Search

Introduction  The absence of standardized reporting for sleep medicine exams across different laboratories can lead to misinterpretation, diagnostic inconsistencies, and suboptimal treatment strategies. This document seeks to establish guidelines for the development of sleep study reports, covering recordings from studies of types 1 to 4, and represents the official position of Associação Brasileira do Sono (ABS; Brazilian Sleep Association) on the standardization of polysomnography (PSG) and cardiorespiratory polygraphies. Materials and Methods  The recommendations for the items to be reported in PSG records were developed by means of a Delphi study, comprised of two voting rounds. In each round, participants had to vote regarding the appropriateness of items to be reported in type-1 to -4 sleep studies, rating them as recommended , optional , or not recommended . The consensus threshold was set at 66% in each voting round, or 75% for the combined responses of recommended and optional . Results  The panel was comprised of 29 experts. After 2 voting rounds and subsequent deliberations by the steering committee, 352 items were included in the final set of recommendations. Consensus was achieved for 339 items (96.3%), of which 145 (41.2%) were classified as recommended , 154 as optional (43.8%), 35 as not recommended (9.9%), and 5 as not allowed (1.4%). No consensus was reached for 13 items (3.7%). The items recommended in this consensus are detailed in the main text. Conclusion  These guidelines provide comprehensive recommendations for reporting diagnostic tests in sleep medicine., Competing Interests: Conflict of Interests GNP is a shareholder at SleepUp Tecnologia em Saúde Ltda. (São Caetano do Sul, SP, Brazil). The other authors have no conflict of interests to declare., (Brazilian Sleep Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Sleep disorders are commonly observed in children with Down syndrome (DS) and can lead to significant behavioral and cognitive morbidities in these individuals., Objective: To perform a systematic review evaluating sleep disorders in individuals with DS., Methods: Search strategies were based on combinations of keywords: "Down syndrome"; "trisomy 21"; "sleep disorders"; "dyssomnias"; "sleep apnea"; "obstructive"; "sleeplessness"; "insomnia"; "parasomnias"; and "excessive daytime sleepiness". PubMed and Science Direct were used. Only original studies and retrospective reviews in English published between January 2011 and March 2021 were included., Results: 52 articles were included, most of them involving children and adolescents under 18 years of age. The main sleep disorder associated with DS was obstructive sleep apnea (OSA). Some studies reported the presence of cognitive dysfunction in patients with DS and sleep-disordered breathing, and few have been found about parasomnia, insomnia, and daytime sleepiness in these patients. Movement disorders and unusual postures during sleep may be related to disordered sleep breathing in DS. The main treatment options for OSA are continuous positive airway pressure therapy (CPAP), surgery, and weight control. Computational modeling associated with MRI has been used to plan surgical interventions in these patients., Conclusions: Individuals with DS are at high risk of developing sleep-related breathing disorders. The main sleep disorder associated with DS was OSA. The presence of sleep-disordered breathing contributes to a worsening of cognitive function in patients with DS.

Introduction: Sleep is essential for human beings, especially children. Insufficient sleep is linked to somatic and psychological problems. This study aims to describe nocturnal sleep patterns in children aged 7 to 13 years and investigate if sex or weekdays influence sleep habits. It also analyses factors associated with sleep length and the difference between sleep habits on weekends and weekdays., Methods: A retrospective cross-sectional study with questionnaires from children with sleep complaints referred to our service (December 2003 to June 2009) in Sao Paulo City, Brazil. Median of sleep hours, time going to bed, waking up, and the difference in amount of sleep during weekends and weekdays were calculated. A generalized linear model was used to find associations between covariates and a) sleep hours, and b) sleep weekend minus - weekdays., Results: We analyzed 577 children (median 9.5 y, 61% boys). Median bedtime was 22h. Median wake up time was 7h on weekdays and 9h on weekends. Median sleep duration was 9.5h during weekdays and 10h on weekends. The median difference in the amount of sleep during weekends and weekdays was 0.5h (IQR=1.5). Shorter sleep duration was associated with age and school schedule. Higher difference weekend - weekdays was associated with older children, girls, and school schedule., Conclusion: Children 7 to 13 years usually sleep more on weekends. Age, morning and full-time classes are associated with shorter sleep duration on weekdays and higher weekend-weekdays; girls sleep more during weekends.

Streptococcal infections are suggested as a risk factor for narcolepsy. This hypothesis is supported by the presence of anti-streptolysin antibodies in 65% of patients with narcolepsy. These infections are associated with the activation of general immunity and concomitant increased permeability of blood-brain barrier after T cell activation during inflammation and fever. It has also been shown a significant association between birth order and narcolepsy in genetically susceptible patients, with positivity for HLA-DQB1⁎0602 allele. Watson and colleagues showed a significant association between birth order and narcolepsy in genetically susceptible patients, with positivity for HLA-DQB1⁎0602 allele. In that study, the disease was predominant in young children cases compared to controls. We report here the case of a child diagnosed with narcolepsy with cataplexy, positivity for the HLA-DQB1⁎0602 and previous history of streptococcal infection.

The Kleine-Levin Syndrome is a differential diagnosis for patients with diurnal excessive sleepiness and a suspicion of narcolepsy. It is characterized by paroxysmal attacks of diurnal excessive sleepiness, associated with one or more symptoms of hyperphagia, hypersexuality, coprolalia and copropraxia. During crisis intervals, there are no symptoms. This pathology predominantly manifests itself in teenagers, being more frequent among males. The course of this disease is unpredictable, with variable duration and frequency. The most accepted physiopathology is that of a hypothalamic dysfunction, although and recently, there has appeared a hypothesis of a post-infectious autoimmune disorder. These patients show an elevated body mass index, which can predispose to association with comorbidities such as the sleep obstructive apnea syndrome. Treatment involves medications with different effects, but there is no specific and effective therapy. Our article shows a classic case of Kleine-Levin Syndrome associated with sleep obstructive apnea syndrome, a rare association in the literature.

We are reporting a case of a 29 year-old female with diagnosis of myotonic dystrophy type 1 (Steinert's disease) with excessive daytime sleepiness, muscle fatigue, snoring, frequent arousals, non-restorative sleep, and witnessed apneas. Pulmonary function tests revealed a mild decrease of forced vital capacity. Nocturnal polysomnography showed an increase of apnea/hypopnea index (85.9 events/h), mainly of central type (236), minimal oxygen saturation of 72%, and end-tidal carbon dioxide values that varied from 45 to 53 mmHg. Bi-level positive airway pressure titration was initiated at an inspiratory pressure (IPAP) of 8 and an expiratory pressure (EPAP) of 4 cm H2O. IPAP was then gradually increased to eliminate respiratory events and improve oxygen saturation. An IPAP of 12cm H20 and an EPAP of 4cm H2O eliminated all respiratory events, and the oxygen saturation remained above 90%. Bi-level positive airway pressure treatment at spontaneous/timed mode showed an improvement in snoring, apneas, and Epworth sleepiness scale decreased from 20 to 10. This case illustrates the beneficial effects of Bi-level positive airway pressure support in central sleep apnea syndrome of a patient with myotonic dystrophy type 1.

This is a series of cases describing the use of citalopram for the treatment of cataplexy in patients with narcolepsy. Cataplexy is the most specific symptom of narcolepsy, being characterized by a sudden and temporary loss of muscle tonus, triggered by episodes of emotion during vigil. Some antidepressants, besides gamma-hydroxybutyrate, are used for the control of cataplexy. As gamma-hydroxybutyrate is not available in Brazil, local treatment is usually done by the use of antidepressants. Citalopram is a selective inhibitor of serotonin reuptake, with reasonable price and with fewer side effects when compared with other drugs of the same type. In this study, we report a series of cases with patients with narcolepsy and cataplexy, treated with citalopram for the control of cataplexy.

Studies have pointed out that approximately 50-60% of narcolepsy patients may demonstrate higher prevalence of periodical leg movements. However, we highlight that the prevalence studies and the effects of periodical leg movements in patients with narcolepsy are limited and with conflicting results. The objective of this study was that of describing and discussing the prevalence of periodical leg movements in patients with narcolepsy in the outpatient facility of diurnal excessive sleepiness of the Federal University of São Paulo, Brazil. We revised 59 files of patients with the clinical and electrophysiological diagnosis of narcolepsy according to the American Academy of Sleep Medicine. Of these 59 cases of patients with narcolepsy, 12 (20.3%) demonstrated periodical leg movements. Thirty five patients (59.3%) had history of cataplexy and 38 patients (64.4%) had the presence of the allele HLA-DQB1⁎0602. There was a higher prevalence of periodical leg movements in patients with cataplexy (p<0.0001) and in patients with the presence of the allele HLA-DQB1⁎0602 (p<0.0001). Our study characterized the higher prevalence of periodical leg movement in patients with narcolepsy, mainly in patients with cataplexy and with the presence of the allele HLA-DQB1⁎0602.

Narcolepsy is a chronic neurological disease characterized by diurnal excessive sleepiness and catapleaxy. It affects 1 in every 2000 to 4000 individuals with personal, social and familiar significant repercussions. The treatment of narcolepsy is mainly based on the use of stimulants for the control of the diurnal excessive sleepiness, in conjunction with behavioral measures and sleep hygiene. Among the stimulants, modafinil has presently been the drug of choice for the treatment of the diurnal excessive sleepiness in patients with narcolepsy. In the worldwide experience, its use is better tolerated and the majority of its side effects is considered light or moderate. However, the clinical use in Brazil was initiated at the end of 2008, with little experience on the narcolepsy population of this country. In this context, the objective of this study was the evaluation of the use of modafinil, verifying the indication of use, causes for discontinuation, daily dosage, efficiency of the treatment in a patient sample of narcoleptics consulted in a specialized center in Brazil. In this study, modafinil was effective for the control of the symptoms related do narcolepsy in 66% of the studied patients. The side effects such as headache, parestesias and diarrhea were the main reasons for the discontinuation of treatment with modafinil. It is important to clinically follow up the patients for a long period to evaluate symptomatology, control of use, tolerability and re-evaluation of the more effective therapeutic dosage able to control narcolepsy. Due to its high cost and clinical benefits, this drug should be on the government׳s list of free drugs for the treatment of these patients.

Narcolepsy is a disease in which there is diurnal excessive sleepiness with sleep attacks and a prevalence in the general population of 1/4000 individuals. Classically, it is characterized by cataplexy, sleep paralysis, hypnagogic hallucinations and fragmented sleep. The use of modafinil in the treatment of narcolepsy is the first option of treatment for diurnal excessive sleepiness. Although considered a safe drug for use in patients with narcolepsy, being utilized for more than 20 years, modafinil possesses a series of side effects, some of them still not fully researched or described. Side effects such as headache, nausea, anxiety, insomnia, lumbago, diarrhea, dyspepsia, rhinitis and vertigo are the most frequent. However, the clinical follow-up of patients under treatment with modafinil must be intensive and the side effects ought to be noted and evaluated. The under-response to treatment or the unexpected side effects must always be directed to differential diagnostics. The objective of this article is to describe an unexpected side effect of the use of modafinil in a patient with incorrect diagnosis of narcolepsy.

Objective: It was to evaluate the degree of fatigue in patients with paralytic poliomyelitis (PP) and with post-polio syndrome (PPS), and correlate it with parameters of sleep and the circadian cycle., Methods: Thirty patients, 17 female (56.7%), participated in the study: they answered the Revised Piper Fatigue Scale and performed a nocturnal polysomnographic study. Eleven had PP (mean age±standard deviation of 47.9±6.4 years), and 19 had PPS (mean age±standard deviation of 46.4±5.6 years)., Results: Our study showed that fatigue was worse in the afternoon in the PP Group and had a progressive increase throughout the day in the PPS Group. We also observed compromised quality of sleep in both groups, but no statically significant difference was found in the sleep parameters measured by polysomnography., Conclusion: Fatigue has a well-defined circadian variation, especially in PPS Group. Poor sleep quality is associated with fatigue and, therefore, sleep disturbances should be evaluated and treated in this group of PPS.

Unlabelled: Postpolio syndrome (PPS) is characterized by progressive muscle weakness due to former infection with poliomyelitis and can be associated with other symptoms such as cold intolerance (CI). Dăoyĭn Qìgōng (DQ) is a technique in Traditional Chinese Medicine that impacts the circulation of energy and blood., Objective: It was to verify the effects of DQ in PPS patients complaining of cold intolerance., Methods: Ten PPS patients were assessed using the visual analogue scale (VAS) adapted for CI before and after intervention with DQ; patients practiced it in a sitting position for 40 minutes, 3 times per week over 3 consecutive months. Patients were reassessed three months after ceasing DQ., Results: There was a statistically significant difference in local and systemic VAS-Cold both at the end of DQ training and three months past the end of this., Conclusion: The DQ technique ameliorated CI complaints in patients with PPS.

Unlabelled: This study was thought to characterized clinical and laboratory findings of a narcoleptic patients in an out patients unit at São Paulo, Brazil., Method: 28 patients underwent polysomnographic recordings (PSG) and Multiple Sleep Latency Test (MSLT) were analyzed according to standard criteria. The analysis of HLADQB1*0602 allele was performed by PCR. The Hypocretin-1 in cerebral spinal fluid (CSF) was measured using radioimmunoassay. Patients were divided in two groups according Hypocretin-1 level: Normal (N) - Hypocretin-1 higher than 110 pg/ml and Lower (L) Hypocretin-1 lower than 110 pg/ml., Results: Only 4 patients of the N group had cataplexy when compared with 14 members of the L group (p = 0.0002)., Discussion: This results were comparable with other authors, confirming the utility of using specific biomarkers (HLA-DQB1*0602 allele and Hypocretin-1 CSF level) in narcolepsy with cataplexy. However, the HLADQB1*0602 allele and Hypocretin-1 level are insufficient to diagnose of narcolepsy without cataplexy.

Objective: The aim of this study is to complement existing data on the expression and characteristics of cyclic alternating pattern (CAP) in children, specifically in the 12 to 24 month age bracket., Method: Descriptive study., Settings: a university pediatric sleep laboratory., Participants: Twelve normal and healthy subjects (6 girls and 6 boys, mean age 18.9 ± 4.72 months; range 12-24 months underwent a standard polysomnography night recording in our pediatric sleep laboratory. Sleep stages and CAP were analyzed according to standard international rules., Results: CAP rate found in children of 12 to 24 months of age was (25.78 ± 10.18%) and it is characterized by a linear increase of 2% per month, from 12% at 12 months reaching 35% at 24 months. With coefficient of determination R² of 0.91. The duration of A phases was 6.93 ± 1.06 seconds, and B phases was found to last 21.44 ± 2.31 seconds. The number of CAP cycles was 173.25 ± 7 3.85 with an average index per hour of 33.55 ± .61. The number of CAP sequences reached 25.25 ± 9.55 per recording. CAP rate for the different type of A phases are (21.83 ± 9.68%), for A1, (2.43 ± 2.30%) for A3 and (1.67 ± 1.11%) for A2., Conclusion: Our study provides normative data on CAP in a group of young children (12 to 24 months). The most salient result of this study is the strong correlation of CAP rate of 2% per month in this age group.

The Brazilian Sleep Association brought together specialists in sleep medicine, in order to develop new guidelines on the diagnosis and treatment of insomnias. The following subjects were discussed: concepts, clinical and psychosocial evaluations, recommendations for polysomnography, pharmacological treatment, behavioral and cognitive therapy, comorbidities and insomnia in children. Four levels of evidence were envisaged: standard, recommended, optional and not recommended. For diagnosing of insomnia, psychosocial and polysomnographic investigation were recommended. For non-pharmacological treatment, cognitive behavioral treatment was considered to be standard, while for pharmacological treatment, zolpidem was indicated as the standard drug because of its hypnotic profile, while zopiclone, trazodone and doxepin were recommended.

Unlabelled: The main post-polio syndrome (PPS) symptoms are new weakness, new atrophy, fatigue, pain and sleep disturbances. Polysomnography is the gold standard for sleep analysis., Objective: To analyze sleep patterns in PPS patients., Method: Sixty patients (mean age 46.8+/-11.3 years) at the Federal University of São Paulo (UNIFESP/EPM) complaining of sleep disturbances were evaluated by means of polysomnography, performed at the Sleep Institute., Results: Sleep efficiency was lower due to high sleep latency and arousal index. The apnea and hypopnea index (AHI) and the periodic limb movements (PLM) index were higher. Sleep architecture was also impaired. There were no abnormalities of oxygen saturation, carbon dioxide levels, respiratory rate or heart rate., Conclusion: New post-polio sleep disturbances were isolated symptoms. It appears that these symptoms were not due to post-polio features, but rather, that they were due to dysfunction of the surviving motor neurons in the brainstem. Abnormal dopamine production, which is responsible for many sleep-related breathing disorders and abnormal movements, may also have been implicated in the present findings.

Post-polio syndrome (PPS) in individuals with polio longer than 15 years is characterized by weakness and/or muscle fatigue, deficit of deglutition and breath and periodic limb movements (PLM) during sleep. We undertook a review of 99 patients with PPS, and assessed the frequency of PLM through polysomnographic recordings at our sleep disorders unit. The total number of PLM, total time of sleep (TTS), efficiency of sleep (EfS), awaking index (AI) and apnea-hypopnea index (AHI) were analyzed. Sixteen patients presented PLM in excess of 5 for the entire night. When comparing these with the group without PLM, a correlation was found (p=0.001). Significant difference was found for the correlation of the parameters: IAH, ID, TTS and EfS when compared the two groups. There is a close relationship between PPS and PLM.

Unlabelled: The main post-polio syndrome (PPS) symptoms are new-onset weakness, new-onset atrophy, fatigue, cold intolerance, and pain associated with sleep disturbances. The polysomnographic study is the gold pattern to analyze sleep disorders., Objective: To assess pain, intolerance to cold and periodic limb movements (PLM) index before and after the use of MIG3 bioceramic fabrics over 4 weeks., Method: 12 patients with PPS from UNIFESP/EPM. All patients were submitted to polysomnography and infra-red examinations with answered scales of pain and intolerance to cold before and after the use of MIG3 bioceramics fabrics., Results: There were significant decreases in pain and PLM index., Conclusion: MIG3 bioceramic fabrics can help in the treatment of pain and PLM in PPS patients.

Background: Studies have shown a high prevalence of migraine among narcoleptic patients. HLA-DQB1*0602 and HLA DRB1 alleles are closely associated with narcolepsy. An increase in the HLA-DRB1 allele frequency in patients with visual aura has raised greater awareness of the genetic background in migraine., Purpose: Since the regions DR and DQ of the HLA are in tightly linkage desiquilibrium we hypothesize that HLA-DQB1*0602 might be associated to the pathophysiology of migraine., Method: We analyzed the presence of HLA DQB1*0602 allele in 50 healthy subjects with no history of migraine, 53 patients with migraine without aura and 52 patients with migraine with aura., Results: There was no difference in the frequency of HLA DQB1*0602 allele when control subjects and all patients were compared. We failed to note any difference in frequencies when comparing migraine patients with and without aura., Conclusion: Further studies with different patient populations, with other hypothalamic markers (melatonin, hypocretin) in migraine patients may shed light on to its pathophysiology.

This article focuses on 2 clinical case reports of narcoleptic patients who experienced an absence of excessive sleepiness during treatment of other illnesses with 40 mg daily intake of prednisone.

Unlabelled: Narcolepsy is characterized by excessive daytime sleep and cataplexy. Little is known about the possible difference in pathophysiology between patients with or without cataplexy., Objective: To quantify T CD4, T CD8 and B lymphocytes in subgroups of patients with narcolepsy and the presence or absence of the HLA-DQB1*0602 allele between groups., Method: Our study was prospective and controlled (transversal) with 22 narcoleptic patients and 23 health control subjects. Patients underwent an all-night polysomnographic recording (PSG) and a multiple sleep latency Test (MSLT). The histocompatibility antigen allele (HLA-DQB1*0602), T CD4, CD8 and B lymphocytes were quantified in control subjects and in narcoleptics., Results: The HLA-DQB1*0602 allele was identified in 10 (62.5%) of our 16 cataplexic subjects and in 2 (33.3%) of the 6 patients without cataplexy (p=0.24). In control subjects, HLA-DQB1*0602 allele was identified in 5 (20%). A significant decrease in T CD4 and B lymphocytes was found in narcoleptic patients with recurrent cataplexy when compared with our patients without cataplexy., Conclusion: Autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis were associated with a decrease in sub-group of T CD4 and B lymphocytes. A drop in B lymphocytes count in reumathoid arthritis might, it is posited, be correlated to the presence of HLA-DRB1 allele along with an overall worsened outcome of the affliction. The theory of an increase in consumption of B lymphocytes over the maturation phase has likewise been put forward. Our study reinforces the view that narcolepsy should be considered from an immunological perspective.