Preoperative differences between male and female patients with sleep apnea.

OBJECTIVES/HYPOTHESIS: To evaluate the differences between female and male patients with obstructive sleep apnea syndrome (OSAS) in the preoperative period. STUDY DESIGN: Nonrandomized cross-sectional study. METHODS: An analysis of 686 patients (111 women and 575 men) with OSAS was completed. Multivariate modeling techniques were employed to correlate gender with the preoperative respiratory disturbance index (RDI), apnea index (AI), hypopnea index (HI), body mass index (BMI), age, and initial symptoms. RESULTS: At presentation, the male patients were significantly younger and had a lower BMI and a higher RDI and AI than the female patients. For the entire OSAS population studied, the RDI increased as the BMI increased (correlation coefficient [r] = 0.35, P = <.001). For the female patients there was a weaker correlation (r = 0.21, P =.034), and in male patients there was a stronger correlation (r = 0.40, P <.001). For the entire population there was a negative correlation between age and RDI (r = -0.15, P <.001). In female patients there was a nonsignificant correlation (r = -0.09, P =.35), and in male patients the correlation was significant (r = -0.16, P <.001). There was no difference in the reporting of the number of symptoms based on gender (P =.355). Female patients noted headaches on awakening more commonly than male patients (P =.001), and male patients noted snoring (P =.014) and stopping breathing during sleep (P =.001) more often than female patients. CONCLUSIONS: The analysis demonstrated that within a surgical population sample, gender differences exist. The findings of this series were as follows: 1) Apnea severity in women was less weight-dependent than in men; (2) in men there was a significant negative correlation between age and apnea severity; and (3) female and male patients reported the same number of signs or symptoms on presentation, although certain signs and symptoms were more commonly reported based on gender. Current clinical evaluation practices must take into account this gender disparity.

Early polysomnographic findings and long-term subjective results in sleep apnea patients treated with laser-assisted uvulopalatoplasty.

OBJECTIVES/HYPOTHESIS: To examine the long-term results of laser-assisted uvulopalatoplasty (LAUP) for the treatment of patients with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: One hundred eighty-two OSAS patients treated with LAUP were followed for an average of 4 years. Of these patients, 131 have completed treatment. Complete polysomnographic data are available on 48 patients. Five patients were eliminated owing to nasal surgery performed during the period between the preoperative and postoperative sleep studies, thus 43 patients were included who had only LAUP treatment. Another three patients were eliminated because their postoperative polysomnograms were performed less than 6 weeks after the last procedure. Complete long-term subjective data are available on 31 patients. METHODS: Between July 1993 and July 1998, 1038 patients were evaluated for LAUP treatment for snoring and OSAS. Of the 1038 patients, 409 were treated with LAUP and the remaining 629 were treated with other surgical procedures, devices, or behavior modification. The 40 patients who underwent only LAUP treatment for OSAS and have complete polysomnographic data are the focus of this study. RESULTS: The significant objective polysomnographic findings include a decrease in the respiratory disturbance index (RDI) from 25.0 +/- 2.8 to 15.3 +/- 2.9 (P = < .0001), and a decrease in the apnea index (AI) from 14.6 +/- 2.6 to 9.0 +/- 2.4 (P = .00248). In addition, the percentage of time spent in rapid eye movement (REM) sleep significantly increased after LAUP, from 13.3% +/- 1.0 to 17.6% +/- 1.4 (P = .0149). The long-term subjective results indicate that the presenting complaints were improved after LAUP in 74.9% +/- 4.1 with a mean follow-up of 4.04 years +/- 72 days (median, 4.63 y). CONCLUSIONS: LAUP remains a safe and effective treatment for carefully selected patients suffering from OSAS. Five years after LAUP was introduced in the United States, objective polysomnographic data demonstrate reduction in the RDI and increased time spent in REM sleep after treatment. In addition, the long-term subjective results show that the presenting symptoms were no longer present in 75% of patients treated with LAUP.

Laser-assisted uvulopalatoplasty for the treatment of mild, moderate, and severe obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Until recently, laser-assisted uvulopalatoplasty (LAUP) has been used to treat only snoring and mild cases of obstructive sleep apnea (OSA). The purpose of this study was to evaluate the efficacy and safety of LAUP in patients with mild, moderate, and severe OSA. STUDY DESIGN: A prospective study of 38 patients who completed LAUP for the treatment of OSA who were evaluated based on the severity level of their preoperative apnea. MATERIALS AND METHODS: Between July 1993 and December 1995, 96 patients with a diagnosis of OSA based on polysomnography underwent staged outpatient LAUP treatment. Thirty-eight patients completed treatment and obtained postoperative polysomnography. Postoperative complications and polysomnographic findings were reviewed. RESULTS: Fifteen patients had a diagnosis of mild apnea, 12 had moderate apnea, and 11 had severe apnea based on preoperative polysomnography. The surgical response rates, defined as greater than or equal to 50% reduction in the postoperative respiratory disturbance index (RDI) and a postoperative RDI of less than 20, were 46.7% in the mild apneics, 41.7% in the moderate apneics, and 45.5% in the severe apneics. Postoperative complications in this series included minor bleeding, oral candidiasis, and temporary velopharyngeal insufficiency. There were no serious complications. CONCLUSIONS: In the carefully selected and prepared patient with mild, moderate, or severe OSA, LAUP should be considered a surgical option for the treatment of this disorder. LAUP remains a cost-effective and safe alternative to uvulopalatopharyngoplasty.

Mitogenic activity of the outer membrane of Treponema denticola.

The outer membrane (OM) was isolated by detergent extraction from Treponema denticola ATCC 35405, ATCC 33521 and ATCC 35404, representing serovars a, b and c, respectively, as well as from two fresh isolates of T. denticola. Strict precautions were undertaken against the introduction of contaminant lipopolysaccharide when the OM was isolated. The OM was active in mitogenic stimulation of C3H/HeOuJ mouse spleen cultures, but to a somewhat lesser extent than purified lipopolysaccharide (LPS) from Escherichia coli 055:B5. Polymyxin B only partially inhibited the response. Unheated OM abrogated mitogenic activity of E. coli LPS, but heated preparations enhanced the mitogenic activity of E. coli LPS, suggesting the presence of a heat-labile cytolytic factor associated with T. denticola OM in addition to a putative lipopolysaccharide and/or heat-stable lipoprotein.

Hyperparathyroidism associated with a chronic hypothyroid state.

Reports of the coexistence of hyperparathyroidism and thyroid disease have raised the issue of a possible etiologic relationship. The present study tests the hypothesis that chronic elevation of thyroid-stimulating hormone (TSH) is related to the development of hyperparathyroidism. Four groups of 60 female rats were treated as follows: group 1, control; group 2, propylthiouracil (PTU) 0.0025%; group 3, PTU 0.0025% plus thyroxine, 5 microg two times per week; and group 4, only thyroxine. The animals' serum calcium, phosphorus, TSH, thyroxine, and parathyroid hormone (PTH) levels were evaluated at 0, 6, 12, and 18 months. Significant elevation of TSH was sustained throughout the 18 months in groups 2 and 3. The PTH levels were also significantly elevated in both group 2 and group 3 animals (P = 0.02). The histopathologic features of the parathyroids were evaluated at 18 months. In the group 2 (PTU only) animals, which had profound hypothyroid, 44% developed parathyroid adenomas. In the group 3 (PTU plus thyroxine) animals, who had mildly elevated TSH levels, 53% developed parathyroid adenomas. These findings are consistent with the hypothesis that prolonged TSH stimulation may lead to hyperparathyroidism in the rat model.

Uvulopalatopharyngoplasty versus laser-assisted uvulopalatoplasty for the treatment of obstructive sleep apnea.

Uvulopalatopharyngoplasty (UPPP) was the first surgical procedure specifically designed to address the palatal abnormalities seen in many patients with obstructive sleep apnea syndrome (OSAS). For adult apneic patients, UPPP remains the most commonly performed operation. Beginning in 1993, laser-assisted uvulopalatoplasty (LAUP) was introduced for the treatment of snoring and sleep apnea. LAUP differs from UPPP because it is performed in the office using only local anesthesia, thus being very cost-effective. Seventy-nine patients with OSAS underwent surgical treatment: 38 treated with LAUP and 41 with UPPP. The overall surgical response rate, defined as a >50% reduction in the postoperative respiratory disturbance index (RDI), was achieved in 21 (51.2%) of UPPP-treated and 18 (47.4%) of LAUP-treated patients. The RDI decreased from 30.3 +/- 3.7 to 22.2 +/- 4.4 events/h in the LAUP patients and from 52.1 +/- 5.0 to 25.5 +/- 2.7 events/h in the UPPP patients. The lowest oxyhemoglobin saturation (LS(aO2)) increased from 72.8 +/- 2.1 to 80.9 +/- 1.3% in the UPPP patients; there was no change in the LAUP patients. Postoperative complications in this series included minor bleeding, oral candidiasis, and temporary velopalatal insufficiency in both groups. In the carefully selected OSAS patient, LAUP should be considered a surgical alternative to UPPP. LAUP may actually be preferable to UPPP in certain cases because LAUP is cost-effective, does not require a general anesthetic or hospitalization, has very few associated complications, and time lost at work is minimal.

Laser-assisted uvulopalatoplasty: postoperative complications.

Laser-assisted uvulopalatoplasty (LAUP) has become a widely used procedure for the treatment of snoring and mild sleep apnea in the United States. Between July 1993 and December 1994, the authors of this study prospectively evaluated 541 consecutive patients referred to their hospital for possible LAUP to treat loud disruptive snoring. Of the 541 patients, 275 patients had a total of 754 LAUP procedures. There were 26 complications (3.45%). These complications included postoperative hemorrhage in 16 patients (2.12%), local infection in 4 patients (0.53%), temporary palatal incompetence in 4 patients (0.53% , and temporary loss of taste in 2 patients (0.27%). None of the 16 patients with postoperative hemorrhage required a blood transfusion. Only 10 patients (1.3%) had hemorrhage that required medical attention; in the other patients, the bleeding stopped spontaneously. There were no cases of hypernasal speech, permanent palatal incompetence, nasopharyngeal stenosis, airway compromise, or death.

Identifying obstructive sleep apnea in patients presenting for laser-assisted uvulopalatoplasty.

The authors report on a series of 850 patients with snoring who were evaluated for laser-assisted uvulopalatoplasty (LAUP). Stepwise multivariate linear regression was employed to correlate patient symptoms and characteristics to the respiratory disturbance index (RDI). Body mass index, falling asleep while driving, snoring every night, and stopping breathing during sleep were found to correlate strongly with an increasing RDI (variance of 25%). Logistic multivariate linear regression analysis was used to predict the outcome of apnea (RDI>10). This model selected all of the above variables, as well as age, male sex, and the total number of symptoms, as being strong predictors of apnea. A receiver operating characteristic curve was used to describe the ability of this model to predict apnea. The authors conclude that otolaryngologists play an important role in the evaluation of OSAS, especially when a snoring patient may undergo LAUP, and they present an algorithm for the evaluation of such a patient. The authors believe that the clinical assessment, including a thorough history and a complete physical examination, remains extremely important in this evaluation. At present, the authors strongly recommend referral for a PSG if there is any suspicion of OSAS.

Laser-assisted uvulopalatoplasty for snoring and obstructive sleep apnea: results in 170 patients.

Laser-assisted uvulopalatoplasty (LAUP) is a procedure for the treatment of snoring and, possibly, sleep apnea. Between July 1993 and December 1994, the authors prospectively evaluated 541 consecutive patients referred to their teaching hospital for possible LAUP to treat loud, disruptive snoring. Of these patients, 274 (51%) had one or more LAUP treatments. As of January 1995, LAUP treatment courses were completed in 170 patients. In this paper, the authors report preliminary results on the use of LAUP in these patients. Among the 170 patients, 105 (62%) had a diagnosis of snoring and 65 (38%) obstructive sleep apnea syndrome (OSAS) based on preoperative polysomnography. LAUP treatment in the snoring only patients resulted in complete or nearly complete elimination of snoring in 63 patients (60%), partial improvement of snoring in 30 patients (29%), and no improvement in 11 patients (10%). Of the 65 OSAS patients treated with LAUP, postoperative polysomnograms were obtained in 33 patients (51%). Surgical success was achieved in 16 (48%) of the 33 patients. However, 7 patients (21%) had repeat polysomnograms that were worse than their preoperative polysomnograms, and 5 patients (15%) had no significant change. The results of this study suggest that LAUP may be a viable surgical option for patients with snoring and mild sleep apnea.

Immunochemical features of a macromolecule of Treponema denticola.

In this study the extraction and the immunochemical features of a lipopolysaccharide-like (LPSL) macromolecule of T. denticola strains 35405, 35404, 33521 and 11 were investigated. The yield of LPSL molecule ranged between 0.5-0.9% of the cell dry weight, it possessed Limulus amebocyte lysate clotting activity, and it contained glucosamine, phosphate, heptose, glucose, small amounts of KDO, myristic and beta hydroxy myristic acid. Sera obtained from healthy individuals (ADA type I) periodontitis, from 3-8 month old infants, or the mouse monoclonal antibody, diluted 1:2, against T. pallidum did not react with the LPSL antigens of T. denticola strains 35405, 35404, 33521, and 11. Sera from patients with ADA type III-IV periodontitis were reactive with two 8-14 kDa bands even at serum dilutions of 1:2000. Sera from patients with ADA type II periodontitis showed good antibody response to the 8-14 kDa band at a dilution of 1:50, but were weekly reactive, or nonreactive at serum dilutions of 1:200. This study indicates that extraction of a lipopolysaccharide-like macromolecule is feasible from the assay spirochetes, and this macromolecule may be used as an antigen for the diagnosis of ADA types II-IV periodontitis.

Parathyroid autotransplantation in patients undergoing a total thyroidectomy: a review of 261 patients.

Parathyroid autotransplantation was first described in 1907 by Halsted. However, this simple and effective method of preserving parathyroid function has been used with increasing frequency only during the past 25 years. Beginning in the late 1960s, our group has transplanted normal parathyroid tissue into the ipsilateral sternocleidomastoid muscle whenever these glands could not be preserved in situ with adequate blood supply. In addition, if the blood supply of all four parathyroid glands appeared compromised, cryopreservation of parathyroid tissue was performed in case the autotransplanted tissue did not function after surgery. Since 1970, 393 patients underwent a total thyroidectomy. Parathyroid glands that could not be saved in situ were biopsied to confirm their identity by frozen section and then autotransplanted. Of the 393 patients who underwent a total thyroidectomy, 261 patients required transplantation of one or more glands. Among those 261 patients who underwent selective parathyroid autotransplantation, 33 (13%) required temporary calcium and vitamin D supplementation. Of these 33 patients, 2 (less than 1%) had permanent hypoparathyroidism and are receiving long-term vitamin D therapy.

Effect of outer membrane of Treponema denticola on bone resorption.

The effect of the outer membrane (outer sheath) of Treponema denticola on bone resorption was studied. Bone resorption was measured by the release of previously incorporated 45Ca from the shafts of the radii and ulnae of 19-day fetal rats. A treated-over-control ratio (T/C ratio) significantly greater than 1 indicated the stimulation of bone resorption by the test substance. The addition of outer membrane of T. denticola increased the release of 45Ca from the assay bones. The minimum concentrations required to yield significant 45Ca release from the assay bones were 15, 22 and 75 micrograms protein/ml for serovars a, b and c, respectively. These protein values corresponded to estimated lipopolysaccharide contents of 0.6, 0.8 and 2.8 micrograms/ml, based on 3-deoxy-2-manno-octulosonate analysis. Heat treatment of outer membrane (60 degrees for 30 min) did not change the effect on 45Ca release. Parathyroid hormone or prostaglandin E2, known to act synergistically with lipopolysaccharides in bone resorption, was also added to the assay system. Neither prostaglandin E2 at 10(-7) M nor parathyroid hormone at 40 ng/ml, by itself, increased 45Ca release. However, in the presence of 10 micrograms protein/ml of outer membrane of serovar b at 120 h, the T/C ratio was increased to 1.31 +/- 0.07 and 1.58 +/- 0.118, respectively. These results suggest that a lipopolysaccharide-like material is present in the outer membrane of T. denticola that may be responsible for bone resorption in the in vitro system.

Phosphorylated nutrient uptake by Treponema denticola and other potential periodontopathogens.

Nutrient uptake may contribute to the survival of certain potential periodontopathogens in the competitive environment of the gingival sulcus. This study was conducted to assess the uptake of commercially available, key radiolabelled phosphorylated compounds by Treponema denticola. There was a linear relationship in the uptake of ATP and G-1-P with cell concentrations of 0.1-2.5 mg of cell dry weight. This uptake reached a steady state within 15 min, and at temperatures of 25-37 degrees C the uptake ranged between 13-21%. At 50 degrees C, or above 50 degrees C the assay cells took up 0-1% of the assay nutrients. The maximum uptake of ATP was 47.5, 38 and 47.6 pmoles for serovars a, b and c. G-1-P yielded maximum uptake values of 306, 304, and 306 pmoles respectively. Significant uptake of ATP, or G-1-P occurred at pH 4.8 for serovars a, or c, while serovar b showed a broad pH range for the uptake of G-1-P. Stannous fluoride at a concentration of 0.17 mM enhanced the uptake of ATP while chlorhexidine digluconate inhibited the uptake of ATP. At concentrations usually employed (0.05-0.5 mM) the metabolic poisons 2,4-dinitrophenol, sodium azide, sodium arsenite and the ATPase inhibitor N,N1-dicyclohexylcarbodiimide did not alter significantly the uptake of ATP. The uptake of ATP, by Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Fusobacterium nucleatum and T. denticola at pH 4.8 was 13.4, 1.5, 6.9, and 18-20.4%, respectively. At pH 6.5 the uptake for the microorganisms indicated above was 22, 1.3, 6.6 and 6.2%, respectively. G-1-P showed the same trend in its uptake by A. actinomycetemcomitans, P. gingivalis, F. nucleatum and T. denticola. This study provides for the first time specific examples of phosphorylated nutrient uptake by potential periodontopathogens, and that the uptake of phosphorylated nutrients can be suppressed by oral hygienic compounds.

Biochemical properties of the outer membrane of Treponema denticola.

The outer membranes (OMs) from serovars a, b, and c of Treponema denticola, originally isolated from periodontal patients, were prepared. Dialysis of the OMs against 20 mM MgCl2 yielded the aggregable (A) and the nonaggregable (NA) moieties of the OMs. The absence of muramic acid, adenosine triphosphatase, hexokinase, and nucleic acid as well as electron microscopy indicated that the OM preparations were homogeneous. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the A and NA moieties of the OMs showed approximately 25 Coomassie brilliant blue R-250 stain-positive bands or 47 silver-stained polypeptides. The relative molecular masses ranged between 14 and 97 kDa. The electrophoretic polypeptide profiles of the A and NA moieties shared many similarities among serovars a, b, and c. However, they exhibited variation in the overall pattern, intensity, or location of the polypeptide stained zones. This was especially true for serovar b. Two-dimensional electrophoretic studies showed an excess of 100 silver-stained spots with isoelectric points of 4.6 to 7.0 and relative molecular masses in the 14- to 97-kDa range. The OMs contained simple proteins, glycoproteins, and lipoproteins. The NA moieties of the OMs contained 4 to 6, 10 to 12, and 4 to 6 glycopeptides as well as two, seven, and two lipoprotein bands for serovars a, b, and c, respectively. The A moieties of the OMs showed 7 to 9, 11 to 13 and 5 to 6 glycopeptides as well as four, five, and three lipoprotein bands for serovars a, b, and c, respectively. Lipopolysaccharide was detected in the OMs of the three serovars following removal of proteins with proteinase K, pronase and silver staining of sodium dodecyl sulfate-polyacrylamide gels, or removal of lipopolysaccharide from the OMs by hot phenol extraction. The 66- and 53-kDa bands were present in serovars b and c, while a band with a relative molecular mass of 45 kDa was present only in serovar c. Endotoxin-like activity was also shown in the OMs of the three serovars by the Limulus amebocyte clotting assay and the chick embryo lethality test. This is the first report on selected biochemical properties of the OM macromolecules of three known serovars of T. denticola.