Pharmacotherapy for obstructive sleep apnea - A systematic review and meta-analysis of randomized controlled trials

Continuous positive airway pressure is the first-line and gold-standard treatment for obstructive sleep apnea (OSA). Pharmacotherapy is not commonly used in treating OSA until recently. Combined noradrenergic and antimuscarinic agents have been clinically applied for OSA patients with variable results. This meta-analysis study aimed to investigate the efficacy of the combined regimen on OSA. A systematic literature search was performed up to November 2022 for the effects of the combined regimen on OSA. Eight randomized controlled trials were identified and systematically reviewed for meta-analysis. There were significant mean differences between OSA patients taking a combined regimen and placebo in apnea-hypopnea index (AHI) [mean difference (MD) -9.03 events/h, 95%CI (-16.22, -1.83 events/h; P = 0.01] and lowest oxygen saturation [MD 5.61%, 95% CI % (3.43, 7.80); P < 0.01]. Meta-regression showed that a higher proportion of male participants was associated with a greater reduction of AHI (p = 0.04). This study showed a positive but modest effect of pharmacotherapy in the reduction of OSA severity. The combination drugs are most applicable to male OSA patients based on their efficacy and pharmacological susceptibility. Pharmacotherapy may be applied as an alternative, adjunctive or synergistic treatment under careful consideration of its side effects.

Palatal hybrid surgery for obstructive sleep apnea-state-of-the-art annotation of uvulopalatopharyngoplasty

BACKGROUND

Surgery for obstructive sleep apnea (OSA) has changed in concept and technique that transformed from radical excision to functional reconstruction. The aim of this study was to investigate the safety and effectiveness of palatal hybrid surgery in OSA patients.

METHODS

Palatal hybrid surgery is a tissue-specific technique (mucosa-preservation, tonsil-excision, fat-ablation, muscle-relocation/suspension) used in treating OSA patients with velopharyngeal obstruction. The study included 46 consecutive adults OSA patients. The palatal hybrid surgery annotates uvulopalatopharyngoplasty in stereoscopic reconstruction of tonsillar fossa (pharyngoplasty), omni-suspension of the soft palate (palatoplasty) and advancement of uvula (uvuloplasty).

RESULTS

No patient experienced airway compromise, voice change or persistent nasal regurgitation following palatal hybrid surgery. One patient existed postoperative tonsillar fossa bleeding received conservative treatment. Postoperative pain in visual analogue scale (VAS) showed average score of 3, 3, 2, 0 at the 1st, 3rd, 7th, 14th day, respectively. Perioperative snoring severity (VAS) (8.7 vs 2.6) and daytime sleepiness (Epworth Sleepiness Scale) (11.3 vs 5.5) all improved significantly (p < 0.001). Posterior air space in retropalatal area increased from 8.4 to 11.1 mm (p < 0.001). Home sleep test showed that apnea-hypopnea index significantly reduced from 41.8 to 18.2 event/h and minimal oxygen saturation increased from 72.4 to 81.5% (p < 0.001). The success rate in individual Friedman stage was 100% (stage I), 63% (stage II) and 58% (stage III) with a total success rate of 63%.

CONCLUSION

Palatal hybrid surgery using tissue-specific maneuver annotates UPPP in concept and technique. The results show that palatal hybrid surgery is mini-invasive with low morbid and is effective in improving subjective clinic symptoms, objective sleep parameters and success rate of OSA.

Quality characteristics of yogurts fermented with short-chain fatty acid-producing probiotics and their effects on mucin production and probiotic adhesion onto human colon epithelial cells

Probiotics can ferment nondigestible carbohydrates and produce short-chain fatty acids (SCFA; acetate, propionate, and butyrate) in the human colon. In this study, the levels of SCFA were determined in the following yogurts fermented with different combinations of probiotics: (1) cocultures of Streptococcus thermophilus and Lactobacillus bulgaricus (control, C); (2) S. thermophilus, L. bulgaricus, and Bifidobacterium bifidum (C-Bb); (3) S. thermophilus, L. bulgaricus, and Lactobacillus acidophilus (C-La); and (4) S. thermophilus, L. bulgaricus, and Lactobacillus gasseri (C-Lg). Results showed that the acetate levels were significantly higher in C-Bb, C-La, and C-Lg yogurts than in C yogurt. Fermentation and physicochemical characteristics of all yogurts were identical. Treatment of mucus-secreting colon epithelial cells (HT29-MTX) with C-Bb, C-La, and C-Lg yogurt supernatants resulted in an increase in the expression of MUC2 and CDX2 and the production of mucin proteins. The adhesion of probiotics onto HT29-MTX cells increased following treatment with C-Bb, C-La, and C-Lg yogurt supernatants. Our data suggest that a yogurt diet rich in acetate improves the protective function of the intestinal epithelium.

Short communication: Effects of moringa extract on adhesion and invasion of Escherichia coli O55 in bovine mammary epithelial cells

The objective of this study was to evaluate the antibacterial activities of extract derived from moringa leaves. In particular, the effect of moringa extract (Mor) on adhesion and invasion of Escherichia coli O55, Enterococcus faecalis, Staphylococcus simulans, and Serratia liquefaciens was evaluated in bovine mammary epithelial cells (MAC-T). Broth microdilution method, minimum inhibitory concentration and minimum bactericidal concentration assays, adhesion and invasion assays, and real-time PCR were performed. The minimum inhibitory concentration and minimum bactericidal concentration of Mor ranged from 12.5 to 50 mg/mL on 18 out of 27 tested isolates. Treatment of E. coli O55 with Mor (100 and 200 μg/mL) inhibited the adhesion and invasion on MAC-T cells via downregulation of adhesion factors (i.e., papC, f17c-A, and eaeA). Also, when MAC-T cells were pretreated with Mor (200 μg/mL, 12 h) and incubated with E. coli O55, Enterococcus faecalis, Staphylococcus simulans, or Serratia liquefaciens, both E. coli O55 and Enterococcus faecalis showed a significant decrease in adhesion and invasion. Staphylococcus simulans exhibited decreased adhesion and increased invasion. Serratia liquefaciens showed increased adhesion and decreased invasion. In addition, Mor increased mRNA expression of antioxidant enzymes (e.g., heme oxygenase-1, NAD(P)H:quinone oxidoreductase-1, and thioredoxin reductase 1) in MAC-T cells. In conclusion, 12.5 to 50 mg/mL of Mor exhibited antibacterial activity against 18 out of 27 tested isolates. Also, pretreatment of 200 μg/mL of Mor to MAC-T cells modulated adhesion and invasion of E. coli O55 and other mastitis-associated pathogens. Furthermore, Mor increased antioxidant capacities in MAC-T cells, but further in vivo studies are needed.

Risk of Alzheimer's Disease in Obstructive Sleep Apnea Patients With or Without Treatment: Real-World Evidence

OBJECTIVE

To assess the risk of Alzheimer's disease (AD) in patients with obstructive sleep apnea (OSA) with or without treatment based on real-world evidence.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patients newly diagnosed with OSA during 1997-2012 were identified using the National Health Insurance Research Database of Taiwan. Patients without OSA were randomly selected and matched in a 1:4 ratio by age, sex, urbanization level, and income. All patients were followed up until death or the end of 2013. The primary outcome was AD occurrence.

RESULTS

This study included 3,978 OSA patients and 15,912 non-OSA patients. OSA was independently and significantly associated with a higher incidence of AD in an adjusted Cox proportional hazard model (adjusted hazard ratio: 2.12; 95% confidence interval [CI], 1.27-3.56). The average period of AD detection from the time of OSA occurrence was 5.44 years (standard deviation: 2.96). Subgroup analyses revealed that the effect of OSA remained significant in patients aged ≥60 years, male subgroups, patients without CPAP or surgical treatment, and patients without pharmacological therapies. Patients with OSA who received treatment (continuous positive airway pressure or surgery) exhibited a significantly reduced risk of AD compared with those without treatment (incidence rate ratio 0.23, 95% CI, 0.06-0.98).

CONCLUSION

OSA is independently associated with an increased risk of AD. Treatment for OSA reduces the AD risk in OSA patients. AD irreversibility renders OSA as a potential modifiable target for slowing or preventing the process of AD development.

LEVEL OF EVIDENCE

IV Laryngoscope, 130:2292-2298, 2020.

Alterations in Alzheimer's Disease-Associated Gene Expression in Severe Obstructive Sleep Apnea Patients

Background: Obstructive sleep apnea (OSA) increases the risk of Alzheimer’s disease (AD), and inflammation may be involved in the early pathogenesis of AD in patients with OSA. However, the potential pathways between OSA and AD have yet to be established. In this study, we aimed to investigate differential expressions of AD-associated genes in OSA patients without evident AD or dementia. Methods: This prospective case-control study included five patients with severe OSA and five age and sex-matched patients with non-severe OSA without evident dementia who underwent uvulopalatopharyngoplasty between 1 January 2013 and 31 December 2015. The expressions of genes associated with AD were analyzed using whole-exome sequencing. Unsupervised two-dimensional hierarchical clustering was performed on these genes. Pearson’s correlation was used as the distance metric to simultaneously cluster subjects and genes. Results: The expressions of CCL2, IL6, CXCL8, HLA-A, and IL1RN in the patients with severe OSA were significantly different from those in the patients with non-severe OSA and contributed to changes in the immune response, cytokine–cytokine receptor interactions, and nucleotide-binding oligomerization domain-like receptor signaling pathways. Conclusions: Inflammation may contribute to the onset of AD and physicians need to be aware of the potential occurrence of AD in patients with severe OSA.

Snoring Sounds Predict Obstruction Sites and Surgical Response in Patients with Obstructive Sleep Apnea Hypopnea Syndrome

Snoring sounds generated by different vibrators of the upper airway may be useful indicators of obstruction sites in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). This study aimed to investigate associations between snoring sounds, obstruction sites, and surgical responses (≥50% reduction in the apnea-hypopnea index [AHI] and <10 events/hour) in patients with OSAHS. This prospective cohort study recruited 36 OSAHS patients for 6-hour snoring sound recordings during in-lab full-night polysomnography, drug-induced sleep endoscopy (DISE), and relocation pharyngoplasty. All patients received follow-up polysomnography after 6 months. Fifteen (42%) patients with at least two complete obstruction sites defined by DISE were significantly, positively associated with maximal snoring sound intensity (40-300 Hz; odds ratio [OR], 1.25, 95% confidence interval [CI] 1.05-1.49) and body mass index (OR, 1.48, 95% CI 1.02-2.15) after logistic regression analysis. Tonsil obstruction was significantly, inversely correlated with mean snoring sound intensity (301-850 Hz; OR, 0.84, 95% CI 0.74-0.96). Moreover, baseline tonsil obstruction detected by either DISE or mean snoring sound intensity (301-850 Hz), and AHI could significantly predict the surgical response. Our findings suggest that snoring sound detection may be helpful in determining obstruction sites and predict surgical responses.

Changes of snoring sound after relocation pharyngoplasty for obstructive sleep apnoea: the surgery reduces mean intensity in snoring which correlates well with apnoea-hypopnoea index

OBJECTIVE

To investigate objective changes of snoring after surgery in patients with obstructive sleep apnoea (OSA) and correlate these with changes in the apnoea-hypopnoea index (AHI).

DESIGN

Prospective case series.

SETTING

A novel measurement, Snore Map, was used to analyse full-night snore sounds in terms of the maximal/mean intensity, peak/mean frequency, snoring index and energy type (Snore Map type, 0-4). Snore sound was classified into three bands according to frequency energy spectrum: B1 (40-300 Hz), B2 (301-850 Hz) and B3 (851-2000 Hz).

PARTICIPANTS

Thirty-four male and two female OSA patients (mean age, 39 years; mean AHI, 53.1/h; mean body mass index, 26.8 kg/m(2) ) with favourable anatomic structure were consecutively enrolled.

MAIN OUTCOME MEASURES

Parameters of polysomnographies and Snore Maps at baseline and six months after operation were compared. Statistical significance was set at P < 0.05.

RESULTS

Thirty-two patients completed this study. The mean reduction in the total-snoring index was insignificant but there were significant decreases in total mean intensity, total peak frequency, total mean frequency and Snore Map type after surgery. There were also significant decreases in the mean intensity in all three bands, the snoring index in B2/B3 and the mean frequency in B1 postoperatively. Changes in the total mean intensity, total mean frequency, B2 mean intensity and B3 snoring index positively correlated with change in the AHI.

CONCLUSIONS

Relocation pharyngoplasty significantly decreases both the snoring sound intensity and snoring frequency. These reductions are directly proportional to the improvement of OSA.

Comparative effects of snoring sound between two minimally invasive surgeries in the treatment of snoring: a randomized controlled trial

Background

Minimally invasive surgeries of the soft palate have emerged as a less-invasive treatment for habitual snoring. To date, there is only limited information available comparing the effects of snoring sound between different minimally invasive surgeries in the treatment of habitual snoring.

Objective

To compare the efficacy of palatal implant and radiofrequency surgery, in the reduction of snoring through subjective evaluation of snoring and objective snoring sound analysis.

Patients and Method

Thirty patients with habitual snoring due to palatal obstruction (apnea-hypopnea index ≤15, body max index ≤30) were prospectively enrolled and randomized to undergo a single session of palatal implant or temperature-controlled radiofrequency surgery of the soft palate under local anesthesia. Snoring was primarily evaluated by the patient with a 10 cm visual analogue scale (VAS) at baseline and at a 3-month follow-up visit and the change in VAS was the primary outcome. Moreover, life qualities, measured by snore outcomes survey, and full-night snoring sounds, analyzed by a sound analytic program (Snore Map), were also investigated at the same time.

Results

Twenty-eight patients completed the study; 14 received palatal implant surgery and 14 underwent radiofrequency surgery. The VAS and snore outcomes survey scores were significantly improved in both groups. However, the good response (postoperative VAS ≤3 or postoperative VAS ≤5 plus snore outcomes survey score ≥60) rate of the palatal implant group was significantly higher than that of the radiofrequency group (79% vs. 29%, P = 0.021). The maximal loudness of low-frequency (40–300 Hz) snores was reduced significantly in the palatal implant group. In addition, the snoring index was significantly reduced in the radiofrequency group.

Conclusions

Both palatal implants and a single-stage radiofrequency surgery improve subjective snoring outcomes, but palatal implants have a greater effect on most measures of subjective and objective snoring. Multi-stage radiofrequency surgery was not tested.

Trial Registration

ClinicalTrials.gov NCT01955083

Positional Dependency and Surgical Success of Relocation Pharyngoplasty among Patients with Severe Obstructive Sleep Apnea

Objective

To examine the effect of positional dependency on surgical success among patients with severe obstructive sleep apnea (OSA) following modified uvulopalatopharyngoplasty, known as relocation pharyngoplasty.

Study Design

Case series with planned data collection.

Setting

Tertiary referred center.

Subjects and Methods

Standard nocturnal polysomnography was used to compare the apnea-hypopnea index (AHI) in different sleep positions before and after relocation pharyngoplasty in 47 consecutive patients with severe OSA (AHI, 59.5 ± 18.2 events/hour; Epworth Sleepiness Scale [ESS] scores, 12.2 ± 4.4) who failed continuous positive airway pressure therapy. Positional (dependency) OSA was defined when the supine:non-supine AHI ratio was >2, otherwise it was defined as nonpositional OSA. Surgical success was defined as a ≥50% reduction in AHI and a postoperative AHI of ≤20 events/hour. Polysomnographic parameters, ESS, and surgical success following surgery were recorded.

Results

Of the 47 patients, 27 (57%) had positional OSA and 20 (43%) nonpositional OSA. The nonpositional OSA patients had higher AHI and ESS scores than the positional OSA patients ( P = .002 and .104, respectively). Relocation pharyngoplasty significantly improved AHI and ESS scores in both positional and nonpositional OSA groups 6 months postoperatively ( P < .05). The overall surgical success rate was 49%; however, positional OSA patients had a significantly higher success rate than nonpositional OSA patients (67% vs 25%, P = .008).

Conclusion

The presence of positional dependency at baseline was a favorable outcome predictor of surgical success among severe OSA patients undergoing relocation pharyngoplasty.

Survey of short-term patient satisfaction after surgery for obstructive sleep apnea

BACKGROUND

To investigate the level of satisfaction of patients who received surgery for obstructive sleep apnea (OSA).

METHODS

A patient satisfaction survey (PSS) was administered three months after surgery to 76 patients who received either a uvulopalatopharyngoplasty (UPPP) alone, or in combination with a septomeatoplasty (SMP), or a midline laser glossectomy (MLG). Patient satisfaction determinants were also explored.

RESULTS

In general, 93.4% of patients rated their overall satisfaction as "excellent" or "very good". High satisfaction levels (excellent + very good >/= 90%) were observed in the dimensions of "professional skill", "personal manner", and "explanation of condition". By contrast, lower satisfaction levels (excellent + very good< 90 %) were observed for "perioperative discomfort". There were no significant differences among the UPPP alone, UPPP + SMP, and UPPP +MLG groups for any dimension of satisfaction (p> 0.05). Older patients had decreased overall levels of satisfaction (adjust R (2) = 0.1, p = 0.02).

CONCLUSIONS

The preliminary results reveal a high overall level of satisfaction after surgery for OSA in this short-term survey. However, modest satisfaction with perioperative discomfort was also noted. Combined nasal or tongue base surgeries can be performed with patient satisfaction comparative to that of UPPP alone. Age may confound satisfaction levels in patients receiving OSA surgery.

Performance on a dementia screening test in relation to demographic variables. Study of 5297 community residents in Taiwan

OBJECTIVE

To examine the relation between performance on a dementia screening test and the demographic variables of age, education, gender, and urban vs rural residency.

DESIGN

Community survey with cluster sampling.

SETTING

One urban and one rural community from each of four geographic regions in Taiwan, Republic of China.

PARTICIPANTS

A total of 5265 nondemented individuals approximately equally divided between men and women and between urban and rural residency with a range in age from 41 to 88 years and in education from 0 to 20 years.

MAIN OUTCOME MEASURE

Score on a Chinese adaptation of the Mini-Mental State Examination.

RESULTS

Lower test scores were associated with older age and less education. The decrease in score with age was faster among participants who had never attended school. Better performance by men and by urban residents was found only among participants with fewer than 6 years of schooling. In this group, the magnitudes of sex and residency differences were comparable among those subjects aged 41 to 64 years and those aged 65 to 88 years. Women who had never worked outside of the home performed poorer than those who had worked outside of the home.

CONCLUSIONS

The influence of educational background on test performance is most evident in individuals with less education. Commonly used dementia screening tests may be unfair to poorly educated individuals, especially women and rural residents. Efforts should be made to develop ecologically relevant cognitive tests for the intended study populations. To help distinguish test bias from different rates of cognitive decline, the study populations should include individuals in predementia age ranges.

A health survey of workers in the pentachlorophenol section of a chemical manufacturing plant

During 1968 to 1985, 109 workers who had been engaged in the production of pentachlorophenol, using non-gamma isomers of hexachloroclohexane (BHC) as the raw material, were surveyed. Endemic chloracne among them had been noted since 1974. The prevalence of chloracne was 73.4% (80/109) in total and 95.2% (20/21) in a trichlorobenzene (TCB) tank area where dioxin and dibenzofurans levels were thousands of ppm. To our knowledge, PCDDs and PCDFs have not previously been reported from thermal decomposition of BHC. Urinary porphyrins were significantly higher among exposed workers than among the controls but there was no significant difference between the workers with chloracne and those without. The conduction velocities of the median motor nerves were much slower among the workers in the TCB tank area where the highest PCDDs contamination appeared. The mortality study cohort was relatively young. Based on the three deaths observed during the follow-up, no association could be drawn.

A modified posterior approach for Moore arthroplasty of the hip - a preliminary report

Prosthetic replacement for displaced femoral neck fracture in the elderly is commonly done through a posterior ("southern') approach. Although this is a good approach post-operative wound infection and dislocation may occur. Such problems have led the authors to modify this surgical approach through the upper part of the quadratus femoris, and the lower part of the hip capsule. Preliminary results in the early post-operative period in ten patients have been encouraging and if done with care it appears to minimise the risk of post-operative infection and dislocation.