Sleep Disorders

LOS ANGELES ? Children with headaches are more likely to be overweight or obese, researchers said here.

LOS ANGELES - During the last three months of their tours of duty in Iraq, U.S. soldiers were prone to twice as many migraines as the general population, according to army researchers.

UPPSALA, Sweden - A nighttime increase in diastolic blood pressure, or blood pressure that fails to dip at night, are significant independent predictors of congestive heart failure, researchers here reported.

SALT LAKE CITY - Don't change your alarm clock for the weekend, recommends an Australian researcher. Sleeping late on Saturday and Sunday mornings may make you more tired and cranky on Monday and Tuesday.

SALT LAKE CITY - A restless leg syndrome diagnosis can be ruled out by a single question, a researcher said here.

SALT LAKE CITY - Adherence to treatment with continuous positive airway pressure (CPAP) by patients with obstructive sleep apnea may be considerably less than believed.

SALT LAKE CITY - The sedative Ambien (zolpidem) appears to reduce the symptoms of central sleep apnea, according to a small open-label study reported here.

SALT LAKE CITY - A 200-mg jolt of caffeine every two hours can keep sleepless people functioning at about 100% of normal for 48 hours, according to researchers here.

SALT LAKE CITY - Rozerem (ramelteon), a melatonin agonist, was found both safe and effective in a laboratory model of transient insomnia.

SALT LAKE CITY - Americans aren't having nightmares-or dreams of any kind-that replay the 9/11 attack on New York, according to sleep researchers.

SALT LAKE CITY - An extreme form of sleep-walking - having sex while asleep - is probably much more common than physicians have previously suspected, researchers reported here.

PHOENIX, Ariz. - A simple but reliable way to distinguish psychogenic nonepileptic seizures from epilepsy is to look at the patient's eyes, researchers here reported.

ROCKVILLE, Md. - The FDA today approved Wellbutrin XL (bupropion extended release) for prevention of major depressive episodes in patients with a history of seasonal affective disorder (SAD). It is the first drug approved for SAD.

ATLANTA ? Women who take yoga classes for two hours a week may feel healthier while undergoing radiation treatment for breast cancer researchers reported here.

ROTTERDAM, The Netherlands ? Liver transplant recipients report being physically fatigued even 15 years after receiving a new organ, according to researchers here.

Patients with psychiatric disordersoften present a diagnostic challenge-even for psychiatrists. Their demeanormay not readily reveal the nature orseverity of the problem. Nevertheless,there are clues that can help you sortthrough the differential and arrive atthe correct diagnosis.

Pulmonary arterial hypertension (PAH) can be difficult to diagnose because the symptoms are nonspecific and the physical findings are usually subtle (Table). In 2004, the American College of Chest Physicians (ACCP) published clinical practice guidelines for the diagnosis and management of PAH.1 Highlights of the ACCP's recommendations for patient assessment include the following:

abstract: Pulmonary arterial hypertension (PAH) is 1 of 5 types of pulmonary hypertension (PH). Symptoms may include dyspnea on exertion, fatigue, near-syncope, and palpitations. Physical findings include lower extremity edema, jugular venous distention, and a loud P2. Findings on chest radiography, transthoracic echocardiography, and electrocardiography can suggest the presence of PAH; however, right heart catheterization is the gold standard for confirming the diagnosis and for differentiating PAH from other forms of PH. It is essential to exclude chronic thromboembolic PH, since this can be surgically corrected. The treatment of PAH depends on the severity. In addition to the standard treatments, such as diuretics and anticoagulation, more advanced treatment options include prostaglandin therapy (epoprostenol, treprostinil, and iloprost), endothelin receptor antagonists (bosentan), and phosphodiesterase inhibitors (sildenafil).

A 15-year-old boy complains of moderate to severe headaches that occur daily and usually last all day; the pain typically worsens toward the end of the day. How will you help this patient?

A 60-year-old woman complains that she has had "no energy" for the past 6 months. She wants to know how she can get a better night's sleep and inquires about new insomnia medications she has seen advertised on television.

Abstract: A number of factors can complicate the diagnosis of asthma in elderly patients. For example, the elderly are more likely to have diseases such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) that--like asthma--can cause cough, dyspnea, and wheezing. Spirometry can help distinguish asthma from COPD, and chest radiography and measurement of brain natriuretic peptide levels can help identify CHF. Important considerations in the management of asthma include drug side effects, drug interactions, and difficulty in using metered-dose inhalers. When discussing the goals of therapy with the patient, remember that quality-of-life issues, such as the ability to live independently and to participate in leisure activities, can be stronger motivators than objective measures of pulmonary function. (J Respir Dis. 2006;27(6):238-247)

Man With Worsening Cough and Dyspnea

Abstract: The management options for persons with obstructive sleep apnea-hypopnea syndrome (OSAHS) include lifestyle changes, continuous positive airway pressure (CPAP), oral appliances, and surgery. Lifestyle modifications work best in persons with mild OSAHS and may include weight loss and cultivation of good sleep habits, such as not sleeping supine. Before initiating CPAP therapy, polysomnography is recommended to determine the best airway pressure for the patient. Although the benefits of CPAP have been well documented, compliance remains an issue; some difficulties may be alleviated through patient/partner education and close follow-up. Oral appliances, which work by mechanically enlarging or stabilizing the upper airway, are preferred by some patients; however, they are less effective than CPAP at reducing the apnea-hypopnea index. Surgical interventions to alleviate upper airway obstruction can be used in select patients. (J Respir Dis. 2006;27(5):222-227)

An 84-year-old woman presented with a 10-month history of dysphagia to solids and a 4-month history of dysphagia and coughing to liquids. She was severely dehydrated and cachectic; over the past 10 months, she had lost 16.2 kg (36 lb). Rhonchi and gurgling sounds were audible on auscultation of the chest.

Initiation of early aggressive therapy is critical to averting fatal outcomes in exacerbations of acute life-threatening asthma.

A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.

The line on the gums of this 30-year-old man indicates lead poisoning. The patient had been employed for 8 months at a lead smelting plant in which no occupational safety precautions had been enforced. He was admitted to the hospital with the classic symptoms and signs of lead poisoning--pain in the nape of the neck that radiated down the spine, posterior thighs, and calves to the plantar aspect of the feet; colicky panabdominal pain; anorexia; weight loss; nausea; vomiting; constipation; bone and muscle tenderness; hyperesthesia of all extremities; insomnia; irritability; generalized weakness; malaise; and dizziness.

Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in theliver. The HCV genotype is 1A.

A 41-year-old man is admitted for evaluation of acutechest pain, which started while he was watchingtelevision after dinner. The retrosternal pain was sudden,severe, pressing, and stabbing; it radiated to the neck andwas associated with dizziness and diaphoresis. The patientrated the pain as 9 on a scale of 1 to 10 (10 being the mostsevere). In the emergency department, he was given2 sublingual nitroglycerin tablets, which promptly relievedhis pain.

Delirium in older adults needs to berecognized early and managed as amedical emergency. Prompt detectionand treatment improve both shortandlong-term outcomes.1,2 Becausedelirium represents one of the nonspecificpresentations of illness in elderlypatients, the disorder can be easilyoverlooked or misdiagnosed. Misdiagnosismay occur in up to 80% of cases,but it is less likely with an interdisciplinaryapproach that includes inputfrom physicians, nurses, and familymembers.3