[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.

[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.

[The Nocturnal Respiratory Rate in COPD Patients of Varying GOLD Severity with/without Nicotine Consumption: Calculation by Means of Breath Sound Analysis]

Respiratory rate is an important risk marker and enables early detection of critically ill and vulnerable patients in clinical routine. The aim of this pilot study with 31 patients (COPD severity levels II - IV) was to determine the mean nocturnal respiratory rate based on breath sound recordings and to investigate the dependence of respiratory rate on COPD severity level and smoker status. The mean respiratory rate of the total collective was 19/min. For the COPD-GOLD severity levels, no significant differences in mean respiratory rate could be observed. When nicotine consumption is taken into account, active smokers showed a significantly higher mean respiratory rate of 20.84 ± 4.45/min compared to non-smokers with 17.41 ± 3.14/min (p < 0.05). In addition, active smokers in the study were significantly more frequent among patients with night-time wheezing (60 % vs. 23.8 %). This might suggest that smokers need to perform increased breathing work with increased breathing rate to compensate for oxygen deficiency in bronchial obstruction. The results of the present study show that with the acoustic recording of breath sounds, a reliable representation and calculation of the breath frequency is possible.

Detection of cell proliferation in adults of the water bear Hypsibius dujardini (Tardigrada) via incorporation of a thymidine analog

The taxon Tardigrada, commonly called "water bears", consists of microscopic, eight-legged invertebrates that are well known for their ability to tolerate extreme environmental conditions. Their miniscule body size means that tardigrades possess a small total number of cells, the number and arrangement of which may be highly conserved in some organs. Although mitoses have been observed in several organs, the rate and pattern of cell divisions in adult tardigrades has never been characterized. In this study, we incubated live tardigrades over a period of several days with a thymidine analog in order to visualize all cells that had divided during this time. We focus on the midgut, the largest part of the digestive system. Our results show that new cells in the midgut arise from the anterior and posterior ends of this organ and either migrate or divide toward its middle. These cells divide at a constant rate and all cells of the midgut epithelium are replaced in approximately one week. On the other hand, we found no cell divisions in the nervous system or any other major organs, suggesting that the cell turnover of these organs may be extremely slow or dependent on changing environmental conditions.

[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.

[Normal and Adventitious Breath Sounds]

Auscultation of the lung is an inexpensive, noninvasive and easy-to-perform tool. It is an important part of the physical examination and is help ful to distinguish physiological respiratory sounds from pathophysiological events. Computerized lung sound analysis is a powerful tool for optimizing and quantifying electronic auscultation based on the specific lung sound spectral characteristics. The automatic analysis of respiratory sounds assumes that physiological and pathological sounds are reliably analyzed based on special algorithms. The development of automated long-term lungsound monitors enables objective assessment of different respiratory symptoms.

[Cheyne-Stokes respiration in patients with chronic heart failure: only a diagnostic marker or also a cardiovascular risk factor?]

Sleep disordered breathing with predominant obstructive or central apnea is an under-recognized but highly prevalent comorbidity in patients with chronic heart failure. As the severity of heart failure increases the prevalence of central sleep apnea (CSA) and Cheyne-Stokes respiration (CSR) is also much more frequent. Cheyne-Stokes respiration is characterized by alternating periods of crescendo and decrescendo respiration followed by central apnea. Present data indicate that CSA-CSR is not only a compensatory response to severe heart failure but also a predictor of worse prognosis. However the results on long-term mortality are not consistent. The prognostic importance of night- and daytime CSR has to be further elucidated. Increased sympathetic nervous activity has been proposed to play a mayor role concerning progression and outcome of chronic heart failure by CSA-CSR.

[Topical therapy of ulcerative colitis]

The availability of new topical preparations for the treatment of left sided ulcerative colitis ulcerosa offers a therapy optimization for many patients. Rectal application of steroids and 5-aminosalicylic acid (5-ASA) is associated with fewer side effects and has a higher therapeutic efficacy in mild to moderate-active left-sided colitis as compared to a systemic therapy. Often it is argued that the patients' compliance is insufficient with a rectal therapy. However, with sufficient information on the proven advantages this is usually not the case. The rectal application of drugs in distal ulcerative colitis is suitable also for the maintenance of remission. Therefore the new therapy guidelines recommend topical therapy more than in former times. Subsequently, these manuscripts focussed specifically on the topical therapy of distal colitis, to elucidate that clear treatment advantages are present in daily practice.

Combined lung-sound and reflux-monitoring: a pilot study of a novel approach to detect nocturnal respiratory symptoms in gastro-oesophageal reflux disease

BACKGROUND

Increased prevalence of respiratory symptoms has been commonly reported in patients with gastro-oesophageal reflux disease (GERD).

AIM

To introduce a novel Lung-Sound-Monitoring device that allows simultaneous measurement of both nocturnal respiratory symptoms and episodes of acidic and biliary refluxes.

METHODS

Nocturnal respiratory symptoms (coughing and wheezing) were continuously recorded in 20 healthy subjects and 30 reflux patients with respiratory symptoms in parallel to combined pH-monitoring and Bilitec measurement.

RESULTS

Analysis could be completed in 20 healthy subjects and in 25 patients with reflux. A clear temporal correlation to reflux phases was detected in 49% of coughing and 41% of wheezing events, respectively. Moreover, 89% of the coughing and 100% of the wheezing events succeeded reflux episodes. Finally, the technique was capable of assessing a statistically significant difference between patients and controls regarding the occurrence of these symptoms.

CONCLUSIONS

Our pilot study establishes the Lung-Sound-Monitoring system as a unique tool to measure objectively the temporal correlation between gastroesophageal reflux and the appearance of respiratory symptoms. It represents a useful technique to identify patients with respiratory symptoms due to reflux, and therefore allows one to determine and quantify the impact of therapeutic interventions such as antireflux therapy on respiratory symptoms.

[Nocturnal long-term monitoring of lung sounds in patients with gastro-oesophageal reflux disease]

Gastro-oesophageal reflux disease (GERD) is one of the most common clinical conditions in the developed countries. Particular interest in pulmonary manifestations of this disease has arisen over the last few years. Although the high coincidence between reflux and chronic cough is unquestioned, the proof of a causal correlation is still lacking. In this paper we present the Marburger Lung-Sound-Monitoring as a new method for the detection of nocturnal respiratory symptoms such as cough, wheezing and throat clearing and their temporal correlation with reflux. This method will in future allow us to precisely record and to evaluate the extent and duration of reflux events and their correlation with respiratory symptoms.

[Wheezing during normal breathing as a sign of bronchial obstruction]

Wheezing is a clinical feature in patients with chronic obstructive airway diseases. Long-term monitoring of wheezing could provide a new dimension of diagnostic information as compared to lung function if wheezing really does represent airway obstruction. Patients with wheezing who were part of our Marburg Respiratory Sound Database (MARS) were studied. 20 patients with asthma and 17 patients with chronic obstructive pulmonary disease (COPD) were analysed with respect to pathological changes of lung function parameters. The patients were matched with persons without wheezing in regard to age, diagnosis and sex. Additionally, 58 healthy persons with normal lung function tests were analysed for the occurrence of spontaneous wheezing during normal breathing. In patients with wheezing, at least one parameter of lung function was pathological. For asthmatic patients significant differences for MEF (50) (p = 0.011), R (tot) (p = 0.002) and Tiffeneau (p = 0.001) were found. In patients with COPD significant differences for FEV (1) (p = 0.002) and MEF (50) (p = 0.030) were found. In none of the healthy persons with normal lung function did we find wheezing. Wheezing as a clinical sign of bronchial obstruction is useable for long-term monitoring. The method provides additional information that can help to monitor nocturnal asthma.

Clinical trial: randomized-controlled clinical study comparing the efficacy and safety of a low-volume vs. a high-volume mesalazine foam in active distal ulcerative colitis

BACKGROUND

Rectally administered mesalazine (mesalamine; 5-aminosalicylic acid) is the first-line therapy for treatment of distal ulcerative colitis. Recently, a high-volume 5-aminosalicylic acid foam has been shown to be as effective and safe as standard 5-aminosalicylic acid enema.

AIM

To study the efficacy and safety of a low-volume vs. a high-volume 5-aminosalicylic acid foam.

METHODS

In this investigator-blinded study, patients with active distal ulcerative colitis [Clinical Activity Index (CAI) > 4, Endoscopic Index > or = 4] were randomized to receive 2 x 1 g/30 mL low-volume (n = 163) or 2 x 1 g/60 mL high-volume 5-aminosalicylic acid foam (n = 167) for 42 days. Primary end point was clinical remission (CAI < or = 4) at the final/withdrawal visit (per-protocol).

RESULTS

330 patients were evaluable for efficacy and safety by intention-to-treat, 290 for per-protocol analysis. Clinical remission rates at week 6 (per-protocol) were 77% on low-volume foam vs. 77% on high-volume foam (P = 0.00002 for non-inferiority). The low-volume foam was associated with a lower frequency of severe discomfort, pain and retention problems.

CONCLUSIONS

Low-volume 5-aminosalicylic acid foam is as effective and safe as a high-volume 5-aminosalicylic acid foam in the treatment of active distal ulcerative colitis, but offers compliance advantages compared to the high-volume preparation.

Pediatric-onset gelastic seizures: clinical data and outcome

Gelastic seizures are an extremely rare form of epilepsy defined as automatic bouts of laughter without mirth commonly associated with a hypothalamic hamartoma. The objective was to survey all Israeli children found to develop recurrent gelastic seizures and report presenting symptoms, electroencephalographic and radiologic data, and response to either antiepileptic drugs or surgery. Ten children who developed gelastic seizures at the age of 1 week to 6.5 years (mean, 25 months) at a frequency from 3 bouts per week to >10 prolonged bouts per day were followed for a period of 1.3-12 years (mean, 6 years). Seven cases were defined as symptomatic: cortical magnetic resonance imaging revealed a hypothalamic hamartoma in four patients and cortical abnormalities in three others. Seizure control was achieved in four patients, including a neonate with status gelasticus and hypothalamic hamartoma, and partial control in one more. Five children remained resistant to polytherapy, including three with hypothalamic hamartoma even after two of them underwent hemartoma excision. Thus, children with gelastic seizures may respond relatively well to drug therapy. Four of the 10 patients became seizure free with drug therapy; in three intractable symptomatic cases, surgery was tried but failed in two of the three.

[Obscure coughing and the feeling of suffocation during sleep. Long-term nocturnal acoustic recording]

A 58-year old male presented with a 6-week history of increasing nocturnal cough, dyspnea and awakening. Physical examination, chest auscultation and lung function in the daytime did not show any pathological findings. Only nocturnal long-term recording of respiratory sounds was helpful: In- and expiratory wheezing, as the acoustic manifestation of airway obstruction, was found throughout the night. As the cause for nocturnal cough and distinct airway obstruction, a pansinusitis with postnasal drip syndrome was diagnosed.

Crohn's disease of the esophagus: treatment of an esophagobronchial fistula with the novel liquid embolic polymer "onyx"

Esophageal involvement in Crohn's disease is very rare. In only a small subgroup of these patients -- up to date fourteen cases have been described in the literature -- the course of the illness may be complicated by esophageal fistula formation. The therapy for fistulizing esophageal Crohn's disease so far has been disappointing, recurrence and progression are likely, and surgery still is the primary treatment modality for refractory patients. We here present a case of severe Crohn's disease with an esophagobronchial fistula and the successful closure of the fistula tract with the novel liquid polymer sealant "Onyx". This approach offers a new option for the treatment of this rare complication of Crohn's disease and should be considered if surgery is not possible.

[Nocturnal long-term recording of breath sounds in patients with bronchial asthma -- a reasonable diagnostic option?]

Alterations in normal breath sounds are an important indication of pathophysiological processes in the bronchial system and the lung. In the presence of non-specific symptoms like dyspnea, wheezing or cough while sleeping it seems reasonable to make a nocturnal long-term recording of breath sounds. Thus specific auscultation phenomena can be recorded qualitative and particularly quantitative in the course. A mobile recording system provides a non-invasive monitoring at home which is independent of vigilance. Furthermore it can be used for follow-up examinations of medical interventions.

Budesonide foam versus budesonide enema in active ulcerative proctitis and proctosigmoiditis

BACKGROUND

Rectal budesonide is an effective treatment of active ulcerative proctitis or proctosigmoiditis.

AIM

To compare the therapeutic efficacy, tolerability and safety, and patient's preference of budesonide foam vs. budesonide enema.

METHODS

Patients with active ulcerative proctitis or proctosigmoiditis (clinical activity index > 4 and endoscopic index > or = 4) were eligible for this double-blind, double-dummy, randomized, multicentre study. They received 2 mg/25 mL budesonide foam and placebo enema (n = 265), or 2 mg/100 mL budesonide enema and placebo foam (n = 268) for 4 weeks. Primary endpoint was clinical remission (clinical activity index < or = 4) at the final/withdrawal visit (per protocol).

RESULTS

A total of 541 patients were randomized--533 were evaluable for intention-to-treat analysis and 449 for per protocol analysis. Clinical remission rates (per protocol) were 60% for budesonide foam and 66% for budesonide enema (P = 0.02362 for non-inferiority of foam vs. enema within a predefined non-inferiority margin of 15%). Both formulations were safe and no drug-related serious adverse events were observed. Because of better tolerability and easier application most patients preferred foam (84%).

CONCLUSION

Budesonide foam is as effective as budesonide enema in the treatment of active ulcerative proctitis or proctosigmoiditis. Both budesonide formulations are safe, and most patients prefer foam.

Patient Education in Inflammatory Bowel Disease does not Influence Patients Knowledge and Long-Term Psychosocial Well-Being

BACKGROUND AND AIMS

Patient education is accepted in many disciplines as a valid component of disease management in chronic diseases. The aim of this prospective study was to analyze the effects of an education program in patients with inflammatory bowel disease.

METHODS

145 patients with inflammatory bowel disease were prospectively included: 73 were educated in four sessions, 72 were educated after the one year evaluation period (control group). The following topics were presented: pathogenesis, diagnostic procedures, course of disease, medical and surgical treatment, nutrition, social problems and support, stress management, and coping with the disease.

RESULTS

The repeated measurement two-way analysis of variances showed no effects of the patient education program on disease-related knowledge, depression and quality of life.

CONCLUSION

This patient education program was not able to increase disease-related knowledge or psychosocial variables in patients with IBD. However, most of the patients were very satisfied with the education program, since as judged by their own assessment it helped them to act responsibly for themselves and their disease.

[Injuries in Olympic handball tournaments: a video analysis]

INTRODUCTION

The aim of the study was to achieve injury situations in European team handball with a video based method.

METHODS

A video tape containing 59 injuries of an Olympic handball tournament were analyzed by two observers (sports-scientist, orthopaedic surgeon). The analysis was based on a method previously published by Teitz, which was developed to analyze ACL-injuries. The parameters body region, field position, contact/non-contact, offense/defense, field player/goal keeper were mainly used.

RESULTS

The most injuries were localized at the head (N = 20), the lower limb (N = 15), thorax and abdomen (N = 9) and the upper limb (N = 9). Concerning the field, the most injuries were in the midfield (N = 20), followed by the left (N = 13) and right (N = 9) outside position. The injured players were mostly in the offense (84 %), and in the majority of cases the field players were affected (97 %). 86 % of the injuries accomplished by contact.

CONCLUSION

The head has a high risk, predominantly of contact injury. Contact-injuries could only be reduced by strict decisions of the referees. Non-contact injuries should be prevented by a special coordinative training.

Insights into angiotensin II receptor function through AT2 receptor knockout mice

Angiotensin II signals via at least two receptors termed AT1 and AT2. The function of the AT1 receptor is well defined, while that of the AT2 receptor is still shrouded in uncertainty. AT2 gene-deficient (-/-) mice have been helpful in unravelling the function of the AT2 receptor. We have studied AT2-/- and AT2+/+ mice with classical physiological techniques developed for the rat. We found that although AT2-/- mice have normal glomerular filtration rate, the pressure-natriuresis relationship in these mice, compared with AT2+/+ mice, is shifted rightward. Moreover, medullary blood flow fails to increase with increased perfusion pressure while the AT1 receptor expression in the kidneys is increased. We used telemetry and found that AT2-/- mice have about 10 mmHg higher blood pressures than AT2+/+ mice and that their circadian rhythm is disturbed. Moreover, their baroreflexes, as measured by spectral analyses, differs from AT2+/+ controls. The cardiac function of AT2-/- mice is remarkably preserved and the differences are subtle. However, if the mice are given l-NAME hypertension, they exhibit an end-systolic pressure-volume relationship that reveals decreased contractility and probable increased vascular stiffness. Furthermore, the hearts of AT2-/- mice hypertrophy more in response to l-NAME than those of AT2+/+ mice and perivascular fibrosis is increased. DOCA-salt treatment also shows a more rightward pressure-natriuresis relationship in AT2-/- compared with AT2+/+ mice. The renal iNOS expression is increased with DOCA-salt treatment. Our findings support the notion that the AT2 receptor signals antiproliferative and antifibrotic effects and that its presence results in lower blood pressures and lesser responses to secondary forms of hypertension. Technical advances that have allowed us to adapt methods for the rat to the much smaller mouse have facilitated our studies.