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The application of computerized optico-structural analysis (OSA) for the evaluation of morphofunctional peculiarities in cells and tissues.
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The influence of nasal continuous positive airways pressure (CPAP) on nocturnal hypertension in obstructive sleep apnea (OSA) patients.
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Is obstructive sleep apnea (OSA) a risk factor for myocardial infarction and cardiac arrhythmias in patients with coronary heart disease (CHD)?
We prospectively studied 74 men 39-78 years of age, with significant (> or = 70%) stenosis of one or more coronary arteries. The investigation included coronary arteriography, ventriculography and ambulatory monitoring of cardio-respiratory variables during sleep using the MESAM-IV. We found 48 subjects with a respiratory disturbance index (RDI) > or = 10 events per hour. Our analyses failed to establish a relationship between RDI, myocardial infarction and known risk factors for coronary heart disease. Similarly, there was no relationship between RDI, number of coronary vessels involved, or left ventricular ejection fraction. Compared to general population studies, however, our group of coronary heart disease patients had a high incidence of obstructive sleep apnea syndrome (35%).
Do beta-blockers pose an unacceptable risk to patients with obstructive sleep apnea (OSA)?
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[Hypoacusis and vertigo as a side effect of the use continuous positive airway pressure (nasal CPAP) in obstructive sleep apnea syndrome (OSAS)].
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Gender differences in the polysomnographic features of obstructive sleep apnea.
We examined the influence of gender on the polysomnographic features of obstructive sleep apnea (OSA) in a retrospective study of 830 patients with OSA diagnosed by overnight polysomnography (PSG). The severity of OSA was determined from the apnea- hypopnea index (AHI) for total sleep time (AHI(TST)), and was classified as mild (5 to 25 events/h), moderate (26 to 50 events/h), and severe (> 50/events/h). Differences in OSA during different stages of sleep were assessed by comparing the AHI during non-rapid eye movement (NREM) (AHI(NREM)) and rapid eye movement (REM) (AHI(REM)) sleep and calculating the "REM difference" (AHI(REM) - AHI(NREM)). Additionally, each overnight polysomnographic study was classified as showing one of three mutually exclusive types of OSA: (1) mild OSA, which occurred predominantly during REM sleep (REM OSA); (2) OSA of any severity, which occurred predominantly in the supine position (S OSA); or (3) OSA without a predominance in a single sleep stage or body position (A OSA). The mean AHI(TST) for men was significantly higher than that for women (31.8 +/- 1.0 versus 20.2 +/- 1.5 events/h, p < 0. 001). The male-to-female ratio was 3.2:1 for all OSA patients, and increased from 2.2:1 for patients with mild OSA to 7.9:1 for those with severe OSA. Women had a lower AHI(NREM) than did men (14.6 +/- 1.6 versus 29.6 +/- 1.1 events/h, p < 0.001), but had a similar AHI(REM) (42.7 +/- 1.6 versus 39.9 +/- 1.2 events/h). Women had a significantly higher REM difference than did men (28.1 +/- 1.5 versus 10.3 +/- 1.1 events/h, p < 0.01). REM OSA occurred in 62% of women and 24% of men with OSA. S OSA occurred almost exclusively in men. We conclude that: (1) OSA is less severe in women because of milder OSA during NREM sleep; (2) women have a greater clustering of respiratory events during REM sleep than do men; (3) REM OSA is disproportionately more common in women than in men; and (4) S OSA is disproportionately more common in men than in women. These findings may reflect differences between the sexes in upper airway function during sleep in patients with OSA.
Technical report: diagnosis and management of childhood obstructive sleep apnea syndrome.
OBJECTIVE: This technical report describes the procedures involved in developing the recommendations of the Subcommittee on Obstructive Sleep Apnea Syndrome in children. The group of primary interest for this report was otherwise healthy children older than 1 year who might have adenotonsillar hypertrophy or obesity as underlying risk factors of obstructive sleep apnea syndrome (OSAS). The goals of the committee were to enhance the primary care clinician's ability to recognize OSAS, identify the most appropriate procedure for diagnosis of OSAS, identify risks associated with pediatric OSAS, and evaluate management options for OSAS. METHODS: A literature search was initially conducted for the years 1966-1999 and then updated to include 2000. The search was limited to English language literature concerning children older than 2 and younger than 18 years. Titles and abstracts were reviewed for relevance, and committee members reviewed in detail any possibly appropriate articles to determine eligibility for inclusion. Additional articles were obtained by a review of literature and committee members' files. Committee members compiled evidence tables and met to review and discuss the literature that was collected. RESULTS: A total of 2115 titles were reviewed, of which 113 provided relevant original data for analysis. These articles were mainly case series and cross-sectional studies; overall, very few methodologically strong cohort studies or randomized, controlled trials concerning OSAS have been published. In addition, a minority of studies satisfactorily differentiated primary snoring from true OSAS. Reports of the prevalence of habitual snoring in children ranged from 3.2% to 12.1%, and estimates of OSAS ranged from 0.7% to 10.3%; these studies were too heterogeneous for data pooling. Children with sleep-disordered breathing are at increased risk for hyperactivity and learning problems. The combined odds ratio for neurobehavioral abnormalities in snoring children compared with controls is 2.93 (95% confidence interval: 2.23-3.83). A number of case series have documented decreased somatic growth in children with OSAS; right ventricular dysfunction and systemic hypertension also have been reported in children with OSAS. However, the risk growth and cardiovascular problems cannot be quantified from the published literature. Overnight polysomnography (PSG) is recognized as the gold standard for diagnosis of OSAS, and there are currently no satisfactory alternatives. The diagnostic accuracy of symptom questionnaires and other purely clinical approaches is low. Pulse oximetry appears to be specific but insensitive. Other methods, including audiotaping or videotaping and nap or home overnight PSG, remain investigational. Adenotonsillectomy is curative in 75% to 100% of children with OSAS, including those who are obese. Up to 27% of children undergoing adenotonsillectomy for OSAS have postoperative respiratory complications, but estimates are varied. Risk factors for persistent OSAS after adenotonsillectomy include continued snoring and a high apnea-hypopnea index on the preoperative PSG. CONCLUSIONS: OSAS is common in children and is associated with significant sequelae. Overnight PSG is currently the only reliable diagnostic modality that can differentiate OSAS from primary snoring. However, the PSG criteria for OSAS have not been definitively validated, and it is not clear that primary snoring without PSG-defined OSAS is benign. Adenotonsillectomy is the first-line treatment for OSAS but requires careful postoperative monitoring because of the high risk of respiratory complications. Adenotonsillectomy is usually curative, but children with persistent snoring (and perhaps with severely abnormal preoperative PSG results) should have PSG repeated postoperatively.
A randomized, controlled crossover trial of two oral appliances for sleep apnea treatment.
Our purpose was to compare the effectiveness and side effects of a novel, single-piece mandibular advancement device (OSA-Monobloc) for sleep apnea therapy with those of a two-piece appliance with lateral Herbst attachments (OSA-Herbst) as used in previous studies. An OSA-Monobloc and an OSA-Herbst with equal protrusion were fitted in 24 obstructive sleep apnea patients unable to use continuous positive airway pressure (CPAP) therapy. After an adaptation period of 156 +/- 14 d (mean +/- SE), patients used the OSA-Monobloc, the OSA-Herbst, and no appliance in random order, using each appliance for 1 wk. Symptom scores were recorded and sleep studies were done at the end of each week. Several symptom scores were significantly improved with both appliances, but to a greater degree with the OSA-Monobloc. Epworth Sleepiness Scale scores were 8.8 +/- 0.7 with the OSA-Herbst, and 8.6 +/- 0.8 with the OSA-Monobloc devices, and 13.1 +/- 0.9 without therapy (p < 0.05 versus both appliances). The apnea/hypopnea index was 8.7 +/- 1.5/h with the OSA-Herbst and 7.9 +/- 1.6/h with the OSA-Monobloc device, and 22.6 +/- 3.1/h without therapy (p < 0.05 versus both appliances). Side effects were mild and of equal prevalence with both appliances. Fifteen patients preferred the OSA-Monobloc, eight patients had no preference, and one patient preferred the OSA-Herbst device (p < 0.008 versus OSA-Monobloc). We conclude that both the OSA-Herbst and the OSA-Monobloc are effective therapeutic devices for sleep apnea. The OSA-Monobloc relieved symptoms to a greater extent than the OSA-Herbst, and was preferred by the majority of patients on the basis of its simple application.
Workplace worries: a preliminary look at online sexual activities at the office-emerging issues for clinicians and employers.
Concerns about the impact of online sexual activities (OSA) on work-life are drastically increasing. This study examined 3,466 respondents who reported OSA, 18.5% of whom reported engaging in OSA at work. They were compared with the 81.5% who engaged in OSA at home, on average time spent in OSA, workplace policies regarding OSA, and relationship status. Two themes were identified and discussed: opportunity and sexual distress. Our findings indicate that participants are cognizant of issues of opportunity (e.g., the OSA from home group was more likely to indicate their workplace has established policies regarding OSA), and privacy, representing an important aspect of this theme (e.g., participants engaging in OSA at work were found to be twice as likely to have extra-marital affairs, compared with the OSA from home group). Secondly, our data suggests that many participants, especially from the OSA at work group, experience OSA-related distress. Engaging in OSA at the workplace may result in decreased productivity, issues of sexual harassment, and concerns about employee well-being. Clearly stated and consistently enforced policies regulating OSA are likely to mitigate workplace OSA. However, a significant minority of employees may have difficulties curbing OSA. Therefore, more sophisticated strategies to deal with workplace OSA should be established. Additional implications of importance for organizations and mental health professionals who support them are discussed.
Dynamic changes in EEG spectra during obstructive apnea in children.
Children are less likely to demonstrate EEG arousal during obstructive sleep apnea (OSA) than adults. We hypothesized that changes in spectral EEG characteristics occur during REM-associated OSA in the absence of arousal. Eight snoring children underwent overnight polysomnography. OSA events during REM periods not associated with EEG or behavioral arousal were identified. EEG signals from C3A2 and C4A1 leads corresponding to 1) < or =10-sec epochs preceding OSA (PRE), 2) the obstructed period (OSA), and 3) < or =10-sec epochs following airflow resumption (POST) were subjected to fast Fourier transform (FFT) routines. Seventy-two isolated OSA, and 14 clusters of > 4 OSA events were analyzed. In single OSA, delta OSA amplitude was lower than in PRE (P < 0.01) and in POST (P < 0.001). Furthermore, POST delta amplitude was higher than PRE (P < 0.01). In contrast, in OSA clusters, the dynamic differences in delta amplitude disappeared after the second OSA. Reciprocal increases and decreases occurred for the theta frequency domain during OSA and post-OSA, while sigma and beta frequency power did not change. We conclude that during isolated OSA episodes without arousal, significant decreases in power selectively occur for delta frequency, and are followed by a rebound increase upon termination of apnea. The delta changes are progressively attenuated during repeated OSA. We postulate that delta changes may reflect ongoing adaptations in sleep pressure which are necessary to relieve the respiratory compromise, and may represent subtle evidence for arousal and consequent sleep fragmentation in children with OSAS.
Evaluation of cross-section airway configuration of obstructive sleep apnea.
Upper airway imaging techniques can be useful to identify the exact location and nature of the obstruction in obstructive sleep apnea (OSA) patients. Ten OSA patients and 10 non-OSA control subjects were imaged using cone-beam computed tomography (NewTom QR-DVT9000) to compare their upper airway structure. The OSA subjects presented higher BMI (OSA: 29.5 +/- 9.05 kg/m(2); non-OSA: 23.1 +/- 3.05 kg/m(2) [P = .034]), lower total volume (mm(3)) of the airway (OSA: 4868.4 +/- 1863.9; non-OSA: 6051.7 +/- 1756.4 [P = .054]), statistically significantly smaller anterior-posterior dimension (mm) of the minimum cross-section segment (OSA: 4.6 +/- 1.2; non-OSA: 7.8 +/- 3.31 [P = .009]), and smaller minimum cross-section area (OSA: 45.8+/-17.5 mm(2); non-OSA: 146.9 +/- 111.7 mm(2) [P = .011]) positioned below the occlusal plane in 70% of the cases (OSA:7 out of 10; non-OSA: 5 out of 10 [P = .030]). The OSA group presented a concave or elliptic shaped airway and the non-OSA group presented a concave, round, or square shaped airway.
Plasma levels of adiponectin, a novel adipocyte-derived hormone, in sleep apnea.
OBJECTIVE: Obstructive sleep apnea (OSA) is associated with obesity, sympathetic activation, systemic inflammation, and cardiovascular morbidity. Obesity, beta-adrenergic agonists, and inflammation are linked to decreased expression and/or secretion of an adipose tissue-derived antiatherogenic hormone, adiponectin. The purpose of the study was to investigate whether OSA affected plasma levels of adiponectin, which might help explain OSA-associated cardiovascular morbidity. RESEARCH METHODS AND PROCEDURES: We randomly selected 68 otherwise healthy male subjects, either with moderate/severe OSA [apnea-hypopnea index (AHI)>or=20; n=35] or without OSA (AHI<or=5; n=33). The diagnosis of OSA was made based on prospective full polysomnography. Adiponectin was measured before polysomnography between 8 and 10 pm. RESULTS: AHI was higher in the OSA group (49.5+/-4.4 vs. 2.9+/-0.4 events/h; p<0.001). OSA subjects were also more obese, with greater BMI (33+/-1 vs. 30+/-1; p=0.016) and percentage body fat (29+/-1% vs. 26+/-1%; p=0.030). Adiponectin levels were 7.67+/-0.73 and 6.33+/-0.51 microg/mL in the OSA and non-OSA groups, respectively, and this difference was significant in covariate analysis (taking into account age, hemodynamic characteristics, measures of body fat, and OSA severity) (p=0.009). After excluding from both groups the subjects with extreme BMI, such that the OSA and non-OSA study cohorts had similar BMI and percentage body fat, subjects with OSA had significantly higher plasma adiponectin (8.49+/-0.92 vs. 6.32+/-0.55 microg/mL; p=0.042), differences also evident in covariate analysis (p=0.017). DISCUSSION: Plasma adiponectin levels are elevated in otherwise healthy subjects with OSA. Therefore, low adiponectin is unlikely to explain the association between OSA and cardiovascular disease.
Peripheral neuropathy in sleep apnea. A tissue marker of the severity of nocturnal desaturation.
Because chronic obstructive pulmonary disease (COPD) is well known to induce peripheral neuropathy and resistance to ischemic nerve conduction failure (RICF), we performed a case-control study examining peripheral nerve function during ischemia in 17 patients with severe obstructive sleep apnea (OSA) without daytime hypoxemia and 10 control subjects. Median nerve conduction was studied before, during, and after a 30-min period of ischemia. Preischemic sensory and mixed nerve potential amplitudes and sensory conduction velocity were lower in OSA patients than in control subjects despite higher supramaximal stimulation. During ischemia, seven OSA patients manifested RICF (OSA-RICF), whereas both the other 10 patients, who were nonresistant to ischemic conduction failure (OSA-NR), and control subjects did not. OSA-RICF patients had the lowest initial nerve-potential amplitude, whereas OSA-NR patients had a response intermediate between that of control subjects and OSA-RICF patients. OSA-RICF patients had a lower mean nocturnal SaO2 and a higher body mass index (BMI) and duration of SaO2 < 70% than did OSA-NR patients. Seven patients (four OSA-RICF and three OSA-NR) were reevaluated after at least 2 mo of treatment with nasal continuous positive airway pressure (nCPAP). RICF disappeared in all OSA-RICF patients, whereas preischemic nerve conduction parameters were unchanged in both OSA-RICF and OSA-NR patients. Thus OSA patients have peripheral nerve dysfunction whose severity is partly related to the level of nocturnal hypoxemia. Abnormal preischemic nerve conduction suggests axonal lesions, whereas RICF, which appears to be a sensitive but nonspecific tissue marker of the severity of hypoxemia, may result from adaptative mechanisms.
Obstructive sleep apnoea is independently associated with the metabolic syndrome but not insulin resistance state.
Obstructive sleep apnoea (OSA) is a cardio-metabolic disorder. Whether metabolic syndrome (MS), insulin resistance (IR) and albuminuria are independently associated with OSA is unclear, but defining the interactions between OSA and various cardiovascular (CV) risk factors independent of obesity facilitates the development of therapeutic strategies to mitigate their increased CV risks. We prospectively recruited 38 subjects with OSA and 41 controls. Anthropometric measurements, glucose, lipids, insulin and blood pressure (BP) were measured after an overnight fast. IR state was defined as homeostasis model assessment (HOMA) value >3.99 and MS diagnosed according to the International Diabetes Federation (IDF) criteria. Subjects with OSA were more obese, more insulin resistant, more hyperglycaemic, had higher Epworth score (measure of day time somnolence) and systolic blood pressure levels. The prevalence of MS was higher in OSA compared with non-OSA subjects (74% vs 24%, p < 0.001). The prevalence of microalbuminuria in both groups was negligible. Logistic regression adjusted for age, BMI and smoking showed that the patient with OSA was 5.9 (95% CI 2.0-17.6) times more likely to have MS than non-OSA patient. Triglyceride (p = 0.031), glucose (0.023) and Epworth score (0.003) values were independently associated with OSA after adjusting for BMI and other covariates whilst IR status was found not to be significant. Using the ROC curve analysis, we found that a waist circumference of >103 cm would predict MS in patients with OSA at 75-78% sensitivity and 61-64% specificity. The agreement between MS and IR state in this cohort is poor. Thus, OSA is associated with MS independent of obesity predominantly due to increased triglyceride, glucose and Epworth score values but not IR or microalbuminuria status. This observation suggests an alternative pathogenic factor mediating the increased cardiovascular risk in patients with OSA and MS, other than that due to IR. The independent link between Epworth score and MS in patients with OSA implicates the role of daytime sleepiness and chronic hypoxia as a potential mediator. Given the discordant between MS and IR state, measurement of waist is useful for predicting mainly MS but not insulin resistance status in patients with OSA. Appropriate pharmacological intervention targeting these independent factors is important in reducing the increased CV risks among patients with OSA.
Efficacy of laser-assisted uvulopalatoplasty.
BACKGROUND AND OBJECTIVE: Laser-assisted uvulopalatoplasty (LAUP) is being used increasingly as a surgical treatment for snoring and obstructive sleep apnea (OSA). There is limited evidence for the success of LAUP in eliminating OSA. This study assesses the efficacy of LAUP in eliminating snoring and OSA and addresses which patients may be the best candidates for LAUP treatment. STUDY DESIGN/MATERIALS AND METHODS: From January 1994 to January 1996, 297 patients were evaluated for snoring, with 190 (64%) exhibiting some degree of OSA documented by a PSG: 41/ 190 (22%) mild OSA; 33/190 (17%) moderate OSA; 85/190 (45%) severe OSA; 31/190 (16%) severity unknown. Ninety patients (90/ 297) have undergone LAUP treatment: 58/90 (64%) with OSA and 32/90 (36%) with snoring only. RESULTS: Our results indicate a significant reduction of snoring in patients without OSA, but diminishing success in patients with increasing degrees of OSA. Additionally, LAUP was not efficacious in treating OSA: pre-op respiratory disturbance index (RDI) of 10.8 vs. post-op RDI of 19.5 for mild OSA (P = 0.14); pre-op RDI of 22.9 vs. post-op RDI of 25.4 for moderate OSA (P = 0.43); pre-op RDI of 56.8 vs. post-op RDI of 46.3 (P < 0.05), which is statistically but not clinically significant (i.e., RDI remained in the severe range). CONCLUSION: We conclude that LAUP is an effective treatment for nonapneic snoring, but does not provide sufficient resolution of OSA, and based on our results, LAUP should be considered as an adjunctive therapy rather than a sole treatment for OSA in most cases.
[A comparative study of patients with chronic obstructive pulmonary disease with and without obstructive sleep apnea syndrome].
We aimed to study whether the presence of obstructive sleep apnea syndrome (OSAS) in patients with chronic obstructive pulmonary disease (COPD) led to differences in clinical picture, gas exchange during awake and sleep states and mechanical ventilation, in comparison with patients with COPD alone. We enrolled 48 COPD patients. In 26 (54.1%), OSAS was ruled out (non-OSAS COPD group) by polysomnography, and in 22 (45.8%) associated OSAS was diagnosed (OSAS COPD group). Patients in the OSAS COPD group experienced greater daytime sleepiness and less dyspnea. Body mass index was not significantly difference. The OSAS COPD group had significantly lower daytime PaO2 (66.4 +/- 10.4 mmHg in the OSAS COPD group and 75.5 +/- 11.2 mmHg in the non-OSAS COPD group; p = 0.01); there were no differences in PaCO2.Pimax in the OSAS-COPD group was 70.6 +/- 23.8 cmH2O, a level that was significantly lower than in the non-OSAS COPD group (Pimax 90.5 +/- 26.1 cmH2O; p = 0.04). Patients in the non-OSAS COPD group experienced longer periods of REM sleep. Nighttime saturation parameters were significantly different in the group with OSAS. We conclude that patients with both OSAS and COPD experience greater oximetric changes than those without OSAS, during both sleep and awake states. The deterioration of respiratory muscle pressures in such patients may play an important role in the changes. The groups also present differences in the intensity of some symptoms, such as degree of daytime sleepiness and dyspnea.
Omics Profiling of Patients with Obstructive Sleep Apnoea Reveals Risks of Diabetes Mellitus and Cardiovascular Diseases.
Obstructive sleep apnoea (OSA) constitutes a multisystemic disorder often associated with cardiovascular and metabolic disorders. Thus, far, the underlying pathophysiological processes are not fully understood. In total, 142 plasma samples were acquired: 50 from controls (CON), 45 from mild/moderate OSA (M-OSA) patients, and 47 from severe OSA (S-OSA) patients. Proteomic and metabolic signatures significantly differed among S-OSA, M-OSA, and CON samples. A novel plasma biomarker panel including two proteins (ACTR2 and ENO1) and three metabolites (2-aminobicyclo[2 2·1], heptane-2-carboxylic acid, 1-O-[2r-hydroxy-hexadecyl]-sn-glycerol, and 1-pentadecene) was developed to identify S-OSA (AUC: 1.000) and distinguish severe cases from nonsevere cases (AUC: 0.813). An independent cohort was used to validate the model by distinguishing S-OSA samples from M-OSA (AUC: 0.729) and CON (AUC: 0.990) samples. Glycolysis pathway activation was identified as a characteristic of OSA; it may contribute to diabetes mellitus onset in OSA patients. Dyslipidaemia, foamy macrophage formation, platelet activation, and actin cytoskeleton might collectively play a key role in vascular damage in OSA patients, contributing to the development of atherosclerosis. These findings reveal molecular bases for OSA-related cardiometabolic complications and provide new diagnostic biomarkers for OSA and the identification of severe cases.