Jan 10, 2020

Abnormal Movements in Sleep as a Post-Polio Sequelae

                                                         By: Richard L. Bruno, 

Published in: American Journal of Physical Medicine and Rehabilitation, 1998; 77: 1-6.


Nearly two-thirds of polio survivors report abnormal movements in sleep (AMS), with 52% reporting that their sleep is disturbed by AMS. Sleep studies were performed in seven polio survivors to objectively document AMS. Two patients demonstrated Generalized Random Myoclonus (GRM), brief contractions and even ballistic movements of the arms and legs, slow repeated grasping movements of the hands, slow flexion of the arms and contraction of the shoulder and pectoral muscles. Two other patients demonstrated Periodic Movements in Sleep (PMS) with muscle contractions and ballistic movements of the legs, two had PMS plus Restless Leg Syndrome (RLS) and one had sleep starts involving only contraction of the arm muscles. AMS occurred in Stage II sleep in all patients, in Stage I in some, and could significantly disturb sleep architecture even though patients were totally unaware of muscle contractions. Poliovirus-induced damage to the spinal cord and brain is presented as a possible cause of AMS. The diagnosis of post-polio fatigue, evaluation AMS and management of AMS using benzodiazepines or dopamimetic agents is described.

Despite numerous late-onset symptoms reported by polio survivors -- fatigue, muscle weakness, pain, cold intolerance, swallowing and breathing difficulties -- one symptom was totally unexpected: abnormal movements in sleep (AMS). As early as 1984 our post-polio patients were reporting muscle contractions as they fell asleep. The 1985 National Post Polio Survey included two questions about AMS: "Do your muscles twitch or jump as you fall asleep?" and "Is you sleep disturbed by muscle twitching?" (1) It was surprising that 63% of the 676 respondents reported that their muscles did twitch and jump during sleep and that 52% -- a third of the entire sample -- said that their sleep was disturbed by twitching.

These percentages are markedly elevated as compared to the incidence of AMS in the general population. In one survey only 29% of those without neurological disease who were at least 50 years old reported AMS, versus 63% of surveyed polio survivors who were 52 years old on average. (2) In another survey only 34% of those older than 64 reported AMS, slightly more than half the incidence of AMS in the younger post-polio sample. (3) Given the apparent increased prevalence of AMS in polio survivors, and with daytime fatigue the most commonly reported Post-Polio Sequelae (PPS), we were interested in objectively documenting AMS, relating them to possible disturbances in sleep architecture and identifying an effective treatment for AMS. (1)


Subjects. Seven polio survivors were referred for sleep studies to a sleep disorders center. This was a sample of convenience, in that the subjects were patients presenting with PPS who themselves knew (three patients) or whose bed mates knew (four patients) that AMS were occurring. Patients were on average 54 years old and 44 years post acute polio which occurred at age 10. The patients had had AMS for a mean of eight years which was on average 35 years post acute polio. Patients reported moderate-to-severe difficulty sleeping at night and moderate-to-severe daytime fatigue that did not respond to the treatments of choice for post-polio fatigue (i.e., pacing of activities, daytime rest periods, energy conservation and use of appropriate assistive devices. (4) In addition to fatigue, patients reported an average of two limbs having late-onset muscle weakness.
Procedure. Patients underwent a standard polysomnographic evaluation with EEG and facial EMG recorded for sleep staging. (5) Blood oxygen saturation, measured using a finger pulse oxymeter, chest and abdominal wall excursion and nasal air temperature were also recorded; video monitoring of sleep was also performed. Surface EMG was recorded from patients' legs as well as from limbs in which AMS were reported.

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México a la vanguardia en el Síndrome de Post Polio

Jan 9, 2020

Polio: Vaccinated British man shed virus for 30 years

Human poliovirus particle

He had an immune disorder that mean the weakened polio virus used to vaccinate him in childhood survived in his body. 
Over time it has mutated into a form of the virus that can cause paralysis and he had no idea the jab had not worked. 
Polio is only endemic in Pakistan, Afghanistan and Nigeria although Nigeria has now gone more than a year without a case. 
The discovery was made by a team from the National Institute for Biological Standards and Control in Potters Bar, Hertfordshire.
They now warn that similar cases could trigger new outbreaks and hamper efforts to eradicate the disease. 
They wrote in the journal PLOS Pathogens: "While maintaining high immunisation coverage will likely confer protection against paralytic disease caused by these viruses, significant changes in immunisation strategies might be required to effectively stop their occurrence and potential widespread transmission."
The man had a full course of polio vaccinations, including three doses of weakened live virus at five, seven and 12 months old, followed by a booster when he was about seven.
He was later diagnosed with a condition that suppresses the immune system, affecting its ability to kill viruses in the gut.
His stool samples contained high levels of polio virus - the researchers estimated the man had been shedding live polio in his stools for as long as 28 years.
The virus had also mutated dramatically and were no longer the weakened, or "attenuated", versions of the virus which are used in the vaccinations.
The infection was neutralised by using blood plasma taken from people with healthy immune systems who had been immunised against polio.

Sewage samples

According to the scientific team, several highly mutated polio strains, originating from vaccines, had recently been isolated from sewage samples in Slovakia, Finland, Estonia and Israel.
All bore the molecular fingerprints of "iVDPVs" - vaccine-derived polio viruses from immunodeficient individuals.
The researchers are calling for enhanced surveillance including sewage sampling and stool surveys to search for the presence of iVDPV strains.
They also suggest the development of efficient anti-viral treatments to interrupt virus replication in people who deficiencies in their immune system.

Post Polio Litaff, Association A.C _APPLAC Mexico

Jan 7, 2020

Trump touted a new antidepressant as a solution for veterans. Only 15 have been treated

In August, President Trump proudly proclaimed that he had directed the Department of Veterans Affairs to buy “a lot” of a drug known as esketamine, the first new major depression treatment with a novel mechanism to hit the U.S. market in decades.
“Its results are incredible,” Trump said at a veterans convention in Kentucky. “I’ve instructed the top officials to go out and get as much of it as you can.”
As of mid-December, the VA had treated just 15 veterans across the country with the drug. The nasal spray, which was developed by Janssen and named Spravato, was only available at seven of the agency’s facilities — out of more than 1,200. The VA treated its first patient with Spravato in June.

Experts disagree on whether the VA’s rollout has been slower than is reasonable. Some have raised safety and efficacy concerns about the treatment, and the effort to get it covered and administered in the private health care system has been rocky. But there is little doubt that the VA’s moves to make Spravato accessible stand in sharp contrast with Trump’s claims that the drug could deliver widespread relief for veterans struggling with depression.
“This was supposed to be a big game-changer,” said Dr. Erick Turner, a psychiatrist at Oregon Health and Science University. But the data on the drug was “nothing to write home about,” he added.
Esketamine is similar to ketamine, an anesthetic that is sometimes misused recreationally but that has also been used off-label for depression. The VA said it initially limited its launch of the new drug only to clinics that had experience with ketamine.
“The roll-out of the drug has been successful due to VA’s implementation plan, which used existing facility expertise to launch at sites with previous experience using ketamine treatment for mental health,” said Susan Carter, a VA spokesperson.
In June, the agency’s medical advisory board declined to approve widespread coverage of Spravato for all veterans, instead restricting the drug’s use to patients who haven’t responded to other treatments and requiring an authorization before it can be prescribed. The drug must be administered under the supervision of a physician and patients must be monitored for two hours after each dose. The monitoring requirements are similar to the process for providing ketamine. The VA turned to clinics with experience in those protocols for the initial use of Spravato.
The VA’s limited rollout mirrors the cautious approach that some in the psychiatric community have taken toward esketamine. That hesitation, in part, stems from looming questions about the data on the drug. Johnson & Johnson, which owns Janssen, submitted five studies in its application to the FDA, only two of which were positive. One of those was a maintenance-of-effect study, which historically has not counted toward the two positive studies the FDA typically wants to see for approval. In particular, experts have questioned whether there is enough data to show the medication is effective in patients age 65 and over, given that many VA patients are in that population.
“[The studies] are not robust. They’re not strong results. You pull one thread and the whole thing unravels,” said Turner.
But some experts expressed surprise that only 15 patients had been treated in the six months since Spravato was made available to veterans and that only a smattering of clinics could provide the drug.
“If you’re going to make a treatment available, make sure there is ease of access to the treatment,” said M. David Rudd, a psychologist who co-founded the National Center for Veterans Studies at the University of Utah and is now the president of the University of Memphis.
Other experts said the agency’s implementation of Spravato has actually been much faster than the drug’s rollout in private clinics and hospital systems, which have struggled to secure preauthorization from insurers to administer the drug or reimbursement for the monitoring required to provide it.
“My take would be they have already implemented across [several] facilities,” said Dr. Cristina Cusin, co-director of a ketamine clinic at Massachusetts General Hospital. Cusin served as a site leader for an esketamine trial sponsored by Janssen.
Cusin said her clinic has not been able to treat a single patient with esketamine since the drug was approved. Some insurers won’t cover the drug. Others won’t pay for the staff to monitor a patient after each dose. Some have said they are working on a bundled insurance code for the drug and monitoring, but Cusin said it’s not clear what reimbursement under such a code would look like. Meanwhile, she said, the clinic is flooded with calls from patients asking about Spravato.
Because the VA doesn’t have to deal with a dozen different insurers like a private hospital system might, Spravato coverage has been more straightforward for the agency, she said.
“It’s been relatively rapid compared to private systems,” she said. Janssen said in a statement that it is working with a variety of appropriate treatment centers to increase the number of locations certified to administer Spravato.
Beyond pushing for the VA to embrace the drug, Trump also made a point in August of saying he hoped the government was “getting [Spravato] at a very good cost.”

Post Polio Litaff, Association A.C _APPLAC Mexico

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