[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]

INTRODUCTION

Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring.

METHODS AND INTENTION

In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57±11 years. Average weight was 100±19 kg by a mean body mass index (BMI) of 33±7 kg/m². 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound.

RESULTS

3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0%), polysomnography in 2229 (58,8%) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound.

DISCUSSION

In nearly 60% of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60% of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

Reliability, validity and critical appraisal of the cross-cultural adapted German version of the Mayo Elbow Performance Score (MEPS-G)

Background

The Mayo Elbow Performance Score (MEPS) is a rating system consisting of four dimensions to evaluate elbow performance. It is a common tool for assessment of elbow impairments worldwide. We determined the validity and reliability of its German version (MEPS-G) after cross-cultural adaptation.

Methods

Six investigators examined 57 patients with elbow pathologies. The MEPS-G was compared to validated elbow scores such as the German versions of DASH, the Oxford Elbow Score, pain level and subjective elbow performance on a VAS. Inter-rater reliability (IRR) and validity of the score and its dimensions were also reviewed. Verification was performed using the intraclass correlation coefficient (ICC), the prevalence and bias with adjusted Kappa (PABAK) and the Spearman correlation.

Results

The IRR of the MEPS-G score was moderate (ICC (2.1) = 0.65). The IRR of the four individual dimensions was moderate to high (K_PABAK = 0.55 -0.81). Validity for the sum score (r = 0.52–0.65) and the dimensions pain (r = 0.53–0.62), range of motion (r = 0.7) and stability (r = − 0.61) was verified. The function subscale reached insufficient validity (r = 0.15–0.39).

Conclusion

The MEPS-G is not sufficiently valid, which is consistent with its English version. The patient-based dimensions were a weakness, demonstrating high risk of bias. There is no general recommendation for the utilization of the MEPS-G as outcome measurement for patients with elbow pathologies.

OUP accepted manuscript

MOTIVATION

Estimating the effects of interventions on patient outcome is one of the key aspects of personalized medicine. Their inference is often challenged by the fact that the training data comprises only the outcome for the administered treatment, and not for alternative treatments (the so-called counterfactual outcomes). Several methods were suggested for this scenario based on observational data, i.e. data where the intervention was not applied randomly, for both continuous and binary outcome variables. However, patient outcome is often recorded in terms of time-to-event data, comprising right-censored event times if an event does not occur within the observation period. Albeit their enormous importance, time-to-event data are rarely used for treatment optimization. We suggest an approach named BITES (Balanced Individual Treatment Effect for Survival data), which combines a treatment-specific semi-parametric Cox loss with a treatment-balanced deep neural network; i.e. we regularize differences between treated and non-treated patients using Integral Probability Metrics (IPM).

RESULTS

We show in simulation studies that this approach outperforms the state of the art. Furthermore, we demonstrate in an application to a cohort of breast cancer patients that hormone treatment can be optimized based on six routine parameters. We successfully validated this finding in an independent cohort.

AVAILABILITY AND IMPLEMENTATION

We provide BITES as an easy-to-use python implementation including scheduled hyper-parameter optimization (https://github.com/sschrod/BITES). The data underlying this article are available in the CRAN repository at https://rdrr.io/cran/survival/man/gbsg.html and https://rdrr.io/cran/survival/man/rotterdam.html.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Early results of a real-world series with two transapical transcatheter mitral valve replacement devices

Aims

Transcatheter mitral valve replacement (TMVR) with dedicated devices promises to fill the treatment gap between open-heart surgery and edge-to-edge repair for patients with severe mitral regurgitation (MR). We herein present a single-centre experience of a TMVR series with two transapical devices.

Methods and results

A total of 11 patients were treated with the Tendyne™ (N = 7) or the Tiara™ TMVR systems (N = 4) from 2016 to 2020 either as compassionate-use procedures or as commercial implants. Clinical and echocardiographic data were collected at baseline, discharge and follow-up and are presented in accordance with the Mitral Valve Academic Research Consortium (MVARC) definitions.

The study cohort [age 77 years (73, 84); 27.3% male] presented with primary (N = 4), secondary (N = 5) or mixed (N = 2) MR etiology. Patients were symptomatic (all NYHA III/IV) and at high surgical risk [logEuroSCORE II 8.1% (4.0, 17.4)]. Rates of impaired RV function (72.7%), severe pulmonary hypertension (27.3%), moderate or severe tricuspid regurgitation (63.6%) and prior aortic valve replacement (63.6%) were high. Severe mitral annulus calcification was present in two patients. Technical success was achieved in all patients. In 90.9% (N = 10) MR was completely eliminated (i.e. no or trace MR). Procedural and 30-day mortality were 0.0%. At follow-up NYHA class was I/II in the majority of patients. Overall mortality after 3 and 6 months was 10.0% and 22.2%.

Conclusions

TMVR was performed successfully in these selected patients with complete elimination of MR in the majority of patients. Short-term mortality was low and most patients experienced persisting functional improvement.

Graphic abstract

Electronic supplementary material

The online version of this article (10.1007/s00392-020-01757-z) contains supplementary material, which is available to authorized users.

[Analysis of Snoring in Patients with Obstructive Sleep Apnea (OSA) by Polysomnography and LEOSound]

INTRODUCTION

 Snoring was monitored in patients with obstructive sleep apnea (OSA) using the LEOSound-Monitor and simultaneously polysomnographic (PSG) recording. In obstructive apneas snoring is normally apparent after apnea termination and the beginning of ventilation. We wanted to know how often obstructive apneas are terminated by ventilation in combination with snoring.

METHODS AND INTENTION

 In 40 patients with OSA (AHI > 15/h) simultaneous polysomnographic recordings were performed amongst long-term respiratory sound monitoring using the LEOSound monitor. Patients' average age was 57 ± 11 years. Average weight was 100 ± 19 kg by a mean body  mass  index (BMI) of 33 ± 7 kg/m². 12 out of 40 recordings had to be rejected for further analysis because of artifacts. Snoring recorded by polysomnography was compared with snoring monitored by LEOSound.

RESULTS

 3778 obstructive apnea episodes were monitored. LEOSound identified snoring in 1921 (51,0 %), polysomnography in 2229 (58,8 %) obstructive apneas. Only in one patient there was a higher difference in snoring episodes between PSG and LEOSound.

DISCUSSION

 In nearly 60 % of obstructive apnea events we found snoring during apnea-terminating hyperpnoea. LEOSound is a good diagnostic tool to monitor snoring. It is necessary to clarify why only 60 % of all obstructive events/hyperpnoea develop snoring. From a pathophysiological point of view opening of collapsed upper airway should lead in a very high percentage to turbulences in airstream and committed snoring.

Revisional Gastric Bypass After Failed Adjustable Gastric Banding-One-Stage or Two-Stage Procedure?

BACKGROUND

Revisional laparoscopic Roux-en-Y gastric bypass (R-LRYGB) is the preferred procedure after failed adjustable gastric banding. Little is known about whether a one-stage procedure (one surgery for band removal and R-LRYGB) or a two-stage procedure (first band removal and later R-LRYGB) is superior. Aim of this study is to compare early- and long-term results of both methods at our institution.

METHODS

Retrospective analysis of 165 (m 26/f 139) consecutive patients (98 one-stage, 67 two-stage) with R-LRYGB. Mean follow-up time was 50.1 ± 38.8 months. Indications for one-stage vs. two-stage procedures, operating time, peri- and postoperative complications, morbidity, mortality, and length of stay (LOS) were analyzed. Data are reported as total numbers (%) and mean ± standard deviation.

RESULTS

Mean age at R-LRYGB was 43.9 ± 10.7 vs. 44.3 ± 10.7 years with a BMI of 37.1 ± 6.8 vs. 39.8 ± 7.1 (one-stage vs. two-stage). In the one-stage group, the main indication for revisional surgery was weight regain (57.1%), followed by dilatation of the esophagus or pouch (37.7%) and gastroesophageal reflux disease (GERD) (36.7%), whereas in the two-stage group, it was band erosion (52.2%) and dilatation of the esophagus or pouch (17.9%) and GERD (11.9%). There was no significant difference in operative time (208.5 ± 61.2 vs. 206.3 ± 73.5 min), LOS (8.6 ± 3.4 vs. 9.3 ± 5.7 days) or mortality (0% overall). Major complications (Clavien-Dindo ≥ IIIa) occurred similarly often in both groups: 15.3% vs. 16.9% (one-stage vs. two-stage).

CONCLUSION

Both approaches achieve good results. However, the one-stage R-LRYGB is the preferable procedure because it reduces costs and LOS by doing without an additional surgical procedure.

[Scientific development of critical care : Position paper]

Demographic changes in Germany means that nursing and medical care is becoming increasingly complex. This is especially true for intensive care. Despite the closure of hospitals in Germany, the number of beds in intensive care units rose between 2002 from 23,113 to 26,162 in 2010. At the same time the number of patients treated in intensive care units increased by 148,989 to 2,049,888. The increasing complexity requires specific education for nurses in intensive care based on a model of advanced nursing practice (ANP). Nursing experts who fulfill an advanced practise nursing are competent to make decisions autonomously and accountably within complex care situations. This includes decisions such as artificial ventilation, weaning, nutrition management and the management of delirium, wounds and pain. Nursing experts are responsible for specific clearly defined areas of care and initiate nurse-led services and practice. Scientific and research based evidence are transferred directly into health care practice and can be implemented directly. The DGF demands a scientific and with it academic development of critical care as advanced nursing practice based on a master level qualification. This also includes the request for expansion of competencies and roles and the assignment of decision making authority within complex health care situations and an orientation on the Competencies for European Critical Care Nurses of the European Federation of Critical Care Nursing Associations (EfCCNa).

[Oral anticoagulation and antiplatelet therapy in patients with atrial fibrillation after coronary interventions]

Dual antiplatelet therapy (DAPT) is the cornerstone of maintenance medication following elective percutaneous coronary intervention and also after acute coronary syndrome (ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, unstable angina pectoris); however, DAPT is not sufficient for stroke prevention in atrial fibrillation (SPAF). For SPAF, oral anticoagulation (OAC) with vitamin K antagonists (VKA) or non-vitamin K-dependent anticoagulants (NOAC) is required. If a patient who is receiving anticoagulants for SPAF, requires a coronary intervention, triple therapy consisting of OAC plus DAPT is given, at least for a limited time following the procedure. This article reviews the current data from studies testing strategies with NOACs plus one or two antiplatelet substances in comparison to triple therapy with VKA.

Effects of BDNF Val66Met genotype and schizophrenia familial risk on a neural functional network for cognitive control in humans

Cognitive control represents an essential neuropsychological characteristic that allows for the rapid adaption of a changing environment by constant re-allocation of cognitive resources. This finely tuned mechanism is impaired in psychiatric disorders such as schizophrenia and contributes to cognitive deficits. Neuroimaging has highlighted the contribution of the anterior cingulate cortex (ACC) and prefrontal regions (PFC) on cognitive control and demonstrated the impact of genetic variation, as well as genetic liability for schizophrenia. In this study, we aimed to examine the influence of the functional single-nucleotide polymorphism (SNP) rs6265 of a plasticity-related neurotrophic factor gene, BDNF (Val⁶⁶Met), on cognitive control. Strong evidence implicates BDNF Val⁶⁶Met in neural plasticity in humans. Furthermore, several studies suggest that although the variant is not convincingly associated with schizophrenia risk, it seems to be a modifier of the clinical presentation and course of the disease. In order to clarify the underlying mechanisms using functional magnetic resonance imaging (fMRI), we studied the effects of this SNP on ACC and PFC activation, and the connectivity between these regions in a discovery sample of 85 healthy individuals and sought to replicate this effect in an independent sample of 253 individuals. Additionally, we tested the identified imaging phenotype in relation to schizophrenia familial risk in a sample of 58 unaffected first-degree relatives of schizophrenia patients. We found a significant increase in interregional connectivity between ACC and PFC in the risk-associated BDNF ⁶⁶Met allele carriers. Furthermore, we replicated this effect in an independent sample and demonstrated its independence of structural confounds, as well as task specificity. A similar coupling increase was detectable in individuals with increased familial risk for schizophrenia. Our results show that a key neural circuit for cognitive control is influenced by a plasticity-related genetic variant, which may render this circuit particular susceptible to genetic and environmental risk factors for schizophrenia.

Antithrombotic therapy in patients with non-valvular atrial fibrillation undergoing percutaneous coronary intervention: should we change our practice after the PIONEER AF-PCI and RE-DUAL PCI trials?

The number of patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI) is increasing. Since these patients have a CHA₂DS₂-VASc score of 1 or higher, they should be treated with oral anticoagulation to prevent stroke. However, combination therapy with oral anticoagulation for prevention of embolic stroke and dual platelet inhibition for prevention of coronary thrombosis significantly increases bleeding complications. The optimal combination, intensity and duration of antithrombotic combination therapy is still not known. In the rather small randomized WOEST trial, the combination of a vitamin K antagonist (VKA) and clopidogrel decreased bleeding compared to the conventional triple therapy with VKA, clopidogrel and aspirin. In the PIONEER AF-PCI trial, two rivaroxaban-based treatment regimens significantly reduced bleeding complications compared to conventional triple therapy without increasing embolic or ischemic complications following PCI. Dual therapy with rivaroxaban and clopidogrel appeared to provide an optimal risk-benefit ratio. In the RE-DUAL PCI trial, dual therapy with dabigatran also reduced bleeding complications compared to conventional triple therapy. With respect to the composite efficacy end point of thromboembolic events (myocardial infarction, stroke, or systemic embolism), death, or unplanned revascularization dabigatran-based dual therapy was non-inferior to VKA-based triple therapy. The upcoming trials AUGUSTUS with apixaban and ENTRUST-PCI with edoxaban will further examine the use of NOACs in this setting. While recent guidelines recommend NOAC-based dual therapy in only a subset of patients (those who are at increased risk of bleeding), the available data now suggest that this should be the preferred choice for the majority of patients. Adding aspirin to this primary choice for up to 4 weeks in patients at especially high ischemic risk would likely prevent atherothrombotic events, but this needs further investigation. Taken together, it is time to adjust our practice and move to dual therapy consisting of a NOAC plus clopidogrel in most patients.

[Platelet inhibition in elderly patients]

Single antiplatelet therapy (SAPT) using predominantly acetylsalicylic acid (ASA) is the baseline anti-thrombotic therapy in primary as well as secondary prevention of atherosclerotic disease. Dual antiplatelet therapy (DAPT) is the cornerstone of maintenance medication following elective percutaneous coronary interventions or acute coronary syndromes (ST elevation myocardial infarction, non-ST elevation myocardial infarction and unstable angina pectoris). In the past the duration of DAPT in particular has been frequently discussed. Current recommendations, such as the "Focused Update DAPT 2017" of the European Society of Cardiology (ESC) emphasize the importance of strategies aiming to reduce an increased risk of bleeding based on clinical predictors. In this case older age is an important factor relevant for bleeding. In this article, the evidence for SAPT or DAPT is summarized with a special focus on patients aged ≥75 years.

Können Physiotherapeuten klinisch relevante Veränderungen des Straight-Leg-Raise-Tests bei Probanden mit subakuten/akuten Beschwerden feststellen?

Hintergrund: Der Straight-Leg-Raise-Test (SLR) dient klinisch häufig zum Wiederbefund. Der kleinste klinisch relevante Unterschied (Minimal clinically important change, MCIC) und die Änderungssensitivität sind unbekannt.

Ziel: Diese longitudinale multizentrische Studie untersuchte den MCIC und die Änderungssensitivität für den Straight-Leg-Raise bei Patienten mit subakuten/akuten unteren Rückenschmerzen (LBP) und/oder unilateralen Beinschmerzen.

Methode: Bei den eingeschlossenen 10 Probanden mit ausstrahlenden LBP wurden zu 2 Zeitpunkten (t1; t2) der SLR beidseitig mit/ohne Dorsalextension, der LBP sowie die unilateralen Beinschmerzen und die Aktivitätseinschränkung gemessen. Zu t2 wurden die subjektive Veränderung des Gesundheitszustands mittels der Global Rating of Change Scale (GROC) und Korrelationen zwischen den Veränderungen im SLR und der genannten Parameter ermittelt. Mithilfe der Area under the Curve (AUC) und der Korrelationen wurden die Änderungssensitivität und die Schwellenwerte für den SLR berechnet.

Ergebnisse: Die Veränderung des LBP zeigte gute bis sehr gute Korrelationen mit dem SLR mit/ohne Dorsalextension. Die AUC mit LBP als Anker erreichte im SLR einen fast akzeptablen Wert. Der dazugehörige Schwellenwert lag bei 17°.

Schlussfolgerung: Die zu kleine Stichprobengröße ließ keine präzisen Aussagen zu. Es gibt jedoch Hinweise, dass der SLR als änderungssensitiv für die Konstrukte unilaterale Beinschmerzen und LBP gelten könnte.

Das Modell der gesundheitsbezogenen Lebensqualität nach Wilson und Cleary

Hintergrund: Messungen zur Evaluation physiotherapeutischer Interventionen sind ein unverzichtbarer Bestandteil der evidenzbasierten Physiotherapie. Der Fokus liegt dabei oft zu stark auf der strukturellen Ebene der biologischen Funktion. Dies widerspricht der Empfehlung, insbesondere komplexe Gesundheitsprobleme im Rahmen eines biopsychoökosozialen Modells zu analysieren. Zur Auswahl von Konstrukten für Ergebnismessungen, die über die strukturelle Ebene hinausgehende Dimensionen der Gesundheit abdecken können, bietet das Modell der gesundheitsbezogenen Lebensqualität (Health-Related Quality of Life, HRQoL) von Wilson und Cleary 36 eine geeignete Grundlage.

Ziel: Dieser Artikel beschreibt das Konzept von Wilson & Cleary 36 und erläutert den Bezug zu den physiotherapeutischen Handlungsfeldern sowie dessen Bedeutung als Grundlage für die Auswahl von Endpunktmessungen.

Methode: Anhand eines Fallbeispiels wird die Anwendbarkeit des Modells dargestellt, um geeignete Konstrukte für Ergebnismessungen zu definieren und Hypothesen zu generieren. Damit werden Unterschiede zum ICF-Modell und Aspekte der konzeptionellen Merkmale von Ergebnismessungen verdeutlicht.

Schlussfolgerung: Für die Physiotherapie hat die Anwendung des Modells von Wilson & Cleary 36 ein hohes Potenzial, stärker die individuellen Ziele und das Gesundheitserleben der Patienten im Rahmen der physiotherapeutischen Intervention zu berücksichtigen.

Effects of aging on T₁, T₂*, and QSM MRI values in the subcortex

The aging brain undergoes several anatomical changes that can be measured with Magnetic Resonance Imaging (MRI). Early studies using lower field strengths have assessed changes in tissue properties mainly qualitatively, using [Formula: see text]- or [Formula: see text]- weighted images to provide image contrast. With the development of higher field strengths (7 T and above) and more advanced MRI contrasts, quantitative measures can be acquired even of small subcortical structures. This study investigates volumetric, spatial, and quantitative MRI parameter changes associated with healthy aging in a range of subcortical nuclei, including the basal ganglia, red nucleus, and the periaqueductal grey. The results show that aging has a heterogenous effects across regions. Across the subcortical areas an increase of [Formula: see text] values is observed, most likely indicating a loss of myelin. Only for a number of areas, a decrease of [Formula: see text] and increase of QSM is found, indicating an increase of iron. Aging also results in a location shift for a number of structures indicating the need for visualization of the anatomy of individual brains.

[Apnea Detection by Means of Respiratory Sound Recordings and Polysomnography - A Comparative Study]

Introduction In this study, recognition of apnoeas by means of polysomnography (PSG) and nocturnal respiratory sound recordings in patients with obstructive sleep apnoea (OSA) was analyzed and compared. Methods In 45 patients with OSA requiring treatment (AHI > 15/h), concomitant polysomnographic recordings and long term respiratory sound recordings by means of LEOSound were performed. Patients' average age was 58 ± 12 years (mean ± standard deviation), average BMI was 33 ± 7 kg/m². Audio-visual apnoea detection by LEOSound was compared to polysomnographic apnoea detection. Increased artifact rate due to dislocation of microphones led to rejection of 11 out of 45 recordings for detailed analysis. Results Comparison of apnea detection by audio-visual analysis and polysomnography yielded a median of 164 apneas for LEOSound recordings and 158 apneas for PSG. Median apnoea index (AI) was calculated to be 20/h for respiratory sounds recording and 21/h for PSG. The correlation of apnea indices from acoustic long term registration and PSG was 0.939 (p < 0.001). Discussion Acoustic long term registration of primary and secondary respiratory sounds is also capable to recognize apnoeas. Exact differentiation between apnoeas and hypopnoeas is only possible in a limited fashion.