Long-term quality of life outcomes of maxillomandibular advancement osteotomy in patients with obstructive sleep apnoea syndrome.

This study was performed to evaluate the long-term impact of maxillomandibular advancement (MMA) surgery on the apnoea-hypopnoea index (AHI) and quality of life (QoL) in patients with obstructive sleep apnoea syndrome (OSAS). The medical files of 12 OSAS patients who underwent MMA by one surgeon between 1995 and 1999 were reviewed retrospectively. Patients received a clinical assessment, polysomnography, and QoL questionnaires as part of routine care preoperatively (n=12), within 2 years postoperative (n=12), and again in 2016 (n=9). A successful surgical outcome was defined as an AHI decrease of >50% with <20 events/h. Of the 66.7% (8/12) of patients who were initially cured, 66.7% (4/6) remained stable at a median follow-up of 19 years. Only the two patients with the highest AHI showed abnormal Epworth Sleepiness Scale scores. After convalescence, most patients reported stable symptomatic improvement. Aesthetic changes were found acceptable and all but one patient stated that they would undergo the surgery again. It is concluded that MMA is a safe and effective procedure. Ageing and weight gain might counterbalance the positive effects of surgery in the long term. It is therefore suggested that re-evaluation every 5 years should be scheduled, since a spontaneous AHI increase over time does not seem to be reflected by symptomatic changes.

European guideline for the diagnosis and treatment of insomnia

This European guideline for the diagnosis and treatment of insomnia was developed by a task force of the European Sleep Research Society, with the aim of providing clinical recommendations for the management of adult patients with insomnia. The guideline is based on a systematic review of relevant meta-analyses published till June 2016. The target audience for this guideline includes all clinicians involved in the management of insomnia, and the target patient population includes adults with chronic insomnia disorder. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to grade the evidence and guide recommendations. The diagnostic procedure for insomnia, and its co-morbidities, should include a clinical interview consisting of a sleep history (sleep habits, sleep environment, work schedules, circadian factors), the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination and additional measures if indicated (i.e. blood tests, electrocardiogram, electroencephalogram; strong recommendation, moderate- to high-quality evidence). Polysomnography can be used to evaluate other sleep disorders if suspected (i.e. periodic limb movement disorder, sleep-related breathing disorders), in treatment-resistant insomnia, for professional at-risk populations and when substantial sleep state misperception is suspected (strong recommendation, high-quality evidence). Cognitive behavioural therapy for insomnia is recommended as the first-line treatment for chronic insomnia in adults of any age (strong recommendation, high-quality evidence). A pharmacological intervention can be offered if cognitive behavioural therapy for insomnia is not sufficiently effective or not available. Benzodiazepines, benzodiazepine receptor agonists and some antidepressants are effective in the short-term treatment of insomnia (≤4 weeks; weak recommendation, moderate-quality evidence). Antihistamines, antipsychotics, melatonin and phytotherapeutics are not recommended for insomnia treatment (strong to weak recommendations, low- to very-low-quality evidence). Light therapy and exercise need to be further evaluated to judge their usefulness in the treatment of insomnia (weak recommendation, low-quality evidence). Complementary and alternative treatments (e.g. homeopathy, acupuncture) are not recommended for insomnia treatment (weak recommendation, very-low-quality evidence).

Sleep matters in Parkinson's disease: use of a priority list to assess the presence of sleep disturbances.

BACKGROUND AND PURPOSE: Despite their high prevalence and clinical impact, sleep disorders in Parkinson's disease appear to receive insufficient attention in clinical practice. We compared the importance of sleep disorders relative to other symptoms and daily issues. Furthermore, we determined whether relevance as perceived by patients correlated with the subjective presence of sleep disruption scored with a rating scale. METHODS: We studied a cohort of 153 consecutive patients (95 men) who were referred for problems other than sleep to our referral center. Prior to their visit, patients ranked their individual top five clinical priorities (of 23 items), indicating the most problematic domains for which they requested medical attention. Additionally, nocturnal sleep quality and excessive daytime sleepiness (EDS) were assessed with validated questionnaires. RESULTS: The top three important domains according to the patient were movement (79.9%), medication (73.2%), and physical condition (63.4%). Sleep was the sixth most frequently reported item, marked by 37.9% of the patients. Amongst the patients who scored sleep as a priority, 47 (81%) had a poor sleep quality (Pittsburgh Sleep Quality Index > 5). Although EDS was present in almost 30% of patients, a minority of them put it on their priority list. CONCLUSION: A priority list can be used to prioritize patient-centered quality of life issues. Our results show that sleep is a clinical priority for about one-third of patients. Surprisingly, EDS was usually not prioritized by patients during the consultation, underscoring the need to use ratings scales alongside subjective priorities.

Subjective sleep quality and daytime sleepiness in a large sample of patients with chronic fatigue syndrome (CFS).

Chronic fatigue syndrome (CFS) is characterised by incapacitating fatigue in combination with a number of minor criteria, including unrefreshing sleep without further specifications, in the absence of psychiatric and internal disease. As little data exist on subjective sleep quality and daytime sleepiness, these parameters were assessed in a large sample of CFS patients. Consecutive patients with a diagnosis of CFS in a tertiary referral centre filled out the Fatigue Questionnaire (FQ), Medical Outcomes Study 36-Item Short Form Health Survey (MOS SF-36), Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Inclusion comprised 415 individuals (mean age 40.5 yr, SD 7.9, range 18-64; 86% female). Mean FQ (26.90; SD 4.04), mean Global Physical Health from the MOS SF-36 (29.30; SD 12.25) and Global Mental Health from the MOS SF-36 (49.62; SD 18.31) scores corresponded with literature data for similar CFS samples. High mean ESS (10.51; SD 5.52) and global PSQI (10.17; SD 4.02) were observed. No significant relationship was found between ESS and global PSQI. In contrast, regression analysis demonstrated a significant cubic relation between ESS and 'PSQI without daytime dysfunction'. A subgroup (n=69) with an insomnia-like phenotype low ESS (<5), high PSQI (mean 11.51; SD 3.86) was observed. The assessment of subjective sleep quality and daytime sleepiness in a large sample of CFS patients indicated high mean PSQI and ESS values. ESS and 'PSQI without daytime dysfunction' were inversely related at the spectral ends of ESS. A distinct subgroup with clinical features of insomnia was identified.

The use of hypnosedative drugs in a university hospital setting.

OBJECTIVE: The use of hypnosedatives (HSs) in the hospital and at home before admission was registered. Also, the incidence of HSs newly started in the hospital and the incidence of withdrawal in chronic users while in hospital was recorded. METHODS: The study population consisted of 517 consecutively admitted patients recruited from 10 wards of the Ghent University Hospital; 493 of them received a questionnaire and were interviewed concerning the use of HSs at home and in the hospital, about the cause and duration of treatment, the type of HSs used, the presence and nature of any concomitant sleep or anxiety disorder. Main outcome measures were the actual use of HSs during hospitalisation as compared with the reported use, the influence of hospitalisation on use of HSs and the assessment of cause and duration of use of HSs. RESULTS: Twenty-nine percent of the study sample took HSs at home and 45.2% while in the hospital. HSs were prescribed to 28.6% of the patients not habituated to chronic use of HSs at home. In contrast, 14.0% of the patients habituated to chronic use of HSs received no sleep medication while in hospital. Patients older than 60 years used more HSs than younger patients. Previous administration of HSs, sleep problems during hospital admission and female sex were predictive of HS-use. The main reason for prescription of HSs in the hospital was continuation of HSs taken at home. The most prescribed HSs were: lormetazepam, lorazepam, alprazolam, diazepam and zolpidem. Almost 10% of the patients were not informed on treatment with HSs. Among the subjects in whom HSs were newly started, 16.0% intended to continue this medication after discharge. Eleven percent took combinations of hypnosedative drugs. CONCLUSIONS: The prevalence of prescription of HSs in the university hospital setting is high. Appropriate guidelines are needed to control the use of HSs during hospitalisation and to ensure withdrawal from these drugs upon discharge.

Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature.

Benzodiazepines (BZDs) constitute the most widely used symptomatic treatment of insomnia and anxiety. Many of these drugs are associated with adverse effects, such as daytime sedation and dependence with continued use. There is a concern about the rationale for and extent of benzodiazepine (BZD) use in the elderly. The sedation due to BZD use is a main risk factor for falls and other accidents. Impaired cognitive function with continuous use appears to be a major side effect. There is a general awareness that BZD use is inappropriate in many patients, and therefore discontinuation should be recommended whenever possible. Moreover, long-term use of these drugs should be actively discouraged. Although no unanimous recommendations concerning the optimal duration of the withdrawal process exist, BZDs may easily be withdrawn during a short period in most patients who are habituated to a low dose, if an initial phase with dose reduction and psychological support are provided. Alternative approaches involve sleep hygiene guidelines, behavioural treatment and psychotherapy tailored to the needs of the individual patient.

Acoustic analysis of snoring: review of literature.

Acoustic analysis of snoring could make patient assessment more accurate, treatment planning more efficient and could provide objective documentation reliable for comparison. However, spectral characteristics are irregular and difficult to analyse. The authors give an overview of the available literature and the various applied methods. These methods differ in purpose and are subject to restrictions. Until now, acoustic analysis of snoring remains controversial. For linking the results of the acoustic analysis with anatomical levels or degree of obstruction, further study is needed to develop a reliable parameter.

Hypersomnolence and narcolepsy; a pragmatic diagnostic neurophysiological approach.

Out of a group of 250 consecutive patients who were examined for various disorders of sleep and waking at Ghent University Hospital within a period of 24 months, 30 patients with hypersomnolence associated with a suspected underlying neurological etiology were selected. The population consisted of 15 males and 15 females with mean age of 36 years (range: 16-60 years). Twenty-one patients had had hypersomnolence for more than 2 years. All patients underwent a single night polysomnography (PSG) and a 4-nap multiple sleep latency test (MSLT). PSG was normal in 23 patients. Sleep onset REM period (SOREMP) was defined as the occurrence of REM sleep within 15 min. after initiation of sleep. PSG demonstrated SOREMP's in only 1 patient and showed evidence of obstructive sleep apnea in 4 patients. Two patients had a low sleep efficiency. MSLT demonstrated hypersomnolence in 17 patients of whom 6 showed SOREMP. Significant hypersomnolence was defined as a mean sleep latency < or = 5 min. 4 patients fulfilled the classical clinical and polygraphic criteria (> or = 2 SOREMP) of narcolepsy. In 8 patients the tentative diagnosis of idiopathic CNS hypersomnolence was made. 13 patients did not sleep during MSLT. These results emphasize the relative importance of MSLT. Our limited 4-nap MSLT protocol proved useful in distinguishing narcolepsy from idiopathic CNS hypersomnolence.

Fast withdrawal from benzodiazepines in geriatric inpatients: a randomised double-blind, placebo-controlled trial.

OBJECTIVE: We have previously demonstrated that temporary substitution with a low-dose hypnosedative drug may lead to successful withdrawal from chronic benzodiazepine (BZD) use in the majority of patients admitted to a geriatric ward. In the present study, a withdrawal programme was evaluated in which the habitual treatment with BZDs was replaced by either 1 mg lormetazepam or placebo, defining withdrawal success rate, sleep quality and withdrawal symptoms as main outcomes. METHODS: The target population was geriatric inpatients who had been taking BZDs for at least 3 months. Subjects suffering from mental disorders were excluded. Lormetazepam or placebo were randomly assigned and given in a double-blind fashion. After 1 week, the replacement therapy was discontinued. Subjective estimations of sleep quality and withdrawal symptoms were registered at predefined intervals, four times in a period of 30 days, using standard questionnaires (the Pittsburgh Sleep Quality Index and the Benzodiazepine Withdrawal Symptom Questionnaire, respectively). RESULTS: The success rate was significantly higher in the lormetazepam substitution group (80% vs 50% in the placebo group, P < 0.05). Both the subjective quality of sleep and withdrawal symptoms were significantly better in the lormetazepam substitution group. Important withdrawal effects were observed in the control group in two patients with a history of chronic alcohol abuse. CONCLUSIONS: Initial replacement therapy with a low-dose BZD is preferred over placebo, since the latter alternative is associated with worse sleep quality and a lower success rate. Placebo must only be used under medical scrutiny, given the potential for unmasking delirious symptoms, especially in patients with concomitant alcoholism.

External nasal dilation reduces snoring in chronic rhinitis patients: a randomized controlled trial.

Chronic rhinitis patients often suffer from unrefreshing sleep and snoring, related to increased nasal resistance to airflow. Previous trials based on subjective assessment of snoring have demonstrated beneficial effects of Breathe Right (BR), a noninvasive external nasal dilator. Polysomnography (PSG) was applied to objectively assess the effects of BR on snoring. Twelve nonobese chronic rhinitis patients participated in the present study, which had a randomized, placebo-controlled design. The presence of snoring and the absence of sleep apnoea was demonstrated during a baseline overnight sleep study. Patients were then randomized for placebo or true nasal dilator treatment, which was also assessed by overnight PSG. The use of BR had no effect on sleep quality, arousal-index apnoea-hypopnoea-index or snoring loudness. Snoring frequency was significantly lowered by BR (173+/-29 snores x h(-l)), compared with placebo (258+/-34 snores x h(-1); p=0.016). The results support the hypothesis that Breathe Right is effective in reducing the amount of snoring in patients with chronic rhinitis. This objective finding is in line with some other reports on subjective improvement of snoring, based upon the judgement of bedpartners.

A programme for short-term withdrawal from benzodiazepines in geriatric hospital inpatients: success rate and effect on subjective sleep quality.

OBJECTIVE: We tested the hypothesis that a short-term programme for withdrawal of benzodiazepines (BZD) is feasible in hospitalized geriatric patients. METHODS: Fifty-six geriatric subjects who had been taking BZD for at least 3 months were asked to discontinue these drugs upon admission to the inpatient ward. A withdrawal programme including initial substitution therapy combined with psychological consulting was offered. The usual BZD medication was replaced by either lormetazepam 1 mg or trazodone 50 mg, administered at bedtime. After 1 week of replacement therapy all sedative medication was stopped. The subjective estimations of sleep quality were evaluated four times during a period of 6 weeks. RESULTS: Forty-nine patients agreed to participate. In this group four subjects (8.2%) resumed BZD use while in the hospital and another seven subjects (14.3%) relapsed after discharge. Therefore, the overall success rate was 77.6% in the group of volunteers and 67. 9% in the total group of eligible patients. The data of the present study further demonstrate that no major withdrawal symptoms occurred and that the subjective quality of sleep remained virtually unchanged in the course of the programme. The sleep quality was not significantly different in patients on trazodone versus patients on lormetazepam. The success rate was similar in both drug substitution groups. CONCLUSIONS: Short-term withdrawal of BZD may be achieved in two-thirds of elderly hospital inpatients without deterioration of sleep quality or other deleterious side-effects.

Effects of changes in central venous pressure on upper airway size in patients with obstructive sleep apnea.

Intraluminal airway pressure and pharyngeal muscle activity are widely recognized as major determinants of the size and collapsibility of the upper airway. In addition, changes in the volume or pressure of tissue surrounding the pharyngeal airway may significantly influence its size. The present study used fast computed tomography (CT) to determine the effects of changes in central venous pressure (CVP) on upper airway size. Ten awake male patients with obstructive sleep apnea (OSA) were studied. Scans were performed at functional residual capacity (FRC) and at the end of a tidal inspiration (VTei) under three conditions of CVP: (1) at baseline (CVP nl) with patients lying supine; (2) at decreased CVP (CVP-) by inflating blood pressure cuffs to 40 mm Hg on both legs; and (3) at increased CVP (CVP+) by elevating both legs to 33 degrees. At FRC, changes in CVP had no significant effect on either mean or minimum cross-sectional area (CSA) of the upper airway. In contrast, an analysis of variance (ANOVA) indicated that alterations in CVP were associated with changes in mean CSA (p = 0.03) and to a lesser extent in minimum CSA (p = 0.07) at VTei. With the legs elevated (CVP+), neither mean nor minimum CSA showed any significant change with tidal breathing. However, after leg-cuff inflation (CVP-), highly significant increases in both mean (163 +/- 22 to 218 +/- 19 mm2, p = 0.001) and minimum (48 +/- 8 to 85 +/- 12 mm2, p = 0.02) CSA were detected. Changes in mean and minimum CSA with tidal breathing at baseline (CVP nl) were intermediate. These results indicate that changes in CVP significantly alter the response of the upper airway to tidal breathing. They further suggest that increases in upper airway size with tidal breathing may be related to reduction in venous blood volume in pharyngeal and neck tissues as the generation of negative intrathoracic pressure during inspiration increases venous return to the chest.

Effects of body position on the upper airway of patients with obstructive sleep apnea.

Fast-CT scanning was used to study the effects of changes in body position on upper airway (UA) size and shape in 11 awake subjects with obstructive sleep apnea (OSA). Six patients with position (P)-dependent OSA were compared with five patients with nonposition (NP)-dependent OSA. Scans were repeated in the prone (PRN), right side (RS), and supine (SUP) body positions at both functional residual capacity and end-inspiratory tidal volume. Significant group, group by position, and borderline group by respiration effects were detected for minimum but not mean UA dimension data. Significant differences between groups were noted in minimum cross-sectional area and minimum lateral distance but not in minimum anteroposterior distance in the RS and SUP positions. Turning from the PRN to the RS or SUP position tended to decrease UA size in the NP group by decreasing the lateral distance, while the opposite effect was found in the P group. The results indicate that changes in body position during wakefulness affect the lateral but not the anteroposterior dimensions of the UA, and the UA behaves differently in patients with NP and P OSA in response to changes in body position.

Relations between sleep stage, posture and effective nasal CPAP levels in OSA.

A retrospective analysis of positional data from 100 male patients with obstructive sleep apnea (OSA) was conducted to determine whether or not 1) the degree of positional dependency was similar in rapid eye movement (REM) compared to non-REM (NREM) sleep, 2) positional dependency correlated with effective levels of nasal continuous positive airway pressure (CPAP) and 3) patients with positional OSA preferentially avoided sleeping in the supine position. The apnea-hypopnea index (AHI) was scored separately for sleep state (NREM and REM) and for posture [off back (AHI-O) and on back (AHI-B)]. The ratio of AHI-O/AHI-B was used to define positional OSA as AHI-O/AHI-B less than or equal to 0.50 (P group) and nonpositional OSA as 0.50 less than AHI-O/AHI-B (NP group). A group of 31 patients who had sufficient sleep time in NREM and REM sleep in both sleep postures was selected. In this group 9 out of 22 subjects who showed positional dependency during NREM sleep became nonpositional during REM sleep (0.05 less than p less than 0.10). The mean effective nasal CPAP level was slightly, but significantly, lower in the P group than in the NP group (8.0 versus 9.1 cm H2O; p less than 0.05). In addition, a correlation between AHI and effective nasal CPAP levels was found (r = 0.491; p = 0.0001). The P group had less supine sleep time (SST) than the NP group (32% versus 45% of total sleep; p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

MRI signal intensity profiles of sellar and perisellar lesions.

Literature data are reviewed and cumulated with our own findings in order to delineate the ability of MRI to evaluate the nature of sellar and perisellar lesions by analyzing their signal intensity profiles. The existence of different trends in T1 and T2 relaxation characteristics was documented within a spectrum of frequently presenting lesions. Magnetic resonance imaging (MRI) signal intensity analysis may contribute to exclude differential diagnostic problems remaining after computer tomographic examination of the sella. MRI should be the primary imaging test (in the absence of the known contra-indications) whenever a suspected pituitary or perisellar lesion has to be studied non-invasively.