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Somnambulism

Somnambulism or sleepwalking is a sleep disorder that is characterized by performing activities that are usually done in full consciousness. This sleep disorder is part of the parasomnia family. Hereditary factors play a major role in developing somnambulism. Other trigger factors include those that contribute to slow wave sleep such as fever, excessive exhaustion and sleep deprivation. Some persons with mental disorders are known to sleepwalk. Sleepwalkers are known to sit up in bed, clean, cook and sometimes even drive.


Typically sleepwalkers have no memory of these episodes. Although their eyes are open, they are not truly conscious. They are likely to have a dazed and glazed look. Sleepwalkers might talk in sleep too. They might even open their eyes though they are still asleep. A typical sleepwalking episode can last anywhere from a few seconds to a few minutes. Sleepwalking occurs during non-REM sleep. Episodes of sleepwalking usually start when a kid is around 5 - 10 years.


Most sleepwalkers do not require any particular treatment. Short-acting tranquilizers are often used. Sleepwalkers are usually prescribed tricyclic antidepressants, and clonazepam. In some cases, ECG is taken during sleep to rule out seizures. Hazardous items must be kept out of their reach. Most experts advice that it is best to gently nudge and guide a sleepwalker back to sleep. Those who have a tendency to sleepwalk must develop a calm soothing bedtime ritual and ensure that they get sufficient rest. Hypnosis is known to help in some cases.

Skin Grafting

Removing healthy skin from one part of the body and transplanting it to another affected part of the body is known as skin grafting. Skin grafting is usually done when a person loses skin from any part of the body due to injury or any type of illness. Skin grafting is performed under general anesthesia. Skin grafting is a vital procedure as no wound can be left open for long. Skin grafting helps to protect the skin and body from fluid loss, aids in temperature regulation and also helps prevent disease causing bacteria and virus from entering the body.


Why skin graft ?

Skin graft aids in placing skin over the body part that requires grafting. Common reasons for skin grafting include:

  • Skin infections
  • Bed sores and ulcers that haven't healed for a long period
  • Injury and open wounds
  • Deep burns

Skin grafting types

Full-thickness graft: This type of grating is suggested for severe burns. Grafting covers both layers of the skin. The blood vessels and the top layer of the skin are removed from the donor site. These grafts are used to cover smaller areas and visible parts of the body, i.e. if visible parts such as face are affected then this type of grafting is used. The back and the abdomen are the most suitable for donor sites. The skin grafted through this method blends well with the surrounding skin and grows along with the surrounding skin. Full thickness grafting is better when compared to partial thickness grafting as it provides better contour and less contraction at the grafted site. The only disadvantage would be that the injury in the donor site needs to be more carefully watched for healing. This procedure requires a few weeks of hospitalization and is supported by therapy.


Split level thickness graft: In this type of grafting, the topmost two layers of the skin are removed, the epidermis and the dermis from the donor site. This type of grafting is used to cover a larger surface of wound. These grafts are delicate and look shiny and smooth. They tend to look paler when compared to the adjoining skin as they do not grow with the surrounding skin. The graft is taken from hidden parts of the body like the inner thigh and the buttocks. In this type of grafting the patient is required to stay a little longer in the hospital as the surgeon has to check if the grafted skin is developing blood vessels or not. If blood vessels develop normally, the healing has begun else fresh grafting needs to be done as it indicates non-acceptance of the skin graft.


Skin graft procedure

Skin graft procedure is normally performed under general anesthesia. The surgeon cleans the affected area and removes the damaged skin, if any. The surgeon measures the affected area and traces an identical pattern over the donor site. Dermatome, a special tool is used to remove the skin from the donor site. The skin is meshed with a tool so that it can be spread completely over the wounded area. The skin is sutured or stapled based on the type of grafting. The donor site, based on whether it is full thickness grafting or split thickness graft is sutured or is smeared with antibiotics. Healing is helped through healing methods like:

Hyperbaric oxygen therapy wherein blasts of pure oxygen are given to heal the wound quickly.

Vacuum-assisted closure the grafted skin is dressed with porous bandage and is attached to a tube that is connected to a vacuum source. This helps in sucking interstitial fluid and thus keeps the area dry.

Skin grafts take time to heal depending on the type and severity of the graft. If the graft is healing well, blood vessels begin to develop thus quickening skin growth. In successful cases of skin grafting, blood vessels begin to appear 36 hours from the time of surgery.


Common risks of grafting include infections and repeated procedure in case of failure. Failure of graft happens due to reasons like hematoma or collection of blood in the injured tissues.


Cataplexy

Cataplexy is muscle weakness accompanied by typically triggered emotions such as laughing, crying or terror. These emotions are exhibited in full conscious awareness. The term cataplexy is derived from Greek 'Kata' meaning down, and 'plexis' meaning stroke. Cataplexy affects about 70% of those with narcolepsy. It is caused by autoimmune destruction of the neurotransmitter hypocretin which regulates arousal and wakefulness. Cataplexy without Narcolepsy (neurological disorder with symptoms of excessive daytime sleepiness, uncontrollable sleep and cataplexy) is rare and the cause is unknown.


Cataplexy Symptoms

Cataplexy manifests itself as muscular weakness. It can range from slackening of facial muscle to complete muscle paralysis with postural collapse. Severe attacks may result in inability to stand or move. Attacks are often brief and last from few seconds to about 30 minutes. This typically involves dropping the jaw, neck weakness and buckling of knees. The cataplectic attack is slow and progressive, so much so, the patient is usually able to avoid injury as they notice the feeling before the attack begins. As they are fully conscious during attacks, even extreme ones, they are aware of what is happening around them. Speech is slurred and vision may be impaired, it could be double vision or inability to focus, but hearing and awareness remain normal.


Cataplexy attacks

The hypothalamus region in the brain regulates basic functions of hormone release, emotions and sleep. During cataplexy, the neurochemical hypocretin is significantly reduced. Hypocretin is a primary chemical in regulating sleep as well as states of arousal and its deficiency can lead to decreased levels of histamine and epinephrine, chemicals that promote wakefulness, arousal and alertness.

Since cataplexy attacks are self-limiting, they resolve without the need for medical intervention. For instance, if the person is reclining comfortably, he/she may transition into sleepiness, hypnagogic hallucinations or a sleep onset period.

Cataplexy worsens with fatigue, and is different from narcoleptic sleep attacks. It is usually triggered by strong emotional reactions such as laughter, surprise, awe, embarrassment or by sudden physical effort, when a person is caught off guard. Such attacks could also occur spontaneously without any identifiable emotional trigger.


Cataplexy - Causes

Most have cataplexy with narcolepsy. Cataplexy is the most dramatic symptom of narcolepsy. And most cataplectic attacks are brought on by strong or extreme emotional feelings such as anger, stress, anxiety, depression and joy. Laughter and other positive emotions are the most common triggers of cataplexy. While the cause of cataplexy without narcolepsy is unknown, secondary cataplexy is linked to reduced levels of the chemical hypocretin, a neurotransmitter in the brain.

Secondary cataplexy is also associated with specific lesions located primarily in the lateral and posterior hypothalamus. Other conditions causing cataplexy include ischemic events, multiple sclerosis, head injury, Paraneoplastic syndromes and infections such as encephalitis. Cataplexy may occur transiently or permanently due to lesions of the hypothalamus caused by surgery especially in difficult tumor resections.


Recent ongoing research has found a clear association of Narcolepsy with an allele of the HLA gene family which provides instructions for the making a group of related proteins known as the Human Leukocyte Antigen (HLA) complex. This allele strongly increases the susceptibility for cataplexy. But 41% of patients without the explicit symptoms of cataplexy are carriers.


Diagnosis

Diagnosis of cataplexy is usually made by symptoms presentation. Excessive daytime sleepiness, sleep onset paralysis, hallucinations are some symptoms strongly evidencing cataplexy. A multiple sleep latency test is often conducted in order to quantify daytime sleepiness.


Treatment

There is no cure for cataplexy but is treated with medications to manage symptoms. There are no behavioral treatments. Those with narcolepsy often try to avoid thoughts and situations that they know are likely to evoke strong emotions as they know that these emotions are likely to trigger cataplectic attacks. Regardless of whether a person has narcolepsy or not, the doctor prescribes a selective serotonin and norepinephrine re uptake inhibitor to alleviate symptoms of cataplexy. Sodium oxybate is another effective drug for cataplexy.

However taking Xyrem and other sleep medications which are narcotic pain relievers or alcohol can lead to difficulty in breathing, coma and even can be fatal. In case of high blood pressure, diabetes, or other health problems, it is recommended to take medications only after consultations with the doctor.


Complications

Cataplexy is not a life threatening condition, unless engaging in potentially dangerous activities while experiencing an attack such as operating heavy machinery or driving motor vehicle. Sleep disturbances and sexual dysfunction can be caused by narcolepsy of which cataplexy is a primary symptom. As cataplexy is sudden, brief loss of voluntary muscle tone can be triggered by strong emotions such as laughter.

Cataplexy can occur during the waking hours and attacks can sometimes be rarely visible such as drooping of eyelids or severe total body collapse. As cataplexy is a neurological problem, chances are it can be misdiagnosed as a seizure disorder. As there is no cure for cataplexy, it has to be managed with medications and modifications of potential triggers.


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Bibliography / Reference

Collection of Pages - Last revised Date: November 22, 2019