Doc1 by SBMirza


									Research Paper
                         S B Mirza

Submitted to:Sir Nawaz



Laryngoscope. 2002 Feb;112(2):357-63.
Histopathology of the uvula and the soft palate in patients with mild, moderate, and severe
obstructive sleep apnea.
Berger G, Gilbey P, Hammel I, Ophir D.
Department of Otolaryngology--Head and Neck Surgery, Meir General Hospital, Kfar Saba,


The distal soft palate and uvula were excised during uvulopalatopharyngoplasty from 34 male
patients with obstructive sleep apnea. Control specimens were retrieved from 7 male cadavers
with no related disorders. All specimens underwent routine processing and the mid-sagittal
sections were studied. Morphometric analysis of the relative proportions of the tissue
constituents was carried out. Also, a qualitative assessment was performed to detect possible
pathologic changes.The body mass index of patients was significantly higher from that of
control subjects. The area fraction occupied by the tissue constituents of the distal portion of
the soft palate and uvula in patients with mild, moderate, and severe obstructive sleep apnea
and in control subjects was similar, with small and insignificant differences regarding the
contents of glands, muscle, fat, blood vessels, and the epithelium. Only the connective tissue
was significantly greater in patients with moderate obstructive sleep apnea than in those with
severe obstructive sleep apnea and control subjects. The qualitative assessment of the
specimens disclosed normal tissue architecture without evidence of destruction. Vascular
engorgement, fibrosis, edema, inflammatory cell infiltration, and dilated glandular ducts were
observed in a portion of patients and control subjects.

CONC LUSIONS: The structure of the distal soft palate and uvula of patients with obstructive
sleep apnea undergoes insignificant changes and is independent of the body mass index levels,
indicating that the pathologic changes are probably the sequela of airway obstruction rather
than its cause.
Radiol Med. 2004 Sep;108(3):238-54.
Magnetic resonance imaging in simple snoring and obstructive sleep apnea-hypopnea
[Article in English, Italian]
Fusco G, Macina F, Macarini L, Garribba AP, Ettorre GC.
Azienda USL BA/4, U.O. Radiologia, Ospedale Giovanni XXIII, Bari.


Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a condition characterised by periodic
cessation of breathing during sleep, associated with Upper Air-Digestive Ways (UADW)
morphologic abnormalities that can be detected, in awake patients, by using various imaging
techniques. The purpose of this study is to determine the usefulness of MR imaging and new
original morphometrical measurements that we are proposing in patients with Sleep
Obstructive Breathing Disordered (SOBD)Study of 70 patients (52 with OSAHS and 18 snoring
without OSAHS) using 1.5T and 0.5T MR imagers with neck and head coils and T1-DP-T2-
weighted SE sequences have done. During the procedure, the patients were awake and with
tidal breathing. sagittal pharyngeal diameters at different levels also evaluated; the length and
maximum width of soft palate; the distance between the hyoid bone and the C2C3-Me line
(ideally joining the geometrical centre of the C2-C3 intervertebral space to the lower point of
mandibular symphysis) measured on the perpendicular; the angle resulting from the
longitudinal axis of the cervical spine and the epiglottis axis (alpha); the slope angle of the
tongue -- resulting from the longitudinal axis of the cervical spine and the longitudinal axis of
the tongue (beta). sagittal, coronal and axial sections of the head and neck was used.In OSAHS
patients, pharynx calibre medium sizes were reduced compared with simple snoring patients.
Only in OSAHS patients (not in simple snorers without OSAHS) 16 patients with narrowing sites
= or <3 mm were observed. On axial images three different narrowing patterns: rounded, with
greater anterior-posterior axis; with greater axis in lateral direction was observed. In OSAHS
patients, on average, increase of the distance between the hyoid bone (Hmr point) and the line
C2C3-Me; increase in the angle resulting between cervical rachis and epiglottis (alpha);
reduction of sloping angle of the tongue (beta) also observed.

CONCLUSIONS: MR imaging, together with the morphometrical measurements, is useful to
evaluate UADW in SOBD. In particular, increase of the distance between the hyoid bone (Hmr
point) and the line C2C3-Me (due to lowering of the hyoid bone), increase in the angle resulting
between the cervical rachis and the epiglottis (alpha) and the reduction of the sloping angle of
the tongue (beta), are highly specific and sensitive indexes in OSAHS were noted. There are
different levels and findings of narrowing in OSAHS and their identification is very important for
a surgical approach: the uvulo-palato-pharyngoplasty (UPPP) has a higher success rate in
patients with obstruction at retro-palatopharynx site, but it is associated with no (or poor)
results in hypopharyngeal obstruction.
Pediatrics. 2006 Oct;118(4):e1100-8.
Increased cerebral blood flow velocity in children with mild sleep-disordered
breathing: a possible association with abnormal neuropsychological function.
Hill CM, Hogan AM, Onugha N, Harrison D, Cooper S, McGrigor VJ, Datta A, Kirkham FJ.
Division of Clinical Neurosciences, University of Southampton, United Kingdom.
Comment in:

      Pediatrics. 2007 Jul;120(1):235-6; author reply 236-7.


 Sleep-disordered breathing describes a spectrum of upper airway obstruction in sleep from
simple primary snoring, estimated to affect 10% of preschool children, to the syndrome of
obstructive sleep apnea. Emerging evidence has challenged previous assumptions that primary
snoring is benign. A recent report identified reduced attention and higher levels of social
problems and anxiety/depressive symptoms in snoring children compared with controls.
Uncertainty persists regarding clinical thresholds for medical or surgical intervention in sleep-
disordered breathing, underlining the need to better understand the pathophysiology of this
condition. Adults with sleep-disordered breathing have an increased risk of cerebrovascular
disease independent of atherosclerotic risk factors. There has been little focus on
cerebrovascular function in children with sleep-disordered breathing, although this would seem
an important line of investigation, because studies have identified abnormalities of the
systemic vasculature. Raised cerebral blood flow velocities on transcranial Doppler, compatible
with raised blood flow and/or vascular narrowing, are associated with neuropsychological
deficits in children with sickle cell disease, a condition in which sleep-disordered breathing is
common. We hypothesized that there would be cerebral blood flow velocity differences in
sleep-disordered breathing children without sickle cell disease that might contribute to the
association with neuropsychological deficits.

Thirty-one snoring children aged 3 to 7 years were recruited from adenotonsillectomy waiting
lists, and 17 control children were identified through a local Sunday school or as siblings of
cases. Children with craniofacial abnormalities, neuromuscular disorders, moderate or severe
learning disabilities, chronic respiratory/cardiac conditions, or allergic rhinitis were excluded.
Severity of sleep-disordered breathing in snoring children was categorized by attended
polysomnography. Weight, height, and head circumference were measured in all of the
children. BMI and occipitofrontal circumference z scores were computed. Resting systolic and
diastolic blood pressure were obtained. Both sleep-disordered breathing children and the age-
and BMI-similar controls were assessed using the Behavior Rating Inventory of Executive
Function (BRIEF), Neuropsychological Test Battery for Children (NEPSY) visual attention and
visuomotor integration, and IQ assessment (Wechsler Preschool and Primary Scale of
Intelligence Version III). Transcranial Doppler was performed using a TL2-64b 2-MHz pulsed
Doppler device between 2 pm and 7 pm in all of the patients and the majority of controls while
awake. Time-averaged mean of the maximal cerebral blood flow velocities was measured in the
left and right middle cerebral artery and the higher used for analysis.

CONCLUSIONS: Cerebral blood flow velocities measured by noninvasive transcranial Doppler
provide evidence for increased cerebral blood flow and/or vascular narrowing in childhood
sleep-disordered breathing; the relationship with neuropsychological deficits requires further
exploration. A number of physiologic changes might alter cerebral blood flow and/or vessel
diameter and, therefore, affect cerebral blood flow velocities. We were able to explore
potential confounding influences of obesity and hypertension, neither of which explained our
findings. Second, although cerebral blood flow velocities increase with increasing partial
pressure of carbon dioxide and hypoxia, it is unlikely that the observed differences could be
accounted for by arterial blood gas tensions, because all of the children in the study were
healthy, with no cardiorespiratory disease, other than sleep-disordered breathing in the snoring
group. Although arterial partial pressure of oxygen and partial pressure of carbon dioxide were
not monitored during cerebral blood flow velocity measurement, assessment was undertaken
during the afternoon/early evening when the child was awake, and all of the sleep-disordered
breathing children had normal resting oxyhemoglobin saturation at the outset of their
subsequent sleep studies that day. Finally, there is an inverse linear relationship between
cerebral blood flow and hematocrit in adults, and it is known that iron-deficient erythropoiesis
is associated with chronic infection, such as recurrent tonsillitis, a clinical feature of many of the
snoring children in the study. Preoperative full blood counts were not performed routinely in
these children, and, therefore, it was not possible to exclude anemia as a cause of increased
cerebral blood flow velocity in the sleep-disordered breathing group. However, hemoglobin
levels were obtained in 4 children, 2 of whom had borderline low levels (10.9 and 10.2 g/dL).
Although there was no apparent relationship with cerebral blood flow velocity in these children
(cerebral blood flow velocity values of 131 and 130 cm/second compared with 130 and 137
cm/second in the 2 children with normal hemoglobin levels), this requires verification. It is of
particular interest that our data suggest a relationship among snoring, increased cerebral blood
flow velocities and indices of cognition (processing speed and visual attention) and perhaps
behavioral (Behavior Rating Inventory of Executive Function) function. This finding is
preliminary: a causal relationship is not established, and the physiologic mechanisms underlying
such a relationship are not clear. Prospective studies that quantify cumulative exposure to the
physiologic consequences of sleep-disordered breathing, such as hypoxia, would be
Sleep Med. 2003 Jul;4(4):349-50.
Sleep disordered breathing may not be an independent risk factor for diabetes,
but diabetes may contribute to the occurrence of periodic breathing in sleep.
Sanders MH, Givelber R.
Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of
Medicine, Pittsburgh, PA, USA.


The study population reflected participants in the on-going Sleep Heart Health Study (SHHS).
Analyses were conducted utilizing data obtained from 4872 SHHS participants without
prevalent cardiovascular disease (CVD) and 1002 participants with self-reported CVD, defined
as hospitalization for non-fatal coronary heart disease, congestive heart failure, myocardial
infarction, coronary artery bypass graft, and stroke.SHHS methodologies have been previously
reported and include performance of overnight, in-home polysomnography (PSG), which
recorded variables reflecting sleep architecture and breathing, permitting identification of
obstructive and central apneas, hypopneas, periodic breathing and oxyhemoglobin saturation
(SpO(2)). Anthropomorphic metrics as well as systemic blood pressure measurements were
obtained at the time of PSG. Other health data were available from questionnaires and the data
sets of the parent cohorts from whom SHHS participants were recruited. The investigators
assessed and compared breathing parameters, sleep architecture and CVD variables in diabetic
and non-diabetic participants. The relationships between diabetes and the various study
parameters, independent of potential confounders, were examined by multivariable modeling.
Linear regression modeling was employed to examine the relationship between continuously
distributed variables such as respiratory disturbance index log (RDI). The relationships between
diabetes and dichotomous outcome variables such as central apnea index (CAI), obstructive
apnea index (OAI), periodic breathing and the percentage of time spent at various levels below
SpO(2) 90% were examined by the logistic regression model. Age, gender, race, BMI and neck
circumference were forced into all multivariable analyses since these factors are associated
with both diabetes mellitus and SDB.

CONCLUSION: The authors concluded that diabetes mellitus is associated with sleep apnea but
that this association is largely explained by risk factors in common for both disorders, most
notably obesity. After adjusting for confounding factors there was no difference between diabetic
and non-diabetic participants with regard to obstructive events. However, even after adjusting for
potential confounders, there was a greater prevalence of periodic breathing in diabetic subjects.
JAMA. 2000 Apr 12;283(14):1829-36.
Association of sleep-disordered breathing, sleep apnea, and hypertension in a
large community-based study. Sleep Heart Health Study.
Nieto FJ, Young TB, Lind BK, Shahar E, Samet JM, Redline S, D'Agostino RB, Newman AB,
Lebowitz MD, Pickering TG.
Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health, The Johns
Hopkins University, Baltimore, MD 21205, USA.


Sleep-disordered breathing (SDB) and sleep apnea have been linked to hypertension, but most
of these studies used surrogate information to define SDB (eg, snoring) and were based on
small clinic populations, or both.Cross-sectional analyses of participants in the Sleep Heart
Health Study, a community-based multicenter study conducted between November 1995 and
January 1998.PARTICIPANTS: A total of 6132 subjects recruited from ongoing population-based
studies (aged > or = 40 years; 52.8% female). Apnea-hypopnea index (AHI, the average number
of apneas plus hypopneas per hour of sleep, with apnea defined as a cessation of airflow and
hypopnea defined as a > or = 30% reduction in airflow or thoracoabdominal excursion both of
which are accompanied by a > or = 4% drop in oxyhemoglobin saturation) [corrected], obtained
by unattended home polysomnography. Other measures include arousal index; percentage of
sleep time below 90% oxygen saturation; history of snoring; and presence of hypertension,
defined as resting blood pressure of at least 140/90 mm Hg or use of antihypertensive

CONCLUSION: Our findings from the largest cross-sectional study to date indicate that SDB is
associated with systemic hypertension in middle-aged and older individuals of different sexes
and ethnic backgrounds.

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