epileptic seizures recruited prospectively for suspected OSAS from January to December 2007. Recordings included at least 13 EEG channels. In total, 25 children (mean age, 6.6 ± 3.8 years, 14 males) were diagnosed with SBD, and 4/25 (16%) children met the criteria for OSAS and epilepsy, with IEDs and/or seizures during sleep. We diagnosed benign epilepsy with centro-temporal spikes in 2 cases, partial symptomatic epilepsy in one, and nocturnal frontal lobe epilepsy in another, while we found PA in 2 patients. The body mass index and the apnea-hypopnea index were significantly higher in children without IEDs/PA. Our study demonstrated a close relationship between pediatric SBD, PA during sleep, and epilepsy that may aggravate the prognosis of SBD. Due to the possibility of an overlap of symptoms, a video-PSG with extended EEG montage is necessary.

Effectiveness of A Computer-Assisted Asthma Management Program on Physician Adherence to Guidelines

Background and Objective. Asthma is an example of a chronic disease for which there are evidence-based guidelines for primary care. The authors undertook this study to demonstrate that physicians’ use and adherence to asthma management guidelines are improved when the guidelines are furnished in a computer-based format. Methods. Based on established guidelines, the authors devised a practical and simple computer-assisted program focused on asthma treatment and monitoring. They then undertook a preliminary investigation, “Easy Asthma Management (EAM)” study, using this program. Finally, the authors evaluated the program's effectiveness by measuring clinical outcomes and changes in prescription patterns before and after the study. Results. A total of 4682 asthma patients followed by 377 physicians were recruited, and 2187 completed the study (46.7%). The means of diurnal and nocturnal symptom scores were significantly reduced after a 3-month enrollment in the EAM study. Interestingly, the fraction of prescriptions for oral β2-agonists, oral methylxanthines, and systemic steroids (oral or injection) significantly decreased after the EAM study (p = .02, p <.001, p <.001, respectively), whereas the fraction of prescriptions for inhaled forms of steroids combined with β2-agonists increased significantly (p <.001). Conclusions. These findings suggest that a computer-assisted asthma management program can be used to improve the clinical outcomes of patients with asthma, and increase physician adherence to established guidelines.

Laser acupuncture does not improve menopausal symptoms

Acupuncture is commonly used to treat menopausal symptoms and other gynecological conditions. Laser acupuncture, more accurately named "laser acupoint stimulation," has the advantages of being noninvasive, reproducible, and convenient. A few studies of conventional acupuncture have suggested a beneficial effect in treating menopausal symptoms. This study sought to investigate the effectiveness of laser acupoint stimulation in relieving symptoms associated with menopause. A double-blind, randomized, placebo-controlled study was conducted in 40 women experiencing active symptoms of menopause. Outcome variables were numbers of diurnal and nocturnal flushes and symptom score, determined using a previously validated scale. A laser acupoint stimulation device was altered to produce identical flashing lights whether or not the laser was operating to allow for a placebo ("laser off") control. Participants received either active or placebo treatment on a fortnightly basis for 12 weeks. The acupoint selection in both groups was individualized to each participant, selected from a set of 10 acupoints. There were no significant differences between the active and placebo treatment groups in numbers of diurnal or nocturnal flushes or in nonflushing symptom scores. Laser acupoint stimulation chosen from a fixed set of acupoints is no more efficacious than manual stimulation with an inert laser probe in altering menopausal symptoms.

Clinical and Cardiovascular Characteristics of Patients with Obstructive Sleep Apnoeas without Excessive Daytime Sleepiness

Objectives To investigate whether patients with obstructive sleep apnoea (OSA) without excessive daytime sleepiness (EDS) have cardiovascular problems and different clinical characteristics to OSA with EDS. Methods Two groups of patients were compared retrospectively, one without EDS (Epworth<11) and another control group with EDS (Epworth>10), adjusted for sex, age, body mass index (BMI) and apnoea-hypopnoea index (AHI). The diurnal and nocturnal symptoms of OSA were analysed along with polysomnography variables, prevalence of hypertension, diabetes mellitus, hyperlipaemia, and history of previous cardiovascular events. After adjusting for multiple confounding factors, a logistic regression was performed to identify the variables associated with OSA without EDS. Results A total of 166 patients without EDS were studied (Epworth 7.2 [2.4]) and 295 with EDS (Epworth 14.5 [2.5]). In the adjusted multivariate logistic regression, OSA without EDS is independently associated with a feeling of restful sleep (95%CI 1.70–3.93), less intellectual deterioration (95%CI, 0.30–0.95) and less effective sleep (95%CI, 0.96–0.99). No differences were found as regards prevalence of cardiovascular comorbidity, previous cardiovascular events, sleep structure, or nocturnal clinical symptoms of OSA. When the patients, who were in the extreme quartiles of the Epworth scale, were analysed, the results obtained were equivalent to those of the whole series, with only intellectual deterioration disappearing from the final model. Conclusions After adjusting for confounding variables, OSA without EDS has a similar prevalence of cardiovascular comorbidity and less diurnal symptoms than OSA with EDS.

Intérêt de la mesure des volumes pulmonaires par pléthysmographie corporelle dans le suivi de l’asthme de l’enfant

In asthmatic children, control of the disease is perfect when no symptoms occur and lung function is normal. The aim of this study is to analyse the role of plethysmography in the follow-up of asthmatic children. We present the results of a retrospective study of lung function (plethysmography and forced expiratory flow) in about 100 asthmatic children aged five to 16years. FEV1/FVC less than 80% predicted was considered as pathological (airflow obstruction). The ratio RV/TLC was considered pathological if greater than 30% and RV was considered pathological if greater than 120% (lung hyperinflation). Bronchodilator reversibility was performed in all patients. All patients were studied in a stable condition. None had developed any asthmatic exacerbations during the past month. We found a significant correlation between the residual volume/total lung capacity (RV/TLC) ratio and, on one hand: FEV1 (p<0.0001, R=-0.374), and on the other hand FEV1/FVC (p=0.07, R=-0.182) or forced expiratory flow 25-75 (p=0.03, R=-0.216). When comparing children with (n=40) and without (n=60) lung hyperinflation, we noticed more diurnal symptoms (30/40 vs 10/60, p=0.05), lower weight (33.9kg vs 41.8kg, p<0.05) and lower body mass index (16.9kg/m(2) vs 18.4kg/m(2), p<0.01). Among the children with defined airway obstruction, 49% also had lung hyperinflation. Twenty-three children had normal forced expiratory ratios but an increase of the ratio RV/TLC or of RV. When compared with children without lung hyperinflation, the age at diagnosis was significantly lower (3.9+/-1.9years vs 6.2+/-3.1years, p<0.01) and weight slightly lower (31+/-10kg vs 40+/-11kg, p=0.04). In conclusion, the use of plethysmography and thus the evaluation of pulmonary hyperinflation contributed to a better appreciation of the asthmatic phenotype in children.

Acute Effects of Passive Smoking on Asthma in Childhood

Although evidence-based asthma guidelines report passive smoke exposure as one of the triggers of asthma symptoms and exacerbations, its prevelance is still high among children with asthma especially in those coming from low income families. Passive smoke exposure affects different aspects of asthma control not only diurnal and nocturnal symptoms and exacerbations but also rescue medication use and lung functions as well as bronchial hyperreactivity, school absenteeism and quality of life. Immediate effects of passive smoke exposure in all these asthma parameters seem to be additive to those of chronic exposure. Smoking cessation interventions therefore play a pivotal role for a better asthma control.

Solifenacin for Therapy Resistant Overactive Bladder

With the availability of the once daily oral antimuscarinic agent solifenacin (5 mg), we started to use it for therapy resistant overactive bladder. We evaluate side effects and efficacy. We reviewed the charts of children treated with solifenacin succinate between August 2005 and August 2008 for therapy resistant OAB. Incontinence was compared at study entry and study end. During the study period 84 boys and 54 girls with a mean age of 9 years 2 months received solifenacin. Mean followup was 22.59 months. While on solifenacin, side effects were observed in 9 of 138 patients (6.5%). Efficacy evaluation included only 99 patients after 3 months of therapy. Mean voided volume after treatment was 253.5 ml, showing a significant 25% increase compared to the mean value before therapy (50.5 vs 203.0 ml, p <0.01). Of the patients 84 (85%) were considered responders, including 45 who were completely dry (full response) and 39 who had fewer nocturnal enuresis or diurnal incontinence symptoms (partial response). Of these 39 patients 17 became dry during the day, 1 became dry during the night and 21 had more than a 50% decrease in nocturnal enuresis and diurnal incontinence symptoms. In 15 patients the outcome was unchanged or worse (no response). In this group of children with OAB we noted favorable results with solifenacin with few side effects. Despite the uncontrolled, retrospective study design the effect is attributable to solifenacin intake.

Efficacy of the bell and pad alarm therapy for nocturnal enuresis

(i) To determine the efficacy of bell and pad alarm therapy as an initial and relapse treatment for nocturnal enuresis; (ii) to explore risk factors for treatment failure; and (iii) to explore risk factors for relapse within 12 months of successful bell and pad alarm therapy. A 22-item questionnaire was sent to 240 children who received bell and pad alarm therapy in a 6-year period via a community centre. The questionnaire recorded demographic characteristics of the child, length of the first bell and pad alarm therapy, outcome of initial treatment and relapse information. The initial response and relapse rates of bell and pad alarm therapy were 84 and 30%, respectively. Female gender, absence of diurnal symptoms and willingness to use alarm therapy were associated with better treatment outcomes. Treatment success was associated with shorter treatment length. The success rate of repeating alarm therapy after relapse was 78%, with an average length of treatment of 10 weeks. The bell and pad alarm therapy is an effective treatment for nocturnal enuresis both as initial therapy and after relapse. The association between patient characteristics and treatment response found in our study may help inform clinicians of likely treatment outcomes, and identify those who may need a different approach.

Diurnal cycle influences peripheral and brain iron levels in mice

Iron movement between organ pools involves a dynamic equilibrium of iron efflux and uptake, and homeostatic mechanisms are likely involved in providing iron to cells and organs when required. Daily iron levels in the plasma pool fluctuate with the diurnal cycle, but clear explanations regarding the objectives and regulation of the flux are lacking. The association between diurnal cycle and iron flux is relevant in the disease of restless legs syndrome (RLS), where individuals display diurnal deficits in motor control, have impaired brain iron metabolism, and perhaps altered iron uptake from the plasma pool. The goal of the present study was to examine diurnal variations in peripheral and regional brain iron to evaluate iron flux between organs in iron-sufficient and iron-deficient mice. In mice fed control diet, liver iron was elevated 30-40%, and plasma iron was reduced 20-30% in the active dark period compared with the inactive light phase. Dietary iron deficiency eliminated this variation in liver iron in male and female mice and in plasma iron in male mice. Reductions in ventral midbrain and nucleus accumbens iron and ferritin were apparent in iron-deficient mice during both diurnal phases, but only during the light phase was an approximately 25% reduction in whole brain iron observed, suggesting different brain iron requirements between phases. These data demonstrate that iron flux between organs is sensitive to diurnal regulatory biology. Importantly, variations in brain iron may have temporal implications regarding neural functioning and may contribute to the diurnal cycle-dependent symptoms of RLS.

Nocturnal Polyuria is Related to 24-Hour Diuresis and Osmotic Excretion in an Enuresis Population Referred to a Tertiary Center

Primary nocturnal enuresis is a heterogeneous disorder, causing a mismatch between overnight diuresis volume and functional bladder capacity. Despite increasing insights in pathogenesis, lack of efficacy of the available treatments is a major problem. We evaluated characteristics of bladder volume and diuresis rate in patients with nocturnal enuresis referred to a tertiary enuresis center. Noninvasive screening including maximal voided volume, 24-hour circadian rhythm of diuresis and osmotic excretion from 1,000 consecutive patients. Of the patients referred as having monosymptomatic nocturnal enuresis 32% were subsequently classified as having nonmonosymptomatic nocturnal enuresis. Differences in bladder volume and nocturnal diuresis characteristics between the monosymptomatic nocturnal enuresis and nonmonosymptomatic nocturnal enuresis groups were minimal. The most common observation is a nocturnal diuresis volume greater than maximal voided volume, which in both groups can be caused by nocturnal polyuria or small bladder volume for patient age. The most striking observation is that the positive correlation between nocturnal diuresis volume rate and nocturnal osmotic excretion and 24-hour fluid intake is significantly higher than with the inversed urinary osmolality overnight, which is not only unexpected based on the theory of the primary suppression of vasopressin levels overnight, but also points to a more important role for nutritional and fluid intake than accepted, if not in the primary pathogenesis, then at least in therapy resistance.

SLEEP-DISORDERED BREATHING

ABSTRACT Sleep-disordered breathing includes both obstructive sleep apnea and central sleep apnea. The former describes a disorder in which a mechanical obstruction repeatedly occurs in the airway so that the flow of air is either completely or partially impeded. Central sleep apnea is characterized by an absence of ventilatory effort. Upper airway resistance syndrome describes airflow limitation. Any patient suspected of having sleep-disordered breathing should be subjected to a careful history with attention to the onset and progression of diurnal and nocturnal symptoms, exacerbating factors, comorbidities, and a family history of similar symptoms. A thorough physical examination should be performed to assess for the body mass index, neck circumference, and anatomical structures that could serve as the site(s) of obstruction. Polysomnography provides an evaluation of the breathing during sleep at night. Certain behavioral modifications may help in upper airway resistance syndrome. An oral appliance is a consideration for mild obstructive sleep apnea. Continuous or bilevel positive airway pressure is an excellent therapeutic modality for obstructive, and sometimes central, sleep apnea. Various surgeries are possible considerations in some cases of obstructive sleep apnea. Addressing nasal congestion with medical therapy, radiofrequency to the inferior turbinates, or nasal septoplasty can improve breathing overall as well as compliance with nasal continuous positive airway pressure.

Deux tiers des malades ayant un reflux gastro-œsophagien ont des symptômes nocturnes: Enquête réalisée par 562 médecins auprès de 36 663 patients

Gastroesophageal reflux disease (GERD) affects about 10% of the French population, who have symptoms at least weekly. Nocturnal symptoms are associated with more severe disease. The aim of this study was to determine the prevalence of nocturnal reflux symptoms among patients seeing general practitioners and to assess their consequences on sleep quality.For three consecutive days, 562 general practitioners identified among all the adult patients they saw those with GERD symptoms (heartburn or regurgitation) in the previous 3 months and characterized the symptoms.Prevalence of GERD among the 36663 consulting patients was 8.3%, and 64.6% of them (that is, 5.4% of the general population) reported nocturnal GERD. Patients with nocturnal symptoms did not differ from those with only diurnal symptoms except smokers had a significantly higher rate of nocturnal than diurnal symptoms (28 versus 23%, p=0.0053). GERD symptoms were related to nocturnal awakening in 58.6% of patients, were present in the early morning for 41.6% and in the evening at bedtime for 39.5%. Nocturnal awakening, difficulty in falling asleep and nightmares occurred significantly more frequently in patients with nocturnal symptoms (respectively 56 versus 24%; 41 versus 31%; 14 versus 9%). Likewise, atypical nondigestive symptoms occurred significantly more frequently in patients with nocturnal symptoms (74 versus 51%, p<0.0001). Quality of sleep was considered "poor or very poor" more frequently in patients with nocturnal symptoms (58 versus 34%, p<0.0001).Approximately 2/3 of GERD patients have nocturnal symptoms that appear to have a significant negative impact on sleep and well-being. These results show the need to evaluate specific therapeutic approaches to reduce sleep disturbances in these patients.