Electrophysiological and Neuropsychological Indices of Cognitive Dysfunction in Patients with Chronic Insomnia and Severe Benzodiazepine Use Disorder.

Benzodiazepine (BDZ) misuse is a growing health problem, with 1-2% of patients under BDZ treatment meeting the criteria for use disorder or dependence. Although BDZ addiction potential has been known for decades, much remains unknown its effects on brain functions. The aim of this study was to assess the neuropsychological and neurophysiological profile of a group of chronic insomniacs taking long-term high doses of benzodiazepine. We recruited 17 consecutive patients admitted to our third-level Sleep Medicine Unit for drug discontinuation (7 males, mean age 49.2 ± 11.2 years, mean education 13.7 ± 3.9 years, mean daily diazepam-equivalent BDZ: 238.1 ± 84.5 mg) and 17 gender/age-matched healthy controls (7 males, mean age 46.8 ± 14.1 years, mean education 13.5 ± 4.5 years). We performed a full neuropsychological evaluation of all subjects and recorded their scalp event-related potentials (Mismatch-Passive Oddball-Paradigm and Active Oddball P300 Paradigm). Patients with chronic insomnia and BDZ use disorder showed a profound frontal lobe executive dysfunction with significant impairment in the cognitive flexibility domain, in face of a preserved working, short and long-term memory. In patients, P300 amplitude tended to be smaller, mainly over the frontal regions, compared to controls. BDZ use disorder has a severe cognitive impact on chronic insomnia patients. Long-term high-dose BDZ intake should be carefully evaluated and managed by clinicians in this specific patient population, especially in relation to risky activities

Obstructive sleep apnea: brain structural changes and neurocognitive function before and after treatment

The paper assesses the effect of obstructive sleep apnea on brain structure and cognitive performance, and the changes after treatment with Continuous Positive Airway Pressure. The main finding is that cognitive impairment is associated with a decrease of grey-matter volume in specific cerebral regions, and that these can be reversed by treatment with an increase of grey-matter volume in specific hippocampal and frontal brain regions. These changes are significantly correlated with the improvement in specific neuropsychological tests (executive-functioning and short-term memory), underlining the importance of early diagnosis and treatment of sleep apnea. Specific neuropsychological measures represent valuable tools for the assessment of therapy success, and can offer the evidence that adherence to treatment can lead not only to clinical, but also to brain-structural, recovery. Objectives: To investigate the cognitive deficits and the corresponding brain morphology changes in OSA, and the modifications after treatment, using combined neuropsychological testing and Voxel-Based-Morphometry. Methods: 17 treatment-naïve sleep apnea patients and 15 age-matched healthy controls. All underwent a sleep study, cognitive tests and magnetic resonance imaging. After threemonths treatment, cognitive and imaging data were collected to assess therapy efficacy. Measurements and Main Results: Neuropsychological results in pre-treatment OSA showed impairments in most cognitive areas, as well as in mood and sleepiness. These impairments were associated with focal reductions of grey-matter volume in the left hippocampus (enthorinal cortex), left posterior parietal cortex and right superior frontal gyrus. After treatment, we observed significant improvements involving memory, attention and executive-functioning that paralleled grey-matter volume increases in hippocampal and frontal structures. Conclusions: The cognitive and structural deficits in obstructive sleep apnea may be secondary to sleep deprivation and repetitive nocturnal intermittent hypoxemia. These negative effects may be recovered by consistent and throughout treatment. Our findings highlight the importance of early diagnosis and successful treatment of this disorder

The paradox of paradoxical insomnia: A theoretical review towards a unifying evidence-based definition

Paradoxical insomnia is one of the most intriguing yet challenging subtypes of insomnia. Despite being recognized for a long time by the international community, it is still unclear whether this entity really exists, which are its features and boundaries. Much of the debate is fuelled by the lack of a consensus on its precise definition. To help filling some of the existing gaps, a systematic review of the literature was conducted, through which 19 different quantitative definitions were obtained. These definitions were then applied to two distinct datasets. The first consisted of 200 chronic primary insomnia patients, diagnosed according to the DSM-IV-TR criteria. The second consisted of 200 age- and sex-matched healthy persons without insomnia. For each dataset, available data from the objective sleep parameters and their subjective estimation were imported and analysed in MATLAB. Depending on the definition used, the prevalence of paradoxical insomnia ranged from 8 to 66%, while agreement between different definitions ranged from −0.19 to 0.9 (using Cohen's kappa coefficient). Based on the results garnered, necessary features for a quantitative definition of paradoxical insomnia were identified. Several open questions remain, such as whether there is a minimum number of hours a patient should sleep to fulfill the criteria for a diagnosis of paradoxical insomnia, and whether sleep latency can be used in the definition along with total sleep time. We conclude by advocating continued study of paradoxical insomnia and sleep state misperception and by providing specific directions for future research. The current understanding of paradoxical insomnia and, more broadly, of sleep state misperception, is greatly hampered by the lack of agreement on a quantitative and evidence-base measure of the discrepancy between subjective and objective sleep evaluation. The current study provides a critical analysis about the strength and the limitations of the available definitions, using both a data-driven and a theory-driven approach. The overarching goal is to motivate a rigorous discussion involving the main experts of the field, to build a consensus, and develop an evidence-based measure of sleep state misperception and/or of paradoxical insomnia

CHIRURGIA IN REGIME DI DAY SURGERY: NOSTRA ESPERIENZA

Con il termine day-surgery s’intende la possibilità clinica, organizzativa ed amministrativa di effettuare interventi chir u rgici o procedure diagnostiche e/o terapeutiche invasive e semiinvasive in regime di ricovero limitato alle sole ore del giorno, in anestesia locale, loco-regionale o generale (1) . Scopo del nostro lavoro è di valutare l’attività di daysurgery integrata nel nostro reparto di chirurgia general