Prolonged partial upper airway obstruction during sleep - an underdiagnosed phenotype of sleep-disordered breathing

Obstructive sleep apnea syndrome (OSAS) is a well-recognized disorder conventionally diagnosed with an elevated apnea–hypopnea index. Prolonged partial upper airway obstruction is a common phenotype of sleep-disordered breathing (SDB), which however is still largely underreported. The major reasons for this are that cyclic breathing pattern coupled with arousals and arterial oxyhemoglobin saturation are easy to detect and considered more important than prolonged episodes of increased respiratory effort with increased levels of carbon dioxide in the absence of cycling breathing pattern and repetitive arousals. There is also a growing body of evidence that prolonged partial obstruction is a clinically significant form of SDB, which is associated with symptoms and co-morbidities which may partially differ from those associated with OSAS. Partial upper airway obstruction is most prevalent in women, and it is treatable with the nasal continuous positive pressure device with good adherence to therapy. This review describes the characteristics of prolonged partial upper airway obstruction during sleep in terms of diagnostics, pathophysiology, clinical presentation, and comorbidity to improve recognition of this phenotype and its timely and appropriate treatment.</p

Neuronavigated Versus Non-navigated Repetitive Transcranial Magnetic Stimulation for Chronic Tinnitus: A Randomized Study

Repetitive transcranial magnetic stimulation (rTMS) has shown variable effect on tinnitus. A prospective, randomized 6-month follow-up study on parallel groups was conducted to compare the effects of neuronavigated rTMS to non-navigated rTMS in chronic tinnitus. Forty patients (20 men, 20 women), mean age of 52.9 years (standard deviation [SD] = 11.7), with a mean tinnitus duration of 5.8 years (SD = 3.2) and a mean tinnitus intensity of 62.2/100 (SD = 12.8) on Visual Analog Scale (VAS 0–100) participated. Patients received 10 sessions of 1-Hz rTMS to the left temporal area overlying auditory cortex with or without neuronavigation. The main outcome measures were VAS scores for tinnitus intensity, annoyance, and distress, and Tinnitus Handicap Inventory (THI) immediately and at 1, 3, and 6 months after treatment. The mean tinnitus intensity (hierarchical linear mixed model: F3 = 7.34, p = .0006), annoyance (F3 = 4.45, p = .0093), distress (F3 = 5.04, p = .0051), and THI scores (F4 = 17.30, p F3 = 2.96, p = .0451) favoring the non-navigated rTMS. Reduction in THI scores persisted for up to 6 months in both groups. Cohen’s d for tinnitus intensity ranged between 0.33 and 0.47 in navigated rTMS and between 0.55 and 1.07 in non-navigated rTMS. The responder rates for VAS or THI ranged between 35% and 85% with no differences between groups (p = .054–1.0). In conclusion, rTMS was effective for chronic tinnitus, but the method of coil localization was not a critical factor for the treatment outcome.</p

Performance of non-invasive devices in evaluation of periodic limb movements and sleep-disordered breathing

Uusia menetelmiä levottomien jalkojen ja kuorsauksen diagnostiikkaan Laajaa unirekisteröintijärjestelmää pidetään unihäiriöiden diagnostiikan vertailustandardina. Sillä tehdyt tutkimukset ovat melko kalliita, koska ne tehdään yleensä unilaboratorioissa hoitajan valvonnassa. Rekisteröintijärjestelmässä on paljon johtoja ja mittalaitteita, jotka voivat häiritä potilasta. Siksi tarvitaan jatkuvaa kehitystyötä, jotta kliinisiin unirekisteröinteihin saadaan liikuteltavia, nukkujaa häiritsemättömiä, edullisia, mutta luotettavia metodeja. Väitöskirjan aihe oli tutkia patjatyyppisten liikeantureiden soveltuvuutta jaksoittaisten raajaliikkeiden havaitsemiseen ja unenaikaisen hengityshäiriön selvittelyyn. Väitöskirjassa esitellään myös uuden metodin, henkitorven päältä rekisteröitävän tiivistetyn äänianalyysin käytettävyyttä unenaikaisten hengityshäiriöiden tutkimuksessa. Levottomat jalat -oireyhtymästä kärsivillä potilailla on unirekisteröinneissä hyvin usein raajojen jaksoittaisia liikkeitä. Väitöskirjan osajulkaisuissa todettiin, että patjatyyppiset static-charge-sensitive bed (SCSB)- ja Emfit-anturit havaitsevat jaksoittaiset raajaliikkeet yhtä hyvin kuin vertailumenetelmänä käytettävä säärilihasten toiminnan mittaus. SCSB- ja Emfit-antureiden hengityssignaaleissa näkyy erityinen, ns. piikikkyys-ilmiö. Unenaikaisen hengityshäiriön yhteydessä pitkäkestoisen piikikkyyden havaittiin liittyvän ilmavirran virtausrajoitukseen ja ihon läpi mitatun hiilidioksidiosapaineen nousuun. Hengityskatkoja (apnea) sisältävien jaksojen aikana hiilidioksidiosapaineen nousua ei havaittu. Kuorsaus liittyy hyvin usein unenaikaisiin hengityshäiriöihin, ja se on tärkeä unitutkimuksiin lähettämisen syy. Kuorsaus voi olla katkeilevaa tai jatkuvaa ja pitkäkestoista. Katkeilevan kuorsauksen tiedetään usein liittyvän uniapneatautiin, mutta pitkäkestoisen kuorsauksen merkitys tunnetaan huonosti. Kuorsauksen ja henkitorven päältä rekisteröitävän äänen analyyseja voidaan käyttää unenaikaisten hengityshäiriöiden tutkimiseen. Väitöskirjassa esiteltävän uuden äänianalyysin perusteella hengityskatkot, pitkäkestoinen virtausrajoitus ja normaali hengitys voitiin erottaa toisistaan. Erityisen mielenkiintoista oli, että jatkuvan, pitkäkestoisen kuorsauksen aikana oli todettavissa selvää virtausrajoitusta, vaikka usein ajatellaan vain katkeilevan kuorsauksen liittyvän hoidettaviin unenaikaisiin hengityshäiriöihin. Tutkitut uudet rekisteröintimenetelmät, SCSB ja Emfit sopivat jaksoittaisten raajaliikkeiden havaitsemiseen. Emfit ja henkitorven päältä rekisteröitävä tiivistetty äänianalyysi voivat auttaa unenaikaisten hengityshäiriöiden selvittelyssä. Kaikkia näitä antureita voidaan käyttää osina laajempia järjestelmiä tai erillisinä rekisteröintilaitteina. Niillä tehtävät rekisteröinnit ovat edullisia, suoritukseltaan helppoja ja häiritsevät potilasta vain vähän, jos lainkaan. Niinpä ne ovat erittäin sopivia liikuteltaviin unirekisteröintijärjestelmiin. Lisäksi niillä kaikilla on erityisominaisuuksia, joiden avulla voidaan havaita ja luonnehtia vielä huonosti tunnettua pitkäkestoista virtausrajoitusta.Polysomnography is considered as the gold standard in diagnosing sleep disturbances. These studies are quite expensive as they are performed in sleep laboratories with continuous attendance by a technician or nurse. Recordings with large amounts of cables and measurement devices can be inconvenient for the patients. Therefore there is a constant need to develop ambulatory, unmolested, inexpensive but reliable methods for clinical sleep investigations. The aim of this thesis was to study the suitability of mattress type movement sensors for the detection of periodic limb movements and in the characterization of sleep-disordered breathing. Also the performance of a new method, compressed tracheal sound analysis, in the evaluation of sleep-disordered breathing is presented in the thesis. Patients with restless leg syndrome have very often periodic limb movements in their sleep recordings. This finding is considered as a supportive criterion in restless legs diagnostics. The gold standard in recording of periodic limb movements is anterior tibialis electromyography. The studies in this thesis showed that the static-charge-sensitive bed (SCSB) and Emfit sensors detect periodic limb movements reliably and the periodic movement indexes were quite comparable with the gold standard. A special signal feature, a spiking phenomenon is seen with both the SCSB and Emfit sensors. Spiking can also reliably be detected with an automatic method that does not need any recording-specific tuning before the analysis. In sleep-disordered breathing prolonged spiking was found to be associated with an increase in transcutaneously measured carbon dioxide (TcCO2). During apnea and hypopnea episodes no significant change in TcCO2 level was observed. The non-round inspiratory flow shapes, which are related to flow limitation, were most constant phenomenon during prolonged spiking episodes. Snoring is very often associated with sleep-disordered breathing and an important reason for referrals to sleep studies. Analyses of snoring and tracheal sound can be used in the evaluation of sleep related breathing disorders. In the compressed tracheal sound analysis the signal curve can visually be divided into three distinct patterns. The characteristics of the patterns differed significantly from each other. Based on the diverse appearances of the patterns, breathing with apneas/hypopneas, flow limitation and normal breathing could be distinguished. The studied non-invasive methods, the SCSB and Emfit seem to be suitable for detecting periodic limb movements. Emfit and compressed tracheal sound analysis can help in the evaluation of sleep-disordered breathing. They all can be used as parts of larger recording systems or even as stand-alone devices. The recordings are inexpensive, easy to perform and cause minimal if any disturbance to a patient. Thus they are very suitable for ambulatory sleep recording systems. Additionally, they all have special features that can detect and characterize the still poorly understood prolonged flow limitation

Pricing methods for new product concepts in the digital environment: Case digital talking books in mobile networks

The purpose of this study is to present central issues in the pricing of a new service, and to test and analyse how the chosen marketing research methods are suited for the pricing explorations of digital products. A potential pricing model is also developed for the product scenario of the case. In the theoretical part of the thesis, the main theories and concepts of new product pricing are discussed. In addition short summaries of new product development, segmentation, and diffusion of innovations are presented. The empirical part of the study focuses on the pricing of digital talking books. Personal interviews were conducted to find out the users' needs and wants. Adaptive conjoint analysis was used to define the product concept. Willingness-to-pay and price sensitivity were studied through direct questioning via a www-survey. As background information, concise overviews of Finnish book publishing industry and current technological development are presented. It was found out that the quality of talking books and the availability of extra-information were experienced as the most important features whereas the language and product's rights were not so important. Based on the responses of the www-survey (208 responses), the mean maximum price of one talking book was almost 16 euros and the price elasticity of the demand around 1,7. The active users of current talking books were willing to pay more for talking books than those who did not have any experience in them. Women also had a greater mean of the maximum price compared to men. The used methods provided rough direction for pricing decisions. However, it became clear that more advanced methods would produce more reliable results. The use of a demo and choice-based conjoint analysis where pricing is one of the studied features would probably result in more valuable findings

Repetitive transcranial magnetic stimulation for chronic prostatitis/ chronic pelvic pain syndrome : A prospective pilot study

Purpose: To evaluate the feasibility, efficacy, and safety of repetitive transcranial magnetic stimulation (rTMS) in patients with treatment-resistant chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Methods: Eleven patients with CP/CPPS were enrolled in this prospective clinical study. rTMS was performed for 5 consecutive days in 20-minute sessions. Patients were evaluated at baseline, after treatment, and at 1, 4, 8, and 12 weeks after the last session with questionnaires concerning pain (numerical rating scale [NRS], the National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI], and the Short Form-36 [SF-36]), urinary symptoms (NIH-CPSI, Danish Prostatic Symptom Score [DAN-PSS-1]), quality of life (NIH-CPSI, SF-36), and psychometrics (Beck Depression Index [BDI]). Telephone-based interviews were used to evaluate side effects, subjective response, and changes in drug consumption. Results: All patients completed the planned treatment and follow-up according to protocol. No patients experienced serious side effects or significant pain increase during or after treatment. Mild transient tension headache responsive to oral pain medication was reported by 2 patients. Decreased pain was observed on the NRS after treatment and at 1 and 8 weeks (P = 0.019, P = 0.006, P = 0.042, respectively) and on the NIH-CPSI pain domain at 1 week (P = 0.04). Improvement in lower urinary tract symptoms was observed after treatment in the NIH-CPSI urinary domain (P = 0.02) but not with the DAN-PSS-1. No significant changes in the BDI were observed. Nine patients reported a positive overall subjective response (82%) and 6 patients (55%) were able to reduce pain medication. Higher age was associated with lower NRS scores after treatment (R = 0.605, P = 0.048) and at 8 weeks (R = 0.659, P = 0.028). Conclusions: rTMS for patients with CP/CPPS seemed to be well tolerated, at least moderately effective in pain reduction, and might be of interest in patients with chronic pelvic pain resistant to conventional treatment. These findings remain to be confirmed by a randomized trial.publishedVersionPeer reviewe

Bimaxillary Advancement as the Initial Treatment of Obstructive Sleep Apnea: Five Years Follow-Up of the Pori Experience

Objectives: Bimaxillary advancement surgery has proven to be effective treatment of obstructive sleep apnea syndrome. According to the Stanford protocol upper airway soft tissue surgery or advancement of tongue by chin plastic surgery is first carried out and if obstructive sleep apnea persists, then bimaxillary advancement is done. This study describes the 5 year outcome of 13 obstructive sleep apnea patients in whom the Stanford protocol was omitted and bimaxillary advancement was carried out as initial surgical treatment. Material and Methods: Patients were divided in two groups. Group A comprised patients with obstructive sleep apnea (OSAS) confirmed by polysomnography in whom ODI-4 (oxygen desaturation index) was 5 or more. Group B consisted of patients with occlusal problems needing orthognathic surgery and with OSAS symptoms but no clear disease on polysomnography, where the ODI-4 index was less than 5. Both groups were treated with bimaxillary advancement surgery (BAS) as initial therapy. Results: In the group A mean ODI-4 was 17.8 (SD 12) before treatment and 3.5 (SD 3.4) at 5-year follow-up (P = 0.018 in paired differences t-test). In group B the ODI-4 remained below 5. In group A mean saturation improved from 94.3% (SD 1.6) to 96.3% (SD 2), P = 0.115 and in group B from 96.3% (SD 1.2) to 97.8% (SD 1.7), P = 0.056 (in paired differences t-test). The static charge sensitive bed evaluation showed improvement in all patients except one. Conclusions: Bimaxillary advancement surgery is safe and reliable as an initial surgical treatment of obstructive sleep apnea syndrome

Prolonged partial upper airway obstruction during sleep – an underdiagnosed phenotype of sleep-disordered breathing

Obstructive sleep apnea syndrome (OSAS) is a well-recognized disorder conventionally diagnosed with an elevated apnea–hypopnea index. Prolonged partial upper airway obstruction is a common phenotype of sleep-disordered breathing (SDB), which however is still largely underreported. The major reasons for this are that cyclic breathing pattern coupled with arousals and arterial oxyhemoglobin saturation are easy to detect and considered more important than prolonged episodes of increased respiratory effort with increased levels of carbon dioxide in the absence of cycling breathing pattern and repetitive arousals. There is also a growing body of evidence that prolonged partial obstruction is a clinically significant form of SDB, which is associated with symptoms and co-morbidities which may partially differ from those associated with OSAS. Partial upper airway obstruction is most prevalent in women, and it is treatable with the nasal continuous positive pressure device with good adherence to therapy. This review describes the characteristics of prolonged partial upper airway obstruction during sleep in terms of diagnostics, pathophysiology, clinical presentation, and comorbidity to improve recognition of this phenotype and its timely and appropriate treatment

Natura 2000-verkoston ekologiset yhteydet Lounais-Lapissa

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Neuronavigated Versus Non-navigated Repetitive Transcranial Magnetic Stimulation for Chronic Tinnitus: A Randomized Study

Repetitive transcranial magnetic stimulation (rTMS) has shown variable effect on tinnitus. A prospective, randomized 6-month follow-up study on parallel groups was conducted to compare the effects of neuronavigated rTMS to non-navigated rTMS in chronic tinnitus. Forty patients (20 men, 20 women), mean age of 52.9 years (standard deviation [ SD ] = 11.7), with a mean tinnitus duration of 5.8 years ( SD  = 3.2) and a mean tinnitus intensity of 62.2/100 ( SD  = 12.8) on Visual Analog Scale (VAS 0–100) participated. Patients received 10 sessions of 1-Hz rTMS to the left temporal area overlying auditory cortex with or without neuronavigation. The main outcome measures were VAS scores for tinnitus intensity, annoyance, and distress, and Tinnitus Handicap Inventory (THI) immediately and at 1, 3, and 6 months after treatment. The mean tinnitus intensity (hierarchical linear mixed model: F 3  = 7.34, p  = .0006), annoyance ( F 3  = 4.45, p  = .0093), distress ( F 3  = 5.04, p  = .0051), and THI scores ( F 4  = 17.30, p  < .0001) decreased in both groups with non-significant differences between the groups, except for tinnitus intensity ( F 3  = 2.96, p  = .0451) favoring the non-navigated rTMS. Reduction in THI scores persisted for up to 6 months in both groups. Cohen’s d for tinnitus intensity ranged between 0.33 and 0.47 in navigated rTMS and between 0.55 and 1.07 in non-navigated rTMS. The responder rates for VAS or THI ranged between 35% and 85% with no differences between groups ( p  = .054–1.0). In conclusion, rTMS was effective for chronic tinnitus, but the method of coil localization was not a critical factor for the treatment outcome