Introduction Olfaction has an important role in physiological and affective processes, as well as the potential to have profound effects on activities such as sleep and learning. We investigated two commercially manufactured odors ("Deep Sleep" and "Oriental," from This Works) purported to promote sleep, compared with control odor, where we aimed to explore whether neural and behavioral differences existed after odor inhalation. Methods In a neuroimaging study, 30 healthy participants were exposed to the odors via an olfactometer during functional magnetic resonance imaging (fMRI). In a further behavioral study using 12 chronic insomniacs, we investigated whether the commercial odors showed effects on sleep during a double-blind, randomized home evaluation. Results In the neuroimaging, the odors were related to activation of olfactory-relevant areas, such as the orbitofrontal cortex, and we found positive connectivity between the piriform cortex and the hippocampus, amygdala, insula, and middle cingulate cortex. Deep Sleep specifically activated the superior temporal gyrus, whereas Oriental activated the caudate. Further, these commercial odors showed some beneficial impact on sleep. Conclusions The perceptual and neural impacts of the commercial odors showed that olfactory stimulation can potentially aid sleep and modify affective processes in a number of ways. Implications The present work opens up opportunities for further investigations into how different odors may lead to specific behavioral and physiological modifications, such as their impact on sleep and well-being, which may provide non-pharmacological alternative approaches.

In homeostasis, somatosensory C fibre afferents are hypothesised to mediate input to the brain about interactions with external stimuli and sympathetic efference provides the output that regulates bodily functions. We aimed to test this hypothesis and whether different types of innocuous somatosensory input have differential effects. Healthy volunteers performed a muscle fatigue (hand-grip) task to exhaustion, which produces increased muscle sympathetic nerve activity (MSNA), as measured through microneurography. Participants completed the muscle fatigue task without concurrent cutaneous sensory stimulation (control) or we applied skin warming (heat pack) as a C fibre stimulation, slow brush stroking as C and A beta fibre stimulation, or vibration as A beta fibre stimulation, to the participants forearm. We also measured heart rate, the duration of the hand-grip task, and ratings of pain at the end of the task. Concurrent skin warming showed increased MSNA compared to the other conditions. Tactile stimuli (brushing, vibration) were not significantly different to the control (no intervention) condition. Warming increased the pain from the muscle contraction, whereas the tactile stimuli did not. We interpret the effect of warming on MSNA as providing relevant afferent information during muscle contraction, which needed to be counteracted via vasoconstriction to maintain homeostasis. Brushing and vibration were less homeostatically relevant stimuli for the muscle contraction and hence had no significant effect. The findings add sensory specificity to our current understanding of homeostatic regulation through somatosensory afferent and sympathetic efferent pathways.

When treating patients with orthognathic surgery, there might be a risk of obstructive sleep apnoea (OSA) due to soft tissue changes in the upper airways, especially in patients treated with isolated mandibular setback or mandibular setback in combination with maxillary advancement. In the present study, we assessed respiratory function during sleep with home cardiorespiratory polygraphy in 62 patients who had not been previously been diagnosed with OSA at three times: prior to orthognathic surgery for aesthetic and functional indications, and then 3 months and 1 year after surgery. We evaluated surgical displacement based on measurements in three dimensions using pre- and post-operative computed tomography. There were only minor changes in the respiratory parameters such as the apnoea-hypopnoea index (AHI), the apnoea-hypopnoea index in the supine position (AHIsup), the oxygen saturation index (ODI) and the snore index. There was no significant correlation between surgical displacement and the AHI, AHIsup and ODI. There was a weak but significant correlation between vertical displacement of the anterior mandible and the snore index. Within the limitations of the present study, the risk for iatrogenic obstruction of the upper airways seems to be low in patients without OSA treated with orthognathic surgery.

Introduction: In orthognathic surgery, understanding the patients motives for treatment is a key factor for postoperative patient satisfaction and treatment success. In countries/systems where orthognathic surgery is funded by public means, patients are referred mainly due to functional problems, although studies of quality of life related changes after treatment indicate that psychosocial and aesthetic reasons might be equal or more important for the patient. There is no available validated condition specific instruments in the Swedish language for quality of life evaluation of patients with dentofacial deformities. Aims/objectives: Cross cultural translation and adaptation of the English-language instrument Orthognathic Quality of Life Questionnaire (OQLQ) into Swedish. Methods: OQLQ was translated into Swedish. A total of 121 patients in four groups were recruited and the Swedish version of the OQLQ (OQLQ-S) was tested by psychometric methods. Reliability was assessed by internal consistency and test-retest reliability. Validity was evaluated by face, convergent and discriminant validity. Results/findings and conclusions: OQLQ-S is reliable and showed good construct validity and internal consistency and can be used in a Swedish speaking population as a complement to clinical variables to evaluate patients with dentofacial deformity.

Continuous positive airway pressure is a common and effective treatment for obstructive sleep apnea, but adherence remains an issue. Both obstructive sleep apnea and oral diseases are associated with cardiovascular diseases, and as oral dryness contributes to treatment abandonment, oral health is of importance for this patient group. The aim was therefore to explore how persons with continuous positive airway pressure-treated obstructive sleep apnea experience situations associated with their oral health, and which actions they take to manage these. An explorative and descriptive design was adopted using the critical incident technique. Based on a purposeful selection, 18 adults with long-term experience of continuous positive airway pressure-treatment were interviewed using a semi-structured interview guide. Both negative and positive situations were described. Negative situations consisted of challenges with breathing, including mouth-breathing, choking sensations, problems with night-time and daytime oral dryness, changes in the saliva composition, and deteriorating oral health. Positive situations included experiences of reduced mouth-breathing and oral dryness. The situations were often successfully managed by mimicking daytime movements, changing sleeping position, adjusting the CPAP-device and mask, increasing oral hygiene efforts, drinking water, using a humidifier or chinstrap, or contacting their oral healthcare clinic. Long-term experience of persons with continuous positive airway pressure-treated obstructive sleep apnea regard situations and actions from everyday life. Successful management can contribute to long-term adherence and decrease negative effects on oral health. More interdisciplinary collaborations could enable identification and adequate recommendations for persons who experience negative situations during their continuous positive airway pressure treatment.

Introduction Oral health is part of general health, and oral diseases share risk factors with several non-communicable diseases. The World Dental Federation (FDI) has published a theoretical framework illustrating the complex interactions between the core elements of oral health (CEOHs): driving determinants, moderating factors, and general health and well-being. However, the framework does not specify which self-reported or clinical measurements to be included in the CEOHs. Objectives To explore oral health measurements relevant for a general adult population to be included in the CEOHs in the FDIs theoretical framework of oral health. Materials and methods A psychometric study was performed, using cross-sectional data from Sweden (N = 630, 54% women, mean age 49.7 years). The data set initially consisted of 186 self-reported and clinical measurements. To identify suitable measurements, the selection was discussed in different settings, including both experts and patients. Principal component analyses (PCAs) were performed to explore, reduce and evaluate measurements to be included in the three CEOHs. Internal consistency was estimated by Cronbachs Alpha. Results The validation process yielded 13 measurements (four clinical, nine self-reported) in concordance with the CEOHs. PCAs confirmed robust validity regarding the construction, predicting 60.85% of variance, representing psychosocial function (number of measurements = 5), disease and condition status (number of measurements = 4), and physiological function (number of measurements = 4). Cronbachs Alpha indicated good to sufficient internal consistency for each component in the constructs (alpha = 0.88, 0.68, 0.61, respectively). Conclusion In a Swedish general adult population, 13 self-reported and clinical measurements can be relevant to include to operationalise CEOHs in the FDIs theoretical framework.

BackgroundOral diseases have been associated with cardiovascular diseases, and persons with continuous positive airway pressure [CPAP]-treated obstructive sleep apnoea [OSA] have an increased risk for negative consequences for both oral and general health. CPAP treatment is often life-long and adherence to treatment is essential. Xerostomia is a common side-effect which can lead to treatment abandonment. Oral health is a changeable part of our general health and well-being and exploring the views of oral health determinants from persons with experience of CPAP-treatment is important to prevent adverse oral health outcomes. The purpose of this study was to explore what persons with experience of CPAP-treated OSA view as determinants for their oral health.MethodsEighteen persons with long-term experience of CPAP-treated OSA were purposively selected. Data were collected by semi-structured individual interviews. A code book based on the World Dental Federations [FDI] theoretical framework for oral health was developed and used to analyse the data using directed content analysis. The domains in the frameworks component driving determinants were used as pre-determined categories. Using the description of driving determinants as a guide, meaning units were extracted from the interview transcripts through an inductive approach. Then, by employing a deductive approach the code book was used to categorise the meaning units into the pre-determined categories.FindingsThe views on oral health determinants described by the informants were compatible with the five domains in the component driving determinants in the FDIs theoretical framework. Ageing, heredity, and salivation (biological and genetic factors), influences from family and the wider society (social environment), location and re-localisation (physical environment), oral hygiene habits, motivation, willingness to change, professional support (health behaviours), and availability, control, finances, and trust (access to care) were viewed as important oral health determinants by the informants.ConclusionThe study points to a variety of individual oral health-related experiences that oral healthcare professionals could consider when designing interventions to reduce xerostomia and prevent adverse oral health outcomes for persons undergoing long-term CPAP-treatment.

Introduction: The World Dental Federation (FDI) has recently proposed a new definition and theoretical framework of oral health. The theoretical framework includes 4 main components and describes the relationships amongst them. In 2020, an international work group proposed the minimum Adult Oral Health Standard Set (AOHSS) of variables to measure oral health, which was mapped onto the FDIs theoretical framework. By using an empirical data set, the proposed variables in the AOHSS and the potential interactions amongst the components of the FDIs theoretical framework can be tested. The purpose of this research was to investigate structural relations of the components of the FDIs theoretical framework of oral health based on data from a general adult population. Methods: Data from a previously conducted Swedish cross-sectional study focusing on oral health were utilised (N = 630; women, 55.2%; mean age, 49.7 years [SD, 19.2]). Variable selection was guided by the AOHSS. Structural equation modeling was used to analyse relationships amongst the components of the FDIs theoretical model (core elements of oral health, driving determinants, moderating factors, and overall health and well-being). Results: The Oral Health Impact Profile (OHIP)-14, xerostomia, and aesthetic satisfaction had statistically significant direct effects on overall health and well-being (p < .05). Driving determinants and moderating factors had statistically significant direct effects on all core elements of oral health (p < .05) except aesthetic satisfaction (p = .616). The predictors explained 24.1% of the variance of the latent variable overall health and well-being. Based on several indices, the proposed model showed acceptable model fit. Conclusions: The FDIs theoretical framework can be used to describe different components of oral health and the relationship amongst them in an adult general population. Further research based on the FDIs theoretical framework in other populations and settings is needed to explore complex interactions and possible relationships that form oral health and to investigate other or additional important social determinants. (C) 2021 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation.

Purpose: Insomnia has adverse effects on people with epilepsy. We aimed to test a novel cognitive behavioral therapy for insomnia (CBT-I) app-based intervention on insomnia symptoms and social psychological factors in people with epilepsy and to examine the possible mechanisms among the factors. Methods: Participants were recruited from neurology clinics in Iran and comprised individuals diagnosed with epilepsy and having moderate to severe insomnia. A two-arm randomized controlled trial design was used, consisting of a treatment group (CBT-I; n = 160) and control group (patient education; n = 160). Primary outcomes were self-reported sleep quality, insomnia severity, and sleep hygiene behavior and objective sleep characteristics measured by actigraphy. Secondary outcomes were attitude, perceived behavioral control, intention, action planning, coping planning, behavioral automaticity, self-monitoring, anxiety, depression, and quality of life (QoL). All outcomes were measured at baseline, and at one, three, and six months postintervention, except objective sleep, which was assessed at baseline, and one and six months postintervention. Data were analyzed using linear mixed models. Results: Current findings showed that sleep quality, insomnia severity, sleep hygiene behavior, and sleep onset latency were significantly improved in the CBT-I group compared with the patient education group at all measurement points. Also, the CBT-I group had significantly improved anxiety, depression, and QoL compared with the patient education group. Mediation analyses showed that attitude, intention, coping planning, self-monitoring, and behavioral automaticity significantly mediated the effect of the intervention on sleep outcomes. Conclusion: Results support the use of the CBT-I app to improve sleep outcomes among people with epilepsy. (C) 2020 Elsevier Inc. All rights reserved.

Purpose of ReviewThe COVID-19 pandemic has promoted behavioral changes and elevated mental distress. Addictive behaviors often increased, generating mental health problems. The present study's primary aim was to investigate associations between different types of behavioral addictions (including behavioral addictions, related conditions, and phenomena) and different types of mental health problems. The secondary aims were: (i) to identify possible sources of heterogeneity and (ii) to explore potential moderators in associations between different types of behavioral addictions (including behavioral addictions, related conditions, and phenomena) and different types of mental health problems.Recent FindingsUsing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), studies from the period between December 2019 and May 2023 were sought from PubMed, Scopus, ISI Web of Knowledge, and Google Scholar in its first ten pages. The articles' relevance was screened and evaluated. The included papers' quality was assessed according to the Newcastle Ottawa Scale. Fisher's Z scores were computed to present magnitudes of associations and I2 indices were used to estimate levels of heterogeneity in the meta-analysis. Among the 85 included studies (N = 104,425 from 23 countries; mean age = 24.22 years; 60.77% female), most were internet-related behavioral addictions, related conditions, and phenomena (28 studies on social media, 25 on internet, 23 on smartphone, and 12 on gaming). The pooled estimation of the associations showed that higher levels of behavioral addictions, related conditions, and phenomena related to internet use (regardless of type) were associated with more mental health problems (regardless of which type). Moderator analyses showed that almost no variables affected heterogeneity for the founded associations.SummaryMost studies of behavioral addictions, related conditions, and phenomena focused on internet-related behaviors, with studies suggesting relationships with specific types of mental health problems during the COVID-19 pandemic. Moreover, associations between behavioral addictions (including behavioral addictions, related conditions, and phenomena) and mental health problems found in the present systematic review and meta-analysis were comparable to the associations identified in studies conducted before the COVID-19 pandemic. How to help people reduce internet-related behavioral addictions, related conditions, and phenomena and address associated mental health concerns are important topics for healthcare providers.

Background: The emerging novel coronavirus disease 2019 (COVID-19) has become one of the leading cause of deaths worldwide in 2020. The present systematic review and meta-analysis estimated the magnitude of sleep problems during the COVID-19 pandemic and its relationship with psychological distress. Methods: Five academic databases (Scopus, PubMed Central, Pro Quest, ISI Web of Knowledge, and Embase) were searched. Observational studies including case-control studies and cross-sectional studies were included if relevant data relationships were reported (i.e., sleep assessed utilizing the Pittsburgh Sleep Quality Index or Insomnia Severity Index). All the studies were English, peer-reviewed papers published between December 2019 and February 2021. PROSPERO registration number: CRD42020181644. Findings: 168 cross-sectional, four case-control, and five longitudinal design papers comprising 345270 participants from 39 countries were identified. The corrected pooled estimated prevalence of sleep problems were 31% among healthcare professionals, 18% among the general population, and 57% among COVID-19 patients (all p-values < 0.05). Sleep problems were associated with depression among healthcare professionals, the general population, and COVID-19 patients, with Fishers Z scores of -0.28, -0.30, and -0.36, respectively. Sleep problems were positively (and moderately) associated with anxiety among healthcare professionals, the general population, and COVID-19 patients, with Fishers z scores of 0.55, 0.48, and 0.49, respectively. Interpretation: Sleep problems appear to have been common during the ongoing COVID-19 pandemic. Moreover, sleep problems were found to be associated with higher levels of psychological distress. With the use of effective programs treating sleep problems, psychological distress may be reduced. Vice versa, the use of effective programs treating psychological distress, sleep problems may be reduced. (C) 2021 The Author(s). Published by Elsevier Ltd.

The effects of cognitive behavioral therapy for insomnia (CBT-I) have consistently been shown to improve insomnia symptoms and other health-related outcomes, but the effects on QoL have been inconsistent. Many factors including the type CBT-I delivery and type of instrument used to assess QoL make the topic complex. The present systematic review and meta-analysis synthesized the evidence of CBT-I efficacy on QoL outcomes across different populations, delivery modes, and methodological aspects. Following the guidelines on preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a literature search was conducted through PubMed, Web of Science, Scopus, and PsycINFO using keywords from relevant MeSH terms based on PICOS (Participants, Intervention, Comparison, Outcome and Study) criteria. Clinical trials investigating the effect of CBT-I as an intervention on QoL with any kind of control group were eligible if they reported mean scores and variation of QoL. Meta-analysis using a random-effect model was conducted to calculate the standardized mean differences (SMDs) in a set including all identified studies, as well as in three sub-sets: face-to-face CBT-I using randomized controlled trials (RCTs), online CBT-I using RCTs, and one-group pre- and post-treatment design. A total of 24 studies comprising 1977 participants (808 in an intervention group) from 12 countries were eligible for meta-analysis. The overall pooled estimate of SMD of QoL when all 24 studies were included was 0.47 (95% CI: 0.22; 0.72; I-2 = 84.5%; tau(2) = 0.31; p < 0.001). The overall pooled estimate of SMD of QoL was 0.46 (95% CI: 0.01-0.90; I-2 = 87.5%; tau(2) = 0.48, p < 0.001) for intervention groups with face-to-face CBT-I compared to controls; 0.47 (95% CI: 0.02-0.92; I-2 = 88.3%; tau(2) = 0.36; p = 0.04) for intervention groups with digital CBT-I compared to controls, and 0.46 (95% CI: 0.12-0.80; I-2 = 52.9%; tau(2) = 0.07; p = 0.08) for one-group pre- and post-comparison using CBT-I intervention compared to baseline. Moreover, effects of CBT-I on QoL were different across populations (pooled SMD = 0.59 for patients with insomnia; 0.29 for patients with insomnia comorbid with another major disorder; and 0.48 for other conditions) and types of QoL instruments (pooled SMD = 0.36 for disease-specific QoL instrument not on insomnia, 0.43 for generic QoL instrument, and 0.67 for a single-QoL-item instrument). The probability of publication bias was ruled out in overall and design specific sub-group analysis based on funnel plot and Eggers test. In conclusion, this meta-analysis confirmed a moderate, overall effect of CBT-I in improving QoL. However, due to small power and heterogeneity, future studies are needed to better explore the impact of moderating factors such as mode of delivery and type of QoL measure for assessment used.

The pathological use of the internet - conceptualized as internet addiction - might be crucial in initiating and increasing sleep disturbances in the community. While inconsistent evidence is reported regarding the association of internet addiction and sleep disturbances, the severity of this association remains unclear. This systematic review and meta-analysis were conducted to increase our understanding of the relationship between internet addiction and sleep disturbances. A systematic review was conducted through Scopus, PubMed Central, ProQuest, ISI Web of Knowledge, and EMBASE using keywords related to internet addiction and sleep problems. Observational studies (cohort, case-control or cross-sectional studies) focusing on association between internet addiction and sleep disturbances including sleep problems and sleep duration were selected. A meta-analysis using random-effect model was conducted to calculate the odds ratio (OR) for experiencing sleep problems and standardized mean differences (SMDs) for sleep duration. Eligible studies (N = 23) included 35,684 participants. The overall pooled OR of having sleep problems if addicted to the internet was 2.20 (95% CI: 1.77-2.74). Additionally, the overall pooled SMDs for sleep duration for the IA group compared to normal internet users was -0.24 (95% CI: -0.38, -0.10). Results of the meta-analysis revealed a significant OR for sleep problems and a significant reduced sleep duration among individuals addicted to the internet. (C) 2019 Elsevier Ltd. All rights reserved.

Alexithymia, a difficulty identifying and expressing emotions experienced by oneself or others, measurably harms quality of sleep. Research has observed the association between alexithymia and sleep problems; however, the cumulative effect of this association is still unknown. Therefore, this systematic review and meta-analysis was conducted to present scientific evidence regarding the relationship between alexithymia and sleep quality. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, and using relevant keywords, we searched six databases: Scopus, PubMed Central, ProQuest, ISI Web of Knowledge, EMBASE, and Science Direct. We selected observational studies on the association between alexithymia and sleep. We conducted meta-analysis using a random-effect model to calculate the effect size (ES) with Fishers z transformation. Eligible studies (N = 26) in 24 papers included 7546 participants from 12 countries. The entire ES for the association between alexithymia and sleep was 0.44 (95 % CI: 0.31, 0.56). Additionally, patient populations had a larger ES (ES = 0.55; 95 % CI: 0.30, 0.79) than healthy populations (ES = 0.30; 95 % CI: 0.20, 0.41). The results of the present systematic review and meta-analysis revealed a significant association between alexithymia and sleep problems, especially among people with any medical condition.

Objectives Sleep disturbances and delirium are frequently observed complications after surgical aortic valve replacement (SAVR) and transcutaneous aortic valve implantation (TAVI), especially in octogenarian patients. However, a knowledge gap exists on patient experiences of sleep and delirium. In particular, patients long-term sleep and delirium experiences are unknown. This article explores and describes how octogenarian patients suffering from delirium after aortic valve replacement experience their sleep and delirium situation. Design An explorative and descriptive design with a longitudinal qualitative approach was applied. Qualitative content analysis following the recommended steps of Graneheim and Lundman was performed. Setting Patients were included at a tertiary university hospital with 1400 beds. Delirium and insomnia screening was performed at baseline and five postoperative days after aortic valve treatment. For qualitative data, 10 patients were interviewed 6-12 months after treatment with focus on delirium. Five of these patients were reinterviewed 4 years after treatment, with focus on their sleep situation. Participants Inclusion criteria; age 80+, treated with SAVR or TAVI and had experienced delirium after treatment. Results For the initial interview, we included five men and five women, four following TAVI and six following SAVR, mean age 83. One overarching theme revealed from the content analyses; Hours in bed represented emotional chaos. Whereas three subthemes described the patients experiences with sleep and delirium, a cascade of distressful experiences disturbing sleep, the struggle between sleep and activity and elements influencing sleep. Four years after the treatment, sleep disturbances persisted, and patients still remembered strongly the delirium incidences. Conclusions For octogenarian patients, sleep disturbances and delirium are long-term burdens and need a greater attention in order to improve patient care.

Background: Octogenarians with aortic stenosis are an increasing population of patients admitted for surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). Although adequate sleep is important after illness and surgery, it has scarcely been studied in the immediate postoperative phase. Aims: To determine and compare the nature of self-reported sleep and insomnia, and recorded sleep-wake patterns in octogenarians during the in-hospital postoperative phase after SAVR or TAVI. Methods: A prospective cohort design was used that included octogenarian patients undergoing SAVR or TAVI at a regional university hospital. Self-reports were used to document sleep and insomnia, and actigraphy was used to record sleep-wake patterns. Data were collected at baseline preoperatively, and then daily for the first five postoperative days. Results: SAVR patients experienced the most insomnia on postoperative nights later in recovery, while TAVI patients experienced the most insomnia on postoperative nights early in recovery. The median total sleep time, as measured by actigraphy, was 6.4 h, and the median sleep efficiency was 79% for the five postoperative nights, but no differences were found between SAVR and TAVI patients on this parameter. All patients slept more during daytime than at night, with SAVR patients having significantly more total sleep hours for all five days than TAVI patients (p < 0.01). Conclusion: Octogenarians with aortic stenosis had disturbed self-reported sleep, increased insomnia, and disturbed sleep-wake patterns postoperatively, resulting in more daytime sleep and inactivity. In patients undergoing SAVR or TAVI, sleep evolves differently during the in-hospital postoperative phase.

Objective: The objective of this study was to evaluate the diagnostic yield and clinical utility of an automated AI video-based seizure detection device, Nelli (R), (SDD) in pharmacoresistant epilepsy patients. The SDD captures and automatically classifies nocturnal motor behavior suggestive of epileptic seizures or non-epileptic motor behavior of potential clinical value. Methods: Patients with focal epilepsy and pharmacoresistance referred for inpatient long-term video-EEG monitoring were prospectively recruited. Participants were monitored in their home at night with the SDD for a median of 15.5 nights. Captured video recordings were analyzed by clinical experts and each SDD-registration session was classified as diagnostic or not. Clinical utility for each participant was assessed from pre-specified utility measures. The outcome measures were compared between major focal motor and subtle focal motor seizures. Results: One SDD-registration session in each of the 20 participants was performed and analyzed. Video recordings were captured in 18 sessions. Diagnostic yield was found in 11 registration sessions (55.0 %) and clinical utility in 8 registration sessions (40.0 %). No significant difference was found between the AI-algorithm classification and clinical experts' consensus assessment of captured video recordings as epileptic or not. Positive predictive value was 81.8 % for registration sessions containing video recordings classified as epileptic seizures. The diagnostic yield and clinical utility were significantly higher among major focal motor seizures (81.8 % and 63.6 %) compared to subtle focal motor seizures. Significance: The SDD is useful to evaluate patients with pharmacoresistant epilepsy and major focal motor seizures (hyperkinetic, tonic, clonic, focal to bilateral tonic-clonic seizures); it may facilitate the diagnostic process in patients referred for long-term inpatient video-EEG evaluation and beneficially change anti-seizure treatments. The SDD provided accurate classification of major focal motor seizures as epileptic, or non- epileptic, and may serve as a useful diagnostic tool to distinguish epileptic and non-epileptic episodic events with a prominent motor component.

Aim To evaluate cortical excitability with transcranial magnetic stimulation (TMS) in children with new-onset epilepsy before and after antiepileptic drugs (AEDs). Method Fifty-five drug-naive patients (29 females, 26 males; 3-18y), with new-onset epilepsy were recruited from 1st May 2014 to 31st October 2017 at the Child Neurology Department, Queen Silvias Childrens Hospital, Gothenburg, Sweden. We performed TMS in 48 children (23 females, 25 males; mean [SD] age 10y [3y], range 4-15y) with epilepsy (27 generalized and 21 focal) before and after the introduction of AEDs. We used single- and paired-pulse TMS. We used single-pulse TMS to record resting motor thresholds (RMTs), stimulus-response curves, and cortical silent periods (CSPs). We used paired-pulse TMS to record intracortical inhibition and facilitation at short, long, and intermediate intervals. Results There were no differences in cortical excitability between children with generalized and focal epilepsy at baseline. After AED treatment, RMTs increased (p=0.001), especially in children receiving sodium valproate (p=0.005). CSPs decreased after sodium valproate was administered (p=0.050). As in previous studies, we noted a negative correlation between RMT and age in our study cohort. Paired-pulse TMS could not be performed in most children because high RMTs made suprathreshold stimulation impossible. Interpretation Cortical excitability as measured with RMT decreased after the introduction of AEDs. This was seen in children with both generalized and focal epilepsy who were treated with sodium valproate, although it was most prominent in children with generalized epilepsy. We suggest that TMS might be used as a prognostic tool to predict AED efficacy.

Continuous monitoring of electroencephalography (EEG), with a focus on amplitude-integrated EEG (aEEG), has been used in neonatal intensive care for decades. A number of systems have been suggested for describing and quantifying aEEG patterns. Extensive full-montage EEG monitoring is used in specialised intensive care units. The American Clinical Neurophysiology Society published recommendations for defining and reporting EEG findings in critically ill adults and infants. Swedish neonatologists and clinical neurophysiologists collaborated to optimise simplified neonatal continuous aEEG and EEG recordings based on these American documents. Conclusion: This paper describes the Swedish consensus document produced by those meetings.

AIMS: We have evaluated long-term weighted mean HbA_1c (wHbA_1c), HbA_1c variability, diabetes duration, and lipid profiles in relation to the development of diabetic peripheral neuropathy (DPN), nephropathy, and retinopathy in childhood-onset type 1 diabetes.

MATERIALS AND METHODS: In a longitudinal cohort study, 49 patients (21 women) with childhood-onset type 1 diabetes were investigated with neurophysiological measurements, blood tests, and clinical examinations after a diabetes duration of 7.7 (±3.3) years (baseline) and followed with repeated examinations for 30.6 (±5.2) years. We calculated wHbA_1c by integrating the area under all HbA_1c values since the diabetes diagnosis. Lipid profiles were analysed in relation to the presence of DPN. Long-term fluctuations of HbA_1c variability were computed as the standard deviation of all HbA_1c measurements. Data regarding the presence of other diabetes complications were retrieved from medical records.

RESULTS: In this follow-up study, 51% (25/49) of the patients fulfilled electrophysiological criteria for DPN. In nerve conduction studies, there was a deterioration in the amplitudes and conduction velocities for the median, peroneal, and sural nerves over time. Patients with DPN had a longer duration of diabetes, higher wHbA_1c, and increased HbA_1c variability. The lowest wHbA_1c value associated with the development of DPN was 62 mmol/mol (7.8%). The presence of albuminuria and retinopathy was positively correlated with the presence of neuropathy.

CONCLUSIONS: More than half of the patients had developed DPN after 30 years. None of the patients who developed DPN had a wHbA_1c of less than 62 mmol/mol (7.8%).

Objectives Obstructive sleep apnea (OSA) has an impact on an individuals quality of life and general health, and can also affect their oral health. The patients experiences, together with intraoral signs and symptoms could indicate the presence of OSA. Knowledge that the patient has, or is at high risk for having OSA can help the dental healthcare provider maintain the oral health and general health for these patients. The purpose was to explore dentists and dental hygienists experiences when encountering adult patients with potential, untreated and treated OSA. Methods A qualitative inductive approach was used. Experienced dentists and dental hygienists working within Swedish Public Dental Service were strategically selected. Semi-structured face-to-face interviews were performed followed by qualitative content analysis. Results Interviews from 13 participants, seven dental hygienist and six dentists, led to three areas describing varied experience: Importance of the patient encounter and identifying intraoral signs both of which describe experiences related to the importance of the initial unstructured conversation and focused clinical assessments, and strategies for nurturing care which point to interest about care, treatment, and collaborations with medical health care providers. Conclusions Dental professionals are not able to consistently recognize patients who have, or are at high risk for OSA. During the patient encounter, is it important to determine if a patient is at risk for, or has oral signs of OSA.

Objective/BackgroundThe Consensus Sleep Diary (CSD) is widely used to assess subjective sleep. Psychometric evaluations and focus-groups support its validity and clinical usefulness, but further research into its validity is needed. The aim of the study was to evaluate a Swedish translation of the CSD regarding test content and response processes in patients with insomnia.Patients/MethodsIn connection with translating the CSD into Swedish, we used cognitive interviewing to evaluate test content and the response process, that is, how people make decisions when responding to survey items. Cognitive interviews were conducted with 13 primary health care patients with insomnia disorder (mean age, 49 years; SD 15.5). Iterative, reparative analysis was used to investigate test content. Descriptive deductive analysis was used to investigate interview transcripts for the themes of the cognitive model: comprehension, retrieval, decision process, and judgement. Together, the themes explain the response process when responding to a patient-reported outcome measure.ResultsThe overall comprehension of the CSD could be affected by poor adherence to the instructions (comprehension). Patients had difficulty with recall if they did not complete the diary immediately in the morning and just before bedtime (retrieval). They could have problems deciding how to respond to certain items because they imbued sleep-related concepts with extra meaning (decision process), and had trouble finding response alternatives nuanced enough to describe their experience of sleep and tiredness (judgement).ConclusionsThis study contributes knowledge on how the instrument is perceived and used by care-seeking patients with insomnia. In this context, the CSD exhibits known flaws such as memory lapses if the diary is not filled in directly in the morning. To increase the accuracy of patients' responses, therapists should support patients in reading the instructions.

Restless legs syndrome (RLS) is a common neurological disorder characterised by an urge to move arms and legs, usually associated with discomfort, pain, motor restlessness, and sleep disturbance. An individually adapted treatment is needed but difficult to optimise, which makes shared decision-making (SDM) important. However, brief validated instruments on how patients with RLS perceive their involvement in treatment decisions are lacking. Therefore, the aim was to validate two instruments, SURE (Sure of myself, Understand information, Risk-benefit ratio, Encouragement, i.e., to assess decisional conflict) and CollaboRATE (brief patient survey focused on SDM, i.e., to assess SDM), in patients with RLS. A cross-sectional design, including 788 participants with RLS (65% females, mean [SD] age 70.8 [11.4] years) from a national patient organisation for RLS, was used. A postal survey was sent out to collect data regarding weight, height, comorbidities, demographics, and RLS-related treatment data. The following instruments were included: the SURE, CollaboRATE, Restless Legs Syndrome-6 Scale, and eHealth Literacy Scale. Confirmatory factor analysis and Rasch models were used to assess the validity and reliability of the SURE and CollaboRATE. Measurement invariance, unidimensionality, and differential item functioning (DIF) across age, gender, and medication groups were assessed. The SURE and CollaboRATE were both identified as unidimensional instruments with satisfactory internal consistency. No DIF across age and gender was identified, while significant DIF was observed for both the SURE and CollaboRATE regarding medication use categories. However, both the SURE and CollaboRATE are potential instruments to be used in research, but also as reflection tools by healthcare professionals, patients, and students to explore and assess SDM, and support its development in clinical care.

Background: Patients with anorexia nervosa exhibit higher levels of behaviours typically associated with autism-spectrum disorder (ASD), but the neural basis is unclear. We sought to determine whether elevated autistic traits in women with anorexia nervosa may be reflected in cortical morphology. Methods: We used voxel-based morphometry (VBM) to examine regional grey matter volumes in high-resolution MRI structural brain scans in women with anorexia nervosa and matched healthy controls. The Autism-spectrum Quotient (AQ) scale was used to assess autistic traits. Results: Women with anorexia nervosa (n = 25) had higher AQ scores and lower bilateral superior temporal sulcus (STS) grey matter volumes than the control group (n = 25). The AQ scores correlated negatively with average left STS grey matter volume in women with anorexia nervosa. Limitations: We did not control for cognitive ability and examined only women with ongoing anorexia nervosa. Conclusion: Elevated autistic traits in women with anorexia nervosa are associated with morphometric alterations of brain areas linked to social cognition. This finding provides neurobiological support for the behavioural link between anorexia nervosa and ASD and emphasizes the importance of recognizing autistic traits in preventing and treating-anorexia nervosa.

This systematic review, meta-analysis and meta-regression assessed the prevalence of restless legs syndrome (RLS) in the general adult population. Studies identified in Scopus, PubMed, Web of Science, and PsycInfo between January 2000 and February 2022 were included if they used a case-control or cross-sectional design and reported data regarding the prevalence of RLS. The protocol was pre-registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022300709). A total of 97 studies including 483,079 participants from 33 different countries met the eligibility criteria. The Newcastle Ottawa Scale was used to evaluate the methodological quality, and the fill-and-trim method was used to correct probable publication bias, while the jack-knife method was performed to assess small study effect. The corrected overall pooled prevalence of RLS was 3% (95% confidence interval [CI] 1.4%-3.8%). The pooled prevalence of RLS syndrome was affected by methodological quality (no data from non-respondents in the included studies), gender (higher among women), study design (lower prevalence in case-control versus cohort and cross-sectional studies). The figures for corrected pooled prevalence among men, women, alcohol consumers and smokers were 2.8% (95% CI 2%-3.7%); 4.7% (95% CI 3.2%-6.3%); 1.4% (95% CI 0%-4.2%); and 2.7% (95% CI 0%-5.3%), respectively. The prevalence among male and female participants was lower in community-based versus non-community-based studies. Moreover, the prevalence was higher in developed versus developing countries and among elders versus adults. In conclusion, RLS is a common disorder in the general adult population, with a higher prevalence in women; however, prevalence data are affected by study design and quality.

Objective: The primary aim was to estimate the pooled mean score of quality of life (QoL) (total, mental and physical health components) among patients with Restless Legs Syndrome (RLS). Secondary aims were to assess: (I) QoL differences for RLS vs. control groups, (II) heterogeneity and possible sources; and (III) moderating variables. Methods: Studies identified in PubMed, Scopus, Web of Science, and ProQuest between January 2000 and December 2022 were included. Methodological quality was assessed with Newcastle Ottawa Scale. The protocol was pre -registered (PROSPERO, CRD42023387318). Results: Twenty-seven studies (20121 participants, 12 countries) were included. The corrected pooled estimated mean score of QoL was 47.92 (27 studies, CI 95 %: 43.11 to 52.72, range 0 -100, i.e., low -high QoL) and was marginally affected by publication year (increased 0.89 by each year, p = 0.12). The corrected pooled estimated mean score of the mental health component was 47.32 (17 studies, 95 % CI: 43.12 to 51.51, range 0 -100) and influenced by RLS instrument (decreased with recent versions, p = 0.05). The corrected pooled estimated mean score of the physical health component was 39.08 (17 studies, 95 % CI: 33.05 to 45.10, range 0 -100), with no statistically significant moderator. The pooled estimated QoL scores were statistically significantly lower in RLS patients compared to control groups with standardized mean difference (SMD) of -0.78, -0.57 and -0.50 respectively for overall QoL (24 studies), physical and mental health components (14 studies). Total QoL SMD was affected by proportion of women. Conclusion: Low QoL was revealed among RLS patients, which was statistically significantly reduced compared to control groups.

Adherence to continuous positive airway pressure treatment for obstructive sleep apnea tends to be poor. Communication influences adherence but has not previously been investigated from a practitioner perspective, although shared decision-making is known to be of great importance. The aim was to describe how practitioners experience communication with patients with obstructive sleep apnea during the initial visit at a continuous positive airway pressure treatment clinic, with focus on facilitators and barriers related to the 4 Habits Model, a communication model comprised of four types of interrelated skills to make encounters more patient-centred: investing in the beginning; exploring the patient perspective; showing empathy; and investing in the end. A descriptive design with qualitative content analysis was used. A deductive analysis was carried out based on interviews with 24 strategically selected practitioners from seven continuous positive airway pressure treatment clinics. The 4 Habits Model was used as a framework for identifying facilitators and barriers to communication. Investments in the beginning was described as creating contact, showing the agenda and being adaptive, while explore the patient perspective included showing awareness, being explorative and creating a participating climate. Show empathy consisted of showing openness, being confirmative and creating acceptance, while showing a structured follow-up plan, being open minded and invitational and creating motivation to build on were descriptions of invest in the end. Awareness of potential facilitators and barriers for patient-centred communication during the beginning, middle and end of a continuous positive airway pressure treatment consultation can be used to improve contextual conditions and personal communication competences among practitioners working with continuous positive airway pressure treatment initiation.

Aims and objectives. To describe facilitators and barriers from a patient perspective in communications between patients with obstructive sleep apnoea syndrome and healthcare personnel during the first meeting when continuous positive airway pressure is initiated. Background. Adherence to continuous positive airway pressure treatment tends to be poor, especially at the initial phase of treatment. Communication between the patient and healthcare personnel has not been studied from the patient perspective, as either a barrier or facilitator for adherence. Methods. A descriptive design using qualitative content analysis was used. Interviews with 25 patients with obstructive sleep apnoea syndrome took place after their initial visit at four continuous positive airway pressure clinics. A deductive analysis based on The 4 Habits Model (i.e. emphasise the importance of investing in the beginning of the consultation, elicit the patients perspective, demonstrate empathy and invest in the end of the consultation) was conducted. Results. Building confidence (i.e. structure building, information transfer, commitment) or hindering confidence (i.e. organisational insufficiency, stress behaviour, interaction deficit) was associated with investing in the beginning. Motivating (i.e. situational insight, knowledge transfer, practical training) or demotivating (i.e. expectations, dominance and power asymmetry, barriers) was associated with eliciting the patients perspective. Building hope (i.e. awareness, sensitivity, demonstration of understanding) or hindering hope (i.e. unprepared, uncommitted, incomprehension) was associated with showing empathy. Agreement (i.e. confirmation, responsibilities, comprehensive information) or disagreement (i.e. structural obscurity, irresponsibility, absent-mindedness) was associated with investing in the end. Conclusions. Understanding of facilitators and barriers, as described by patients, can be used to improve contextual conditions and communication skills among healthcare personnel. Relevance to clinical practice. A patient-centred communication technique should be used in relation to all stages of The 4 Habits Model to facilitate shared decision-making and improve adherence to continuous positive airway pressure treatment.

BACKGROUND: Continuous positive airway treatment (CPAP) is the recommended treatment for patients with obstructive sleep apnea (OSA). Outcome measures often focus on clinical and/or self-rated variables related to the medical condition. However, a brief validated instrument focusing on the whole life situation (i.e., ethos) suitable for clinical practice is missing. The aim of this study was to investigate factorial structure, categorical functioning of the response scale, and differential item functioning across sub-populations of the Ethos Brief Index (EBI) among patients with obstructive sleep apnea (OSA) before and after initiation of continuous positive airway pressure (CPAP).

METHODS: A prospective design, including 193 patients with OSA (68% men, 59.66 years, SD 11.51) from two CPAP clinics, was used. Clinical assessment and overnight respiratory polygraphy were used to diagnose patients. Questionnaires administered before and after 6 months of CPAP treatment included EBI, Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale, and global perceived health (initial item in SF-36). The validity and reliability of the EBI were investigated using Rasch and confirmatory factor analysis models. Measurement invariance, unidimensionality, and differential item functioning across gender groups, Apnea-Hypopnea Index, and ESS groups were assessed.

RESULTS: The reliability of the EBI was confirmed using composite reliability and Cronbach's alpha. The results supported unidimensionality of the EBI in confirmatory factor analysis and the Rasch model. No differential item functioning was found. A latent profile analysis yielded two profiles of patients with low (n = 42) and high (n = 151) ethos. Patients in the low ethos group were younger and had higher depression scores, lower perceived health, and higher body mass index.

CONCLUSIONS: The EBI is a valid tool with robust psychometric properties suitable for use among patients with OSA before and after treatment with CPAP is initiated. Future studies should focus on its predictive validity.

The benefits of continuous positive airway pressure (CPAP) treatment for obstructive sleep apnea are well established, but adherence tends to be low. Research exploring CPAP practitioners beliefs around determinants of CPAP adherence, and the actions they use in clinical practice to promote CPAP adherence is lacking. This study aimed to: (i) develop and validate a questionnaire to assess beliefs and current practices among CPAP practitioners; (ii) explore practitioners beliefs regarding the main determinants of patient adherence, and the actions practitioners most commonly use to promote CPAP adherence; and (iii) explore the associations between perceived determinants and adherence-promotion actions. One-hundred and forty-two CPAP practitioners in Sweden and Norway, representing 93% of all Swedish and 62% of all Norwegian CPAP centres, were surveyed via a questionnaire exploring potential determinants (18 items) and adherence-promotion actions (20 items). Confirmatory factor analysis and second-order structural equational modelling were used to identify patterns of beliefs, and potential associations with adherence-promotion actions. Patients knowledge, motivation and attitudes were perceived by practitioners to be the main determinants of CPAP adherence, and educating patients about effects, management and treatment adjustments were the most common practices. Knowledge was shown to predict educational and informational actions (e.g. education about obstructive sleep apnea and CPAP). Educational and informational actions were associated with medical actions (e.g. treatment adjustment), but knowledge, attitude and support had no association with medical actions. These findings indicate that a wide variety of determinants and actions are considered important, though the only relationship observed between beliefs and actions was found for knowledge and educational and informational actions.

Adherence to continuous positive airway pressure (CPAP) treatment tends to be low. Brief validated instruments focusing on shared decision making have not been used in a CPAP context. The aim was to investigate factorial structure, categorical functioning of the response scale and differential item functioning across sub-populations of the CollaboRATE and Sure questionnaires among patients with obstructive sleep apnea (OSA) before CPAP treatment is initiated. A prospective design, including 193 objectively diagnosed (polygraphy) OSA patients (68% men, 59.7 years, SD 11.5) from two CPAP clinics was used. Data were collected with the following questionnaires; Sure, CollaboRATE, Attitudes to CPAP Inventory, Epworth sleepiness scale, minimal insomnia symptoms scale, and hospital anxiety and depression scale. Objective CPAP use was collected after 6 months; 49% demonstrated decisional conflict on SURE and 51% scored low levels of shared decision making on CollaboRATE. Unidimensionality was found for both CollaboRATE (one factor explaining 57.4%) and SURE (one factor explaining 53.7%), as well as local independence. Differential item functioning showed both to be invariant across both male and female patients. Internal consistency (Cronbach's alpha 0.83) and composite reliability (0.89) were good. Latent class analyses showed that patients with low decisional conflict and high shared decision making were more adherent to CPAP treatment. CollaboRATE and SURE provided good validity and reliability scores to measure shared decision making and decisional conflict in relation to CPAP treatment. The questionnaires can be used by healthcare personnel as a tool to simplify the assessment of shared decision making.

PurposeTo develop and validate a Swedish questionnaire to measure propensity for behaviour change regarding food habits, physical activity and weight reduction in patients with hypertension. DesignCross-sectional design. MethodsA total of 270 consecutive patients with hypertension diagnosed at four primary care centres in Sweden were included. The 6-item Swedish version of the Propensity to Achieve Healthy Lifestyle Scale (PAHLS) was developed to measure propensity for behaviour change regarding food habits, physical activity and weight reduction. The PAHLS (i.e., including three items for preparedness and three items for capacity) was developed by three multiprofessional researchers inspired by the transtheoretical model of behaviour change in collaboration with clinically active nurses. Data were collected by questionnaires on food habits (i.e., the Food Frequency Questionnaire), physical activity (the International Physical Activity Questionnaire), propensity for a healthy lifestyle (the PHLQ), as well as during a clinical examination. Exploratory (EFA) and confirmatory factor analyses (CFA), as well as Rasch analysis, were used. ResultsOf the 270 patients (50% women), 27% scored low levels of physical activity on the International Physical Activity Questionnaire, and 34% of the patients were obese (body mass index 30kg/m(2)). The EFA (explaining 54% of the variance) showed unidimensionality for the PAHLS that was supported by both CFA and Rasch analyses. No floor and 1.9% ceiling effects were found. Multiple group CFA (an extension of structural equationmodelling) showed that the PAHLS operated equivalently across both male and female patients. Internal consistency (Cronbachs alpha 0.83) and composite reliability (0.89) were good. ConclusionThe initial testing of PAHLS provided good validity and reliability scores to measure propensity for behaviour change in patients with hypertension. Relevance to Clinical PracticeThe PAHLS can be used by nurses as a tool to simplify shared decision-making in relation to behavioural changes.

Objective: 1) To describe the prevalence of undiagnosed obstructive sleep apnea (OSA) and depressive symptoms in hypertensive men and women below 65 years of age, and 2) to describe the association of OSA to subjective sleep complaints, depressive symptoms and global perceived health. Design: Cross-sectional design focusing on nursing care outcomes of obstructive sleep apnea. Setting: Four primary care health centres in Sweden. PATIENTS: 411 consecutive patients (52% women), mean age 57.9 years (SD 5.9 years), with diagnosed hypertension (BP > 140/90). Main Outcome Measures: Prevalence of OSA and depressive symptoms, and association of OSA to sleep complaints, depressive symptoms and global perceived health. RESULTS: Mild, moderate and severe OSA was seen among 29%, 16% and 14% of patients, respectively. Depressive symptoms were seen in 16% of the total group, with a higher prevalence among men, compared to women, 21% vs. 12%. No differences were found regarding blood pressure, estimated sleep need, sleep sufficiency index, insomnia symptoms, daytime sleepiness or depressive symptoms with respect to different degrees of OSA. Apnea-hypopnea index was significantly associated to perceived health after adjustment for gender and comorbidities, but when depressive symptoms and non-restorative sleep were added to the model, 33% of the variance in global perceived health was explained. Conclusion: OSA is highly prevalent among patients with hypertension in primary care and does together with sleep complaints and depressive symptoms have a negative impact on global perceived health. Hypertensive patients without subjective sleep complaints or depressive symptoms may still have OSA

Background Continuous positive airway treatment (CPAP) is first-line treatment for obstructive sleep apnea (OSA), but adherence tends to be low. A clinical tool focusing on motivation to use CPAP is missing. The purpose was to develop a brief questionnaire to assess motivation to use CPAP that is psychometrically robust and suitable for use in clinical practice. Methods A convenience sample including 193 treatment naive patients with OSA (67% men; mean age = 59.7 years, SD 11.5) from two CPAP clinics was used. Clinical assessments and full night polygraphy were performed. Questionnaires administered before CPAP treatment included the newly developed Motivation to Use CPAP Scale (MUC-S), Minimal Insomnia Symptoms Scale (MISS), Epworth Sleepiness Scale (ESS), and Attitude towards CPAP treatment Inventory (ACTI). The validity and reliability of the MUC-S were investigated using Rasch and exploratory factor analysis models. Measurement invariance, dimensionality and differential item functioning (i.e., across gender groups, excessive daytime sleepiness (ESS), insomnia (MISS) and attitude towards CPAP (ACTI) groups) were assessed. Results The results supported a two-factor solution (autonomous motivation, 6 items, factor loadings between 0.61 and 0.85 and controlled motivation, 3 items, factor loadings between 0.79 and 0.88) explaining 60% of the total variance. The internal consistency was good with Cronbachs alpha of 0.88 and 0.86 for the two factors. No differential item functioning was found. A latent class analysis yielded three profiles of patients with high (n = 111), moderate (n = 60) and low (n = 22) motivation. Patients with high motivation were older, had higher daytime sleepiness scores, more insomnia symptoms and a more positive attitude towards CPAP. Conclusions The MUC-S seems to be a valid tool with robust psychometric properties suitable for use at CPAP clinics. Future studies should focus on how motivation changes over time and if MUC-S can predict objective long-term CPAP adherence.

BACKGROUND: Both short and long sleep durations have been associated to increased mortality. Knowledge about sex-specific differences among elderly regarding associations between sleep duration, cardiovascular health, and mortality is sparse.

OBJECTIVE: The aims of this study are to examine the association between self-reported sleep duration and mortality and to investigate whether this association is sex specific and/or moderated by cardiovascular morbidity, and also to explore potential mediators of sleep duration effects on mortality.

METHODS: A population-based, observational, cross-sectional design with 6-year follow-up with mortality as primary outcome was conducted. Self-rated sleep duration, clinical examinations, echocardiography, and blood samples (N-terminal fragment of proBNP) were collected. A total of 675 persons (50% women; mean age, 78 years) were divided into short sleepers (≤6 hours; n = 231), normal sleepers (7-8 hours; n = 338), and long sleepers (≥9 hours; n = 61). Data were subjected to principal component analyses. Cardiovascular disease (CVD) and hypertension factors were extracted and used as moderators and as mediators in the regression analyses.

RESULTS: During follow-up, 55 short sleepers (24%), 68 normal sleepers (20%), and 21 long sleepers (34%) died. Mediator analyses showed that long sleep was associated with mortality in men (hazard ratio [HR], 1.8; P = .049), independently of CVD and hypertension. In men with short sleep, CVD acted as a moderator of the association with mortality (HR, 4.1; P = .025). However, when using N-terminal fragment of proBNP, this effect became nonsignificant (HR, 3.1; P = .06). In woman, a trend to moderation involving the hypertension factor and short sleep was found (HR, 4.6; P = .09).

CONCLUSION: Short and long sleep duration may be seen as risk markers, particularly among older men with cardiovascular morbidity.

PurposeThe purpose of this study was to explore whether associations between self-reported sleep duration, depressive symptoms, anxiety, fatigue and daytime sleepiness differed in older community-dwelling men and women. DesignCross-sectional. MethodsA community-dwelling sample of 675 older men and women (mean age 77.7years, SD 3.8years) was used. All participants underwent a clinical examination by a cardiologist. Validated questionnaires were used to investigate sleep duration, depressive symptoms, anxiety, fatigue and daytime sleepiness. Subjects were divided into short sleepers (6hours), n=231; normal sleepers (7-8hours), n=338; and long sleepers (9hours), n=61. ancovas were used to explore sex-specific effects. ResultsDepressive symptoms were associated with short sleep in men, but not in women. Fatigue was associated with both short and long sleep duration in men. No sex-specific associations of sleep duration with daytime sleepiness or anxiety were found. ConclusionNurses investigating sleep duration and its correlates, or effects, in clinical practice need to take sex into account, as some associations may be sex specific. Depressive symptoms and fatigue can be used as indicators to identify older men with sleep complaints.

Introduction

Differentiation between self-produced tactile stimuli and touch by others is necessary for social interactions and for a coherent concept of “self”. In attention-deficit-hyperactivity-disorder (ADHD), tactile hypersensitivity and social cognition problems are part of the symptomatology, but pathophysiological mechanisms are largely unknown. Differentiation of self- and non-self- generated sensations might be key to understand and develop novel strategies for managing hypersensitivity. Here, we compared the neural signatures of affective self- and other-touch between adults with ADHD and neurotypical controls (NC).

Methods

Twenty-eight adult ADHD participants and 30 age- and gender-matched NC performed a self-other-touch-task during functional magnetic resonance imaging: they stroked their own arm, an object, or were stroked by the experimenter. In addition, tactile detection thresholds and rubber hand illusion (RHI) were measured.

Results

ADHD participants had more autistic traits than NC and reported to engage less in interpersonal touch. They also reported to be more sensitive to tactile stimuli. Compared to NC, ADHD participants showed enhanced responses to both the self- and other-touch conditions: stronger deactivation during self-touch in the anterior and posterior insula, and increased activation during other-touch in primary somatosensory cortex. ADHD participants had intact tactile detection thresholds, but were less susceptible to the RHI.

Conclusions

Unaltered detection thresholds suggest that peripheral processing is intact, and that hypersensitivity might be driven by central mechanisms. This has clinical implications for managing somatosensory hypersensitivity in ADHD. The more pronounced differentiation between self- and other-touch might indicate a clearer self-other-distinction. This is of interest regarding body ownership perception in both NC and ADHD, and possibly other psychiatric conditions with altered self-experiences, like schizophrenia. A sharper boundary of the own body might relate to deficits in social cognition and tactile hypersensitivity.

Differentiation between self-produced tactile stimuli and touch by others is necessary for social interactions and for a coherent concept of "self." The mechanisms underlying this distinction are unknown. Here, we investigated the distinction between self-and other-produced light touch in healthy volunteers using three different approaches: fMRI, behavioral testing, and somatosensory-evoked potentials (SEPs) at spinal and cortical levels. Using fMRI, we found self-other differentiation in somatosensory and sociocognitive areas. Other-touch was related to activation in several areas, including somatosensory cortex, insula, superior temporal gyrus, supramarginal gyrus, striatum, amygdala, cerebellum, and prefrontal cortex. During self-touch, we instead found deactivation in insula, anterior cingulate cortex, superior temporal gyrus, amygdala, parahippocampal gyrus, and prefrontal areas. Deactivation extended into brain areas encoding low-level sensory representations, including thalamus and brainstem. These findings were replicated in a second cohort. During self-touch, the sensorimotor cortex was functionally connected to the insula, and the threshold for detection of an additional tactile stimulus was elevated. Differential encoding of self-vs. other-touch during fMRI correlated with the individual self-concept strength. In SEP, cortical amplitudes were reduced during self-touch, while latencies at cortical and spinal levels were faster for other-touch. We thus demonstrated a robust self-other distinction in brain areas related to somatosensory, social cognitive, and interoceptive processing. Signs of this distinction were evident at the spinal cord. Our results provide a framework for future studies in autism, schizophrenia, and emotionally unstable personality disorder, conditions where symptoms include social touch avoidance and poor self-vs.-other discrimination.

Humans need to be able to differentiate between signals they produce themselves and signals that arise from non-self-causes. It has long been discussed that the brain uses a copy of the motor command, an efference copy, to predict the sensory outcomes of ones own action - and to attenuate these. While studies in humans suggest that cerebellum and supplementary motor area play crucial roles in the attenuation, a study in mice suggests a global suppression during self-touch. However, the sensory percepts of self-touch are not fully cancelled out. Humans touch themselves frequently suggesting a behavioral relevance of self-touch, as to refocus attention, to calm oneself down during stress, to itch or for self-enjoyment. We discuss studies on sensory attenuation as well as the behavioral relevance of self-touch and open questions for future research.

Social touch is important for interpersonal interaction. Gentle touch and slow brushing are typically perceived as pleasant, the degree of pleasantness is linked to the activity of the C-tactile (CT) fibers, a class of unmyelinated nerves in the skin. The inability to experience pleasure in general is called anhedonia, a common phenomenon in the chronic pain condition fibromyalgia. Here, we studied the perception and cortical processing of gentle touch in a well-characterized cohort of fibromyalgia. Patients and controls participated in functional brain imaging while receiving tactile stimuli (brushing) on the forearm. They were asked to provide ratings of pleasantness of the tactile stimulus and ongoing pain. We found high distress, pain catastrophizing, and insomnia, and a low perceived state of health in fibromyalgia. Further, patients rated both slow (CT-optimal) and fast (CT-suboptimal) brushing as less pleasant than healthy participants. While there was no difference in brain activity during touch, patients showed deactivation in the right posterior insula (contralateral to the stimulated arm) during pleasantness rating and activation during pain rating. The opposite pattern was observed in healthy participants. Voxel-based morphometry analysis revealed reduced grey matter density in patients, in the bilateral hippocampus and anterior insula. Our results suggest anhedonia to gentle touch in fibromyalgia with intact early-stage sensory processing but dysfunctional evaluative processing. These findings contribute to our understanding of the mechanisms underlying anhedonia in fibromyalgia.

The sensation of pressure allows us to feel sustained compression and body strain. While our understanding of cutaneous touch has grown significantly in recent years, how deep tissue sensations are detected remains less clear. Here, we use quantitative sensory evaluations of patients with rare sensory disorders, as well as nerve blocks in typical individuals, to probe the neural and genetic mechanisms for detecting non-painful pressure. We show that the ability to perceive innocuous pressures is lost when myelinated fiber function is experimentally blocked in healthy volunteers and that two patients lacking A beta fibers are strikingly unable to feel innocuous pressures at all. We find that seven individuals with inherited mutations in the mechanoreceptor PIEZO2 gene, who have major deficits in touch and proprioception, are nearly as good at sensing pressure as healthy control subjects. Together, these data support a role for A beta afferents in pressure sensation and suggest the existence of an unknown molecular pathway for its detection. The mechanisms underlying deep pressure sensing are not fully understood. Here the authors demonstrate that while two individuals lacking A beta fibers demonstrate impaired deep pressure sensing, seven individuals with PIEZO2 loss of function mutations display normal deep pressure responses.

Neuroscientific research on pleasant touch has focused on the C-tactile pathway for gentle stroking and has successfully explained how these sensory fibers transmit information about affective social touch to the brain and induce sensations of pleasantness. The C-tactile social/affective touch hypothesis even proposes that C-tactile fibers form a privileged pathway underlying social touch. However, deep pressure is a type of touch commonly considered pleasant and calming, occurring in hugs, cuddling, and massage. In this paper we introduce a paradigm for studying pleasant deep pressure and propose that it constitutes another important form of social touch. We describe development of the oscillating compression sleeve (OCS) as one approach to administering deep pressure and demonstrate that this touch is perceived as pleasant and calming. Further, we show that deep pressure can be imaged with functional magnetic resonance imaging (MRI) using the air-pressure driven OCS and that deep pressure activates brain regions highly similar to those that respond to C-tactile stroking, as well as regions not activated by stroking. We propose that deep pressure constitutes another social touch pathway of evolutionary importance signaling the close proximity of conspecifics. This article is part of a Special Issue entitled: The Neurobiology of Social and Affective Touch. (c) 2020 The Authors. Published by Elsevier Ltd on behalf of IBRO. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). research on pleasant touch has focused on the C-tactile pathway for gentle stroking and has successfully explained how these sensory fibers transmit information about affective social touch to the brain and induce sensations of pleasantness. The C-tactile social/affective touch hypothesis even proposes that C-tactile fibers form a privileged pathway underlying social touch. However, deep pressure is a type of touch commonly considered pleasant and calming, occurring in hugs, cuddling, and massage. In this paper we introduce a paradigm for studying pleasant deep pressure and propose that it constitutes another important form of social touch. We describe development of the oscillating compression sleeve (OCS) as one approach to administering deep pressure and demonstrate that this touch is perceived as pleasant and calming. Further, we show that deep pressure can be imaged with functional magnetic resonance imaging (MRI) using the air-pressuredriven OCS and that deep pressure activates brain regions highly similar to those that respond to C-tactile stroking, as well as regions not activated by stroking. We propose that deep pressure constitutes another social touch pathway of evolutionary importance signaling the close proximity of conspecifics. This article is part of a Special Issue entitled: The Neurobiology of Social and Affective Touch. (c) 2020 The Authors. Published by Elsevier Ltd on behalf of IBRO. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Touch plays a significant role in human social behavior and social communication, and its rewarding nature has been suggested to involve opioids. Opioid blockade in monkeys leads to increased solicitation and receipt of grooming, suggesting heightened enjoyment of touch. We sought to study the role of endogenous opioids in perception of affective touch in healthy adults and in patients with fibromyalgia, a chronic pain condition shown to involve reduced opioid receptor availability. The pleasantness of touch has been linked to the activation of C-tactile fibers, which respond maximally to slow gentle touch and correlate with ratings of pleasantness. We administered naloxone to patients and healthy controls to directly observe the consequences of µ-opioid blockade on the perceived pleasantness and intensity of touch. We found that at baseline chronic pain patients showed a blunted distinction between slow and fast brushing for both intensity and pleasantness, suggesting reduced C-tactile touch processing. In addition, we found a differential effect of opioid blockade on touch perception in healthy subjects and pain patients. In healthy individuals, opioid blockade showed a trend toward increased ratings of touch pleasantness, while in chronic pain patients it significantly decreased ratings of touch intensity. Further, in healthy individuals, naloxone-induced increase in touch pleasantness was associated with naloxone-induced decreased preference for slow touch, suggesting a possible effect of opioid levels on processing of C-tactile fiber input. These findings suggest a role for endogenous opioids in touch processing, and provide further evidence for altered opioid functioning in chronic pain patients.

Affective touch plays an important role in childrens social interaction and is involved in shaping the development of the social brain. The positive affective component of touch is thought to be conveyed via a group of unmyelinated, low-threshold mechanoreceptive afferents, known as C-tactile fibers that are optimally activated by gentle, slow, stroking touch. Touch targeting these C-tactile fibers has been shown to decrease the heart rate in infants. The current study investigated the relationship between age and psychophysical ratings in response to affective touch. A total of n = 43 participants (early childhood: aged 5-8 years, 9 girls, 12 boys; late childhood: aged 9-12 years, 12 girls, 10 boys) were presented with C-tactile optimal and sub-optimal stroking velocities and rated touch pleasantness on an affective pictorial scale. For both age groups, we found that children preferred C-tactile-targeted stimulation. A comparison with previously published data showed that the childrens preference for C-tactile-targeted stimulation was similar to those obtained in adolescents and adults. We speculate that the effect of C-tactile-targeted touch, which is linked with pleasantness, shapes the childrens preference for C-tactile over non-C-tactile-targeted stimulation, and that C-tactile afferent stimulation is important for social development.

Body image disturbance is a core symptom in anorexia nervosa (AN). Recent research suggests that abnormalities in touch perception may contribute to the disease mechanisms in AN. Here, we used functional magnetic resonance imaging (fMRI) to study possible abnormalities in cortical processing of affective touch in AN. Gentle skin strokes were applied to the right forearm during fMRI scanning in women diagnosed with AN (n = 25) and in matched healthy controls (HC; n = 25). Blocks of skin stroking were alternated with blocks of static skin indentation. Participants provided ratings of the pleasantness of skin stroking stimulation. AN participants perceived skin stroking as significantly less pleasant than HC. We observed no group differences for the contrast between skin stroking and skin indentation in primary tactile regions. We did find, however, significantly less activity in the AN group in areas including left caudate nucleus. Also, we found less activity in the AN group in bilateral lateral occipital cortex for the main effect of skin stroking. Our results suggest that abnormal functioning of the dorsal striatum could affect evaluation of pleasant tactile stimuli, and that abnormal functioning of the lateral occipital cortex might be related to disturbed body image perception.

The insula is important for the processing of pleasant aspects of touch whereas its role in the processing of emotionally neutral touch has been less explored. Here, we used a network approach to investigate the insular processing of pleasant stroking touch and emotionally neutral vibratory touch, analysing functional magnetic resonance imaging data from 23 healthy adult participants. Vibration and skin stroking activated areas in the posterior, middle and anterior insula. Psychophysiological interaction analyses suggested that skin stroking increased functional connectivity between the posterior and ventral anterior insula. Vibration instead increased functional connectivity between the posterior and dorsal anterior insula, and induced a stronger decrease of the default mode network activity compared to stroking. These results confirmed findings from previous studies showing that the posterior insula processes affective touch information. We suggest that this is accomplished by relaying tactile information from the posterior insula to ventral anterior insula, an area tightly connected to the emotional parts of the brain. However, our results also suggested that the insula processes tactile information with less emotional valence. A central hub in this processing seemed to be the right dorsal anterior insula.

Idiopathic normal pressure hydrocephalus is usually regarded as a disease characterised by gait and balance disturbance, cognitive dysfunction and urinary symptoms. We report a rare case where iNPH should be considered as a cause of seizures.

Objectives: The pathogenesis of idiopathic normal pressure hydrocephalus (iNPH) takes place in structures close to the cerebral ventricular system. Suprachiasmatic nucleus (SCN), situated close to the third ventricle, is involved in circadian rhythm. Diurnal disturbances are well-known in demented patients. The cognitive decline in iNPH is potentially reversible after a shunt operation. Diurnal rhythm has never been studied in iNPH. We hypothesize that there is a disturbance of circadian rhythm in iNPH-patients and the aim was to study any changes of the diurnal rhythm (mesor and circadian period) as well as any changes of the diurnal amplitude and acrophase of the activity in iNPH-patients before and after a shunt operation. Patients and methods: Twenty consecutive iNPH-patients fulfilling the criteria of the American iNPH-guidelines, 9 males and 11 females, mean age 73 (49-81) years were included. The patients underwent a pre-operative clinical work-up including 10 m walk time (w10mt) steps (w10 ms), TUG-time (TUGt) and steps (TUGs) and for cognitive function an MMSE score was measured. In order to receive circadian rhythm data actigraphic recordings were performed using the SenseWear 2 (BodyMedia Inc Pittsburgh, PA, USA) actigraph. Cosinor analyses of accelerometry data were performed in "R" using non-linear regression with Levenburg-Marquardt estimation. Pre- and post-operative data regarding mesor, amplitude and circadian period were compared using Wilcoxon-Mann-Whitney test for paired data. Results: Twenty patients were evaluated before and three month post-operatively. Motor function (w10mt, w10 ms, TUGt, TUGs) was significantly improved while MMSE was not significantly changed. Actigraphic measurements (mesor, amplitude and circadian period) showed no significant changes after shunt operation. Conclusion: This is the first systematic study of circadian rhythm in iNPH-patients. We found no significant changes in circadian rhythm after shunt surgery. The conceptual idea of diurnal rhythm changes in hydrocephalus is still interesting from a theoretical standpoint and warrants further studies that could include a combination of better designed actigraphic studies in combination with neuroendocrine markers and imaging methods

BACKGROUND:

Vascular injuries in transsphenoidal surgery for pituitary adenomas are uncommon but can result in serious disability or death.

CASE DESCRIPTION:

A 46-year-old man, who underwent resection of a pituitary adenoma with suprasellar extension via a transsphenoidal approach, presented with massive epistaxis five days postoperatively. Angiography revealed an arteriovenous fistula (AVF) between the right sphenopalatine artery and a deep vein draining to the right internal jugular vein, as well as contrast agent extravasation at the fistula point. The AVF was catheterized and successfully occluded with N-butyl-2-cyanoacrylate.

CONCLUSIONS:

Transsphenoidal pituitary surgery can be complicated by massive epistaxis from a lesion of a small branch of the external carotid artery. Airway protection through intubation and investigation with conventional digital subtraction angiography is recommended. The treatment of choice is endovascular embolization because it can be done immediately at the angiography suite.