Effect of pramipexole in treatment of resistant restless legs syndrome

When atherosclerotic plaques develop, the cross-sectional area of the artery at that point often increases to accommodate the plaque without any reduction in lumen size. In consequence the angiogram does not detect a high proportion of atherosclerotic plaques. The increase in size of the artery (compensatory dilatation-arterial remodelling) varies widely in degree between different plaques even in the same artery. Dilatation of a degree to prevent any loss of lumen size is regarded as adequate compensatory dilatation. In contrast, other plaques are associated with no or minimal increase in the vessel cross-sectional area and a reduction in lumen size in present (inadequate compensation). High-grade stenosis is in particular associated with a total failure of remodelling. Such plaques may have had a rapid growth phase, out-pacing the ability of the medial smooth muscle cells to undergo a rearrangement. The phenomenon of remodelling has important consequences for pathologists who use the traditional method of comparing the lumen size relative to the cross-sectional area of the vessel at the site of a plaque to measure stenosis. The area of the vessel at this point may be anything up to 60% above its size before the plaque developed. An error is introduced which on average overestimates diameter stenosis by 30% when compared to an angiographic equivalent method in which the lumen size at the lesion is compared to the lumen size at an adjacent segment of artery without a plaque.     

Ropinirole for restless legs syndrome

Restless legs syndrome (RLS) is a common and underdiagnosed condition that results in a desire to move the extremities often associated with paresthesia/dysesthesia, motor restlessness, worsening of symptoms at rest with at least temporary relief by activity, and worsening of symptoms in the evening or night. We tested the new dopamine agonist ropinirole in 16 patients with RLS in an open-label trial. The mean daily dose was 2.8+/-2.3 mg (range, 0.5-12.0). The 13 patients who completed the study reported a 58.7% improvement (p = 1.08 x 10(-8)) as judged by the abbreviated International Restless Legs Study Group questionnaire. Three patients discontinued the medication secondary to adverse events (rash and nervousness) and other extenuating circumstances. These encouraging preliminary results justify larger and more controlled trials of ropinirole in patients with RLS.     

Parasomnias including the restless legs syndrome

The three states of mammalian being, W, REM sleep, and NREM sleep, are not mutually exclusive, and may occur simultaneously, oscillate rapidly, or appear in dissociated or incomplete form to produce primary sleep parasomnias. In addition, dysfunctions of a wide variety of organ systems may take adwide variety of organ systems may take advantage of the sleeping state to declare themselves, resulting in secondary sleep parasomnias. Contrary to popular opinion, the majority of the often bizarre and frightening experiences are not the manifestation of underlying psychological or psychiatric conditions. There is an interesting interaction between sleep-disordered breathing and parasominas. Formal study in an experienced sleep disorders center will usually reveal a diagnosable and treatable condition that explains the spells. Continued study of unusual sleep-related events undoubtedly will reveal more fascinating conditions, expanding our knowledge of sleep physiology, and strengthening the bonds between clinicians and basic-science sleep researchers.     

Clonazepam: benzodiazepine therapy for the restless legs syndrome

Clonazepam is one of several agents used for the treatment of the restless legs syndrome of ESRD. The drug's pharmacokinetic profile demonstrates safety in patients with altered kidney function. Future studies may provide an enhanced understanding of the physiological basis of the disorder to lead to improved pharmacological therapy. Other medication alternatives such as narcotics, dopamine agonists, clonidine, and gabepentin are available for patients unable to tolerate or receive benefit from clonazepam.     

Evidence of peripheral axonal neuropathy in primary restless legs syndrome

The aim of this study was to assess the risk and prognostic factors of gut perforation after orthotopic liver transplantation in children with biliary, atresia using univariate and stepwise regression analysis. Among 51 pediatric recipients who underwent transplantation because of biliary atresia after failure of portoenterostomy, 10 patients (20%) had 19 episodes of gut perforations after 14 transplantations. The median delay between transplantation and perforation was 13 days. These perforations were treated either by suture (n = 21) or ostomy (n = 11). The study of preoperative and perioperative variables showed that children with gut perforation were in surgery for a significantly longer period of time including a longer period of receiving hepatectomy and undergoing portal venous clamp. These children also needed large amounts of blood transfused during hepatectomy. After transplantation there was no difference regarding total steroid doses and early occurrence of cytomegalovirus disease between the two groups. Stepwise regression analysis identified three factors associated with the occurrence of gut perforation: duration of transplant operation, posttransplant intra-abdominal bleeding requiring reoperation, and early portal vein thrombosis. During the postoperative course, severe fungal infections were significantly more frequent in the gut perforation group. The 3-year patient survival rate was 70% in the group with gut perforation and was not different from the group without perforation (80%). This study shows that children with previous portoenterostomy carry a high risk of developing gut perforation after liver transplantation. This is especially true for those patients with the most difficult hepatectomies, which are responsible for the iatrogenic injury of the bowel. Other risk factors pointed out in this study were splanchnic congestion in case of prolonged portal venous clamp time or early portal vein thrombosis and repeated trauma of the bowel caused by reoperations. On the other hand, other well known risk factors, such as steroid therapy and viral diseases, were not involved in the occurrence of gut perforations in this study. Besides emergent surgical treatment, this type of complication requires aggressive therapy against fungal infections.     

Polysomnographic sleep measures in patients with uremic and idiopathic restless legs syndrome

In the present study, the nocturnal electroencephalographic sleep pattern, the number of periodic leg movements (PLM) during sleep and wakefulness, and the subjective sleep parameters of patients with uremic (n = 10) and idiopathic (n = 17) restless legs syndrome (RLS) were compared. The main finding was that the total number of PLM (p = 0.019), the PLM index (p = 0.018), and the PLM index while awake (p = 0.003) were significantly higher in patients with uremic RLS compared with patients who had idiopathic RLS. Additionally, both groups showed a distinct time-of-night pattern of PLM activity. Polysomnographic measures of sleep continuity (total sleep time, sleep efficiency, sleep onset latency, time awake) and sleep architecture (amount of nonrapid eye movement sleep stages 1, 2, 3, and 4 and the amount of rapid eye movement sleep) did not differ between uremic and idiopathic RLS patients. With regard to subjective parameters, sleep quality was estimated to be worse in uremic RLS (p = 0.033), whereas other parameters (for example, severity of RLS, quality of life) did not differ between the two groups. It is suggested that uremia itself worsens the motor symptoms of RLS, probably as a result of increased excitability.     

Circadian rhythm of periodic limb movements and sensory symptoms of restless legs syndrome

The symptoms of restless legs syndrome (RLS) worsen while patients are sitting or lying and also worsen at night. The current study was designed to determine if the periodic limb movements (PLMs) and sensory symptoms of RLS are modulated by an independent circadian factor. We recorded sleeping and waking PLMs and waking sensory symptoms in eight volunteers with RLS for 3 successive nights and days, starting with a polysomnographic recording of 2 nights, followed by a third night of sleep deprivation and the day after sleep deprivation. This study showed that both the PLMs and sensory symptoms were worst at night with a maximum for both between midnight and 1:00 AM and a minimum between 9:00 and 11:00 AM. Sleep and drowsiness had a tendency to worsen PLMs and sensory symptoms after the night of sleep deprivation. Circadian temperature curves were normal in all four patients with adequate data collection. The highest PLM counts occurred on the falling phase of the circadian temperature curve whereas the lowest PLM counts occurred on the rising phase of the curve. We conclude that the PLM and sensory symptoms in RLS are influenced by a circadian rhythm, and that the "worsening at night" criterion of the RLS Definition Criteria is, at least in part, distinct from the "worsening while lying or sitting" criterion.     

A controlled study of additional sr-L-dopa in L-dopa-responsive restless legs syndrome with late-night symptoms

OBJECTIVE: To investigate whether a combination treatment of regular-release levodopa (rr-L-dopa) and sustained-release levodopa (sr-L-dopa) compared with monotherapy of rr-L-dopa improves sleep quality and reduces periodic limb movements (PLM) in patients with restless legs syndrome (RLS) and problems with maintaining sleep. BACKGROUND: Reappearance of RLS symptoms during the second half of the night while being treated with rr-L-dopa is a common problem in the treatment of sleep disturbances caused by RLS. METHODS: A randomized, controlled, double-blind crossover trial was undertaken. Eligible patients fulfilled the diagnostic criteria of the International RLS Study Group, and met an actigraphically confirmed higher number of PLM per hour time in bed (PLM index) during the second half compared with the first half of the night under treatment with rr-L-dopa. During the crossover periods the patients received 100 to 200 mg rr-L-dopa plus either placebo or 100 to 200 mg sr-L-dopa at bedtime for 4 weeks each period. RESULTS: Thirty patients with RLS (11 men and 19 women) were assessed by actigraphy and subjective sleep quality, and showed a significant improvement in PLM index (p < 0.0001), in "time in bed without movements" (p < 0.0001), and in subjective sleep quality (p < 0.001). Eight of 30 patients reported an altered pattern of RLS symptoms, characterized by a time shift of RLS symptoms into the afternoon or evening, five of these during monotherapy with rr-L-dopa. CONCLUSIONS: A combination therapy of rr-L-dopa and sr-L-dopa is better than monotherapy with rr-L-dopa in reducing the frequency of PLM and problems maintaining sleep, even in patients who are severely affected.     

Periodic limb movement disorder and restless legs syndrome in children with attention-deficit hyperactivity disorder

Sleep disruption can lead to symptoms of attention-deficit hyperactivity disorder (ADHD) in children. Since periodic limb movement disorder and/or restless legs syndrome can cause sleep disruption, we assessed whether these two specific sleep disorders are likely to occur in children with ADHD. We asked a series of 69 consecutive parents of children with ADHD questions about the symptoms of periodic limb movement disorder. Based on a positive response to these periodic limb movement disorder queries, 27 children underwent all-night polysomnography. Eighteen children (aged 2 to 15 years) of the 27 (26% of the 69 children with ADHD) had 5 or more periodic leg movements in sleep per hour of sleep and had complaints of sleep disruption, thus fulfilling the criteria for periodic limb movement disorder. A comparably age- and sex-matched group of children referred to a sleep laboratory for sleep complaints but without ADHD showed only a 5% prevalence (2 of 38 subjects) of periodic leg movements in sleep (P=.017). Eight of the 18 children with ADHD and periodic limb movement disorder and one of the two control patients with periodic limb movement disorder had both a personal and parental history of restless legs syndrome symptomatology. This study further documents the occurrence of periodic limb movement disorder and restless legs syndrome in children and is the first large-scale study establishing a possible comorbidity between ADHD and periodic limb movement disorder. We propose that the sleep disruption associated with periodic limb movement disorder and restless legs syndrome and the motor restlessness of restless legs syndrome while awake could contribute to the inattention and hyperactivity seen in a subgroup of ADHD-diagnosed children.     

Sleep disturbance in spinocerebellar ataxias: is the SCA3 mutation a cause of restless legs syndrome?

OBJECTIVE: We sought to determine possible technical causes of inconclusive results on CT-guided core biopsies of lesions suggestive of malignancy and to determine the frequency with which such lesions are eventually found to be malignant. MATERIALS AND METHODS: We retrospectively reviewed 116 consecutive CT-guided thoracic and abdominal core biopsies performed with a 20-gauge automatic biopsy system. Biopsy results were conclusive (n = 94) if pathology confirmed malignancy and inconclusive (n = 22) if pathology results were negative for malignancy or were nondiagnostic. Lesion volume, location, number of cores, and biopsy technique (paraxial or coaxial) were compared for the conclusive and inconclusive biopsy results. Malignancy within the group of inconclusive biopsy results was determined from a second biopsy, radiographic follow-up, or surgery. RESULTS: Regression analysis identified only the biopsy method as a significant factor affecting biopsy outcome: The paraxial method was more likely to yield a conclusive result than the coaxial method (p < .002). For the two biopsy methods, lesions had similar volumes, locations, and numbers of cores obtained. For single core biopsies, both methods were equivalent. However, if two or more cores were obtained, a conclusive result was achieved in more than 90% of biopsies with the paraxial method versus 65% for the coaxial method. On follow-up, results of 14 (64%) of 22 inconclusive biopsies were malignant, indicating an overall false-negative rate of 12%. CONCLUSION: CT-guided core biopsy performed with 20-gauge automatic biopsy systems and the paraxial method will yield conclusive results significantly more often than the coaxial method. In the event of inconclusive results, malignancy will exist often enough to warrant follow-up.     

Familial painful restless legs syndrome correlates with pain dependent variation of blood flow to the caudate, thalamus, and anterior cingulate gyrus

To understand the relationship of caudate, thalamic, and anterior cingulate perfusion to pain states, we investigated familial restless legs syndrome in a father and daughter during the state of pain induced by immobility using semiquantitative regional cerebral blood flow (rCBF) brain single photon emission computed tomography (SPECT). The father underwent 4 brain SPECT scans using the rCBF tracer 99mTc-HMPAO several weeks apart, at different pain levels and after treatment with L-dopa. Caudate, thalamic, and anterior cingulate rCBF indices were measured. The caudate nuclei showed a 13% reduction in rCBF with increasing pain. The thalami and anterior cingulate showed a 7 and 6.6% increase in rCBF, respectively, with increasing pain. Compared to normal controls at rest, there was a decrease in caudate rCBF by 13% and an increase in thalamic rCBF by 3%. Linear regression for the caudate nuclei revealed a significant reduction in rCBF (p < 0.05), as pain increased. The daughter underwent an identical rCBF brain SPECT scan procedure at a high pain level induced by immobilization. Her scan showed a 12% reduction in caudate rCBF and a 1.2% increase in the anterior cingulate rCBF compared to healthy controls. The study supports the association between pain and decreased regional cerebral blood flow to the caudate nucleus as reported in fibromyalgia syndrome. There is increase in anterior cingulate rCBF with increasing pain. Our findings also corroborate that there is increased thalamic rCBF with pain stimulation.     

Pergolide: treatment of choice in restless legs syndrome (RLS) and nocturnal myoclonus syndrome (NMS). A double-blind randomized crossover trial of pergolide versus L-Dopa

A double-blind randomized crossover study of 0.125 mg Pergolide (Lilly) at bedtime versus 250mg L-Dopa + Carbidopa (Roche) was conducted in 16-day phases in 11 patients with idiopathic restless legs syndrome. Two patients reported a partial and 9 patients a complete relieve of motor restlessness while receiving Pergolide. Only 1 patient experienced an improvement of restlessness after L-Dopa. The patients showed polysomnographically a mean decrease in NMS cluster disturbed time by 45% from control on L-Dopa (p < 0.025) and by 79% from control on Pergolide (p < 0.001). In addition, Pergolide increased the total sleep time compared to L-Dopa (p < 0.05). In conclusion, the dopamine agonist Pergolide is superior to L-Dopa in the treatment of RLS and NMS.     

Treatment of restless leg syndrome with pergolide--an open clinical trial

Dopaminergic treatment with levodopa (L-dopa) has been proven as the treatment of first choice in patients with restless leg syndrome (RLS). Augmentation of symptoms and end-of-dose rebound phenomena under L-dopa/decarboxylase inhibitor treatment present major problems in some patients. To evaluate the efficacy of pergolide in RLS, we treated 15 patients suffering from severe RLS, who had previously experienced an augmentation of symptoms under long-term treatment with L-dopa, in an open clinical trial with pergolide. All patients reported an improvement of their RLS symptoms. Our study shows that pergolide, if administered at a mean dose of 0.4 mg in combination with domperidone, is a very effective drug in the treatment of sleep disturbances and daytime symptoms associated with RLS, and does not cause any serious side effects during the observation period of 6 months.     

Encouraging attendance at a screening mammography programme: determinants of response to different recruitment strategies

Our objectives were 1) to determine the education attainment level (EAL) of parents attending the pediatric emergency department (PED); 2) to assess the readability level (RL) of the written instructions available to these parents; and 3) to revise these instruction forms at a level of comprehension based on the EAL of parents. We used a questionnaire of EAL and RL assessment using the SMOG and FOG readability formulas. We then revised the written instructions and used parents in the PED to pretest them. The setting was a PED in a tertiary care hospital (Children's Hospital of Western Ontario). The participants were 1034 parents of children in the PED between 8 AM and 11 PM over a six-month period. Parents were chosen at 30-minute intervals on randomly selected weekdays and weekends. A total of 1022 completed the study. Seven forms commonly used in the PED were assessed for RL. Seven forms were rewritten at grade 6 to 7 RL, and each was pretested in 21 of 24 parents or guardians in the PED using a standardized questionnaire with open-ended questions. Ninety percent of respondents spoke English, and 85% had English as their first language. Forty-nine percent of parents had a grade 13 or lower EAL. This included the following EALs; < grade 12 EAL, 23%; < grade 10 EAL, 15%; and < grade 8 EAL, 4%. Of the seven forms tested, five were written at a college RL. Pretesting of revised forms elicited the following responses from parents: easy to understand (100%), understood everything (96-100%), worth remembering (77-96%), liked the form (67-100%), found it informative (52-85%), and thought it was applicable to all people (82-100%).(ABSTRACT TRUNCATED AT 250 WORDS)     

The syndrome of painful legs and moving toes--a case report

The syndrome of painful legs and moving toes is an uncommon and distressing condition with pain in the feet or legs and involuntary movements of the toes. It can follow spinal cord or cauda equina trauma, lumbar radiculopathy, injury to the feet, peripheral neuropathy or without any preceding causes. Ephaptic transmission in damaged nerve roots or peripheral nerves with central reorganisation may be the underlying mechanism of the syndrome. Treatment is difficult. We report a case of this syndrome following peripheral neuropathy, with a good early response to the GABA agonists baclofen and clonazepam. The role of different GABA agonists in the treatment of this condition needs to be better defined.     

Adie syndrome as the initial sign of primary Sj?gren syndrome

PURPOSE: To report Adie syndrome as the initial sign of primary Sj?gren syndrome. METHODS: Case report. RESULTS: Adie syndrome was associated with necrotizing gingivitis and xerostomia. Antibodies against Ro (SS-A) were present. Prednisone and antimalarial drugs were ineffective in treating Adie syndrome but improved the necrotizing gingivitis. CONCLUSION: Search for Sj?gren syndrome is mandated in patients with Adie syndrome. The latter condition is likely related to ganglionitis, a mechanism responsible for peripheral nervous system involvement in primary Sj?gren syndrome.     

Pharmacokinetic MRI for assessment of malignant glioma response to stereotactic radiotherapy: initial results

The parasites of the red rockfish Sebastes capensis off northern Chile are described quantitatively for the first time and compared with those of congeneric species of the Northern Hemisphere as well as of other Chilean marine fishes. Sixteen species were recorded, including 8 ectoparasites (2 copepods, 2 isopods, 1 turbellarian, and 3 monogeneans) and 8 endoparasites (2 acanthocephalans, 3 digeneans, and 3 nematodes). The ectoparasites Lepeophtheirus chilensis and Caligus cheilodactylus, and the endoparasites Pseudopecoelus sp. and Corynosoma sp. were predominant. Eighty percent of the fishes harbored 3-6 parasite species. Four parasite genera new to the genus Sebastes were found in S. capensis, which also shares several parasite genera with its congeneric species from other geographic areas. However, in contrast to its congeners, S. capensis exhibits a lower helminth species richness, although when all the metazoan fauna is considered the species number and diversity are similar. When compared with other demersal fishes of the Chilean coast, S. capensis shows a high number of species and high parasite abundance. Diphtherostomum sp. and Gnathia sp. are new generic records for the parasite fauna of Chilean coast fishes and the finding of Paramicrocotyle sp., Neobenedenia melleni, and Interniloculus chilensis in this study represents a new geographical record for these parasites.