Treatment of sleep disorders in elderly patients

Opinion statement Sleep disorders are common among the elderly and are associated with diminished quality of life, increased risk for development of psychiatric disorders, inappropriate use of sleep aids, and decreased daytime functioning. The most common and important sleep disorders in the elderly include insomnia, obstructive sleep apnea syndrome, restless legs syndrome, rapid eye movement sleep behavior disorder, and the advanced sleep phase syndrome. In this article, we summarize the current treatment strategies for each of these sleep-related disorders. Before contemplating specific treatments, the authors recommend that more conservative and nonpharmacologic therapies be attempted first because the elderly are more likely to have medication side effects or complications related to surgery. Many sleep problems can be treated by simple sleep hygiene modifications that can be implemented and adopted easily. For others, therapies that specifically consider older adults may be required. For each of the sleep disorders we provide an updated discussion of therapies beginning with diet and lifestyle, pharmacologic treatment, interventional procedures, surgery, assistive devices, physical and speech therapy, exercise, and emerging therapies with specific considerations for older adults.     

Tolerance and Conditioning to Neuro-Muscular Electrical Stimulation Within and Between Sessions and Gender

This study was conducted to determine: 1) If healthy subjects can be conditioned to tolerate clinically useful electrically induced muscle contraction; and 2) If there is a gender difference in response to such conditioning. Healthy volunteers (10 males, 11 females, mean age of 27.6 ± 5.8 yrs) were tested during each of 6 testing sessions. Maximal voluntary isometric contractions (MVIC) of the right quadriceps femoris (RQF) recorded by a computerized dynamometer. Electrical stimulation delivered through two surface electrodes and stimulation amplitude increased until the subject indicated to stop. After a 1 min rest the amplitude increased again to the same phase charge level, and the electrically induced contraction (EIC) was recorded by the dynamometer. Measurements of stimulation amplitude were repeated in each of 10 stimulation bouts per session. Measurements of EIC were repeated in session six. Statistical analyses included Multivariate ANOVAs, and Newman-Kuel’s post-hoc tests (p < 0.01). Mean values of phase charge increased from session 1 to 6 for all subjects. Males tolerated significantly higher phase charge. The mean %MVIC torque generated by female subjects was initially only 11.2 ± 21.6% but reached 42.9 ± 25.4% at the end of the 6th session. Males’ %MVIC torque values were significantly higher reaching 49.0 ± 41.6% and 73.5 ± 18.7% in the first and last trials respectively. Using the criterion that electrically induced contractions must be at least 25% of MVIC to be considered clinically useful, 36% of females were below this threshold at the end of the last session. In contrast, all males exceeded the 25% MVIC threshold at the end of the study. Most healthy subjects can be conditioned to electrical stimulation of the quadriceps, but depending on the criteria of therapeutic value and gender, some males and even more females may not reach the desired stimulation goal in 6 sessions. Females may require more conditioning sessions to reach contraction levels of therapeutic benefits. The reason(s) for the confounding factor of gender remains unknown.

Key Points

• Neuromuscular electrical stimulation (NMES) can strengthen skeletal muscles
• Tolerance to NMES improves within 6 sessions
• Conditioning is a key to eliciting stronger contraction and to increasing the number of subjects that can benefit from NMES
• Healthy males can tolerate higher stimulusintensity and higher electrically induced quadriceps femoris contraction.

Key Words: Neuromuscular electrical stimulation, tolerance, conditioning, gender     

Resolution of medullary nephrocalcinosis in children with metabolic bone disorders

Ultrasonographic resolution of nephrocalcinosis (NC) has been reported in children with furosemide-induced NC, but not in other entities. We report the cases of four children with metabolic bone disease, two with hypophosphatasia and two with X-linked hypophosphatemic rickets, in whom we observed resolution of renal calcifications. At the time of ultrasonographic resolution of NC, 3 of the patients were on anticalciuric diuretics, and all 4 had normal urinalysis, serum creatinine and electrolyte profiles, as well as estimated creatinine clearance. In 3 of the children, evidence of mild tubular dysfunction was found. It thus seems that in some children with bone and mineral disorders who develop NC, ultrasonographic resolution of the renal calcifications can be seen; however, mild tubular dysfunction may remain and require follow-up. Further studies are suggested to explore the possible role of anticalciuric diuretics in promoting the resolution of NC.     

Surgical excision of papillary fibroelastoma for known or potential embolization

BACKGROUND AND AIM OF THE STUDY: Papillary fibroelastoma (PFE) is a rare and histologically benign tumor, but it may have malignant propensity for life-threatening complications. Herein are described four cases of PFE which reflect the clinical diversity of this lesion. The diagnostic and surgical approach utilized is also briefly reviewed. METHODS: The files of four patients with cardiac valvular PFE treated at the authors' center between January 2002 and November 2003 were reviewed. The diagnosis was strongly suggested by echocardiography. Tumors were noted in aortic (n = 2), mitral (n = 1) and tricuspid (n = 1) sites. Indications for surgery were myocardial infarction (both aortic tumors), previous stroke (mitral tumor), and preventive (tricuspid tumor). RESULTS: Surgical excision with a conservative, valve-sparing approach was performed in all cases. For the first aortic tumor, the aortic valve was reconstructed with a patch of autologous pericardium. None of the patients had evidence of valvular regurgitation after excision on intraoperative transesophageal echocardiography, and all had an uneventful recovery. There were no cases of recurrence or regurgitation on follow up echocardiography. CONCLUSION: PFE is an uncommon but increasingly recognized cause of embolic phenomena. Prompt identification allows for surgical excision, which seems to be curative, safe and well-tolerated. A conservative valve-sparing approach is recommended because of the absence of recurrence after total excision.     

Interaction of calbindin D28k and inositol monophosphatase in human postmortem cortex: possible implications for bipolar disorder

OBJECTIVES: Therapeutically relevant concentrations of lithium (Li) exert an uncompetitive inhibition on inositol monophosphatase (IMPase). It has recently been shown that calbindin D28k (calbindin) activates IMPase. Purified calbindin attaches to a specific amino acid sequence on purified IMPase enhancing its activity by several hundred fold. We studied whether calbindin activates IMPase in postmortem human brain crude homogenate, whether differences in calbindin levels between lymphocytes and brain may be responsible for our previous finding of reduced IMPase activity in lymphocytes but not brain of bipolar patients, and whether calbindin protein levels are altered in postmortem brain from bipolar patients versus control subjects and schizophrenic and major depressive patients. METHODS: IMPase activity in human postmortem brain specimens with or without 10 microM human recombinant calbindin was quantified spectrophotometrically in an enzyme-linked immunosorbent assay (ELISA) reader. Calbindin protein levels in postmortem brain were determined using Western blot analysis. RESULTS: Supplementation of human recombinant calbindin to postmortem human brain crude homogenate enhanced IMPase activity by 3.5-fold. No difference in postmortem temporal cortex calbindin protein levels was found between bipolar patients versus comparison groups. Two-fold higher calbindin protein levels were found in Li-treated bipolar patients compared with other bipolar patients. Subchronic Li treatment in mice did not affect brain calbindin protein levels significantly. Chronic Li treatment reduced calbindin protein levels in the frontal cortex but not in the hippocampus. CONCLUSIONS: Calbindin is a physiological activator of IMPase in human brain. Protein levels of calbindin are not altered in postmortem temporal cortex of bipolar patients.     

Transient decrease of neutrophil chemotaxis following aerobic exercise

PURPOSE: Intense exercise affects the immune system, increasing the susceptibility of athletes to viral and bacterial infections. We have previously shown a significant decrease of fMLP-neutrophil migration 24 h after aerobic exercise. In this study we aimed to look at the differential effect of different chemoattractants on neutrophil migration following aerobic exercise, to determine the recovery time, and to better understand the role of the cell skeleton behind the impaired chemotaxis. METHODS: Sixteen female volunteers aged 22-30 yr were tested before, 24, and 48 h after aerobic exercise (30 min running at 70% (.)VO(2max). The submaximal exercise test was conducted a week after the (.)VO(2max) test.We studied the membrane cell receptor response to fMLP, IL-8, and C5a, which have specific ligand-receptor pathways. Further, we studied the cytoskeletal response by investigating the cell polarization and the F-actin polymerization. RESULTS: Significant decrease of the neutrophil net chemotaxis was detected with fMLP, IL-8 and C5a, 24 h after exercise (50 +/- 5%, P = 0.0001; 48 +/- 12%, P = 0.0015; and 32 +/- 11%, P = 0.011, respectively). Complete recovery was observed within 48 h with all chemoattractants. Normal neutrophil random migration and F-actin polymerization were found. Decreased neutrophil polarization was detected (46 +/- 6% vs 22 +/- 8% of polarized cells, before and after effort, respectively; P = 0.004). Correlation between polarization and chemotactic migration was found (r = 0.945; P = 0.001). CONCLUSIONS: The impaired chemotactic response, observed 24 h after exercise, was similar using different chemoattractants. This finding indicates a possible exercise-induced effect on a common factor at the ligand-receptor level. The abnormal cell polarization indicates skeletal dysfunction that should be further investigated and elucidated. The normal fMLP-stimulated-F-actin polymerization reflects an adequate pathway of signal transduction for the formyl peptide.     

Suicide bombing attacks: update and modifications to the protocol

OBJECTIVE: To review the experience of a large-volume trauma center in managing and treating casualties of suicide bombing attacks. SUMMARY BACKGROUND DATA: The threat of suicide bombing attacks has escalated worldwide. The ability of the suicide bomber to deliver a relatively large explosive load accompanied by heavy shrapnel to the proximity of his or her victims has caused devastating effects. METHODS: The authors reviewed and analyzed the experience obtained in treating victims of suicide bombings at the level I trauma center of the Hadassah University Hospital in Jerusalem, Israel from 2000 to 2003. RESULTS: Evacuation is usually rapid due to the urban setting of these attacks. Numerous casualties are brought into the emergency department over a short period. The setting in which the device is detonated has implications on the type of injuries sustained by survivors. The injuries sustained by victims of suicide bombing attacks in semi-confined spaces are characterized by the degree and extent of widespread tissue damage and include multiple penetrating wounds of varying severity and location, blast injury, and burns. CONCLUSIONS: The approach to victims of suicide bombings is based on the guidelines for trauma management. Attention is given to the moderately injured, as these patients may harbor immediate life-threatening injuries. The concept of damage control can be modified to include rapid packing of multiple soft-tissue entry sites. Optimal utilization of manpower and resources is achieved by recruiting all available personnel, adopting a predetermined plan, and a centrally coordinated approach. Suicide bombing attacks seriously challenge the most experienced medical facilities.