Complete concentric collapse at the soft palate in sleep endoscopy: what change is possible after UPPP in patients with CPAP failure?

PURPOSE: The aim of this work was to assess whether uvulopalatopharyngoplasty in patients with failure for positive airway pressure not only reduces the degree of obstructive sleep apnea but also to determine as well if it changes the collapse pattern of the soft palate and thereby fulfills the qualifications for implementing upper airway stimulation (UAS) as an adjunctive solution. METHOD: Fifteen patients with intolerance for positive airway pressure were included in this retrospective cohort study. Polygraphy and drug-induced sleep endoscopy were used in order to evaluate the reduction of the apnea-hypopnea index (AHI), as well as the change of collapse pattern at the soft palate level before and about 3 months after uvulopalatopharyngoplasty and tonsillectomy (TE-UPPP). RESULTS: In 93% of the patients, a postoperative change of the initially complete concentric palatal collapse pattern could be found during drug-induced sleep endoscopy. In one patient, no obstruction at all was seen at the soft palatal level. Only one patient still presented with a complete concentric collapse at velum level. AHI decreased from mean 34.7 events per hour to 20.2/h and oxygen desaturation index from 25.3 events per hour to 16.1/h. CONCLUSION: Patients seeking for positive airway pressure alternatives could not only benefit from reduction of AHI by TE-UPPP postoperatively; additionally, by changing the collapse pattern at the soft palate, they might also fulfill criteria for upper airway stimulation (UAS) in case of persistent OSA of at least moderate degree.

[Sleep endoscopy and complete concentric collapse in CPAP failure]. / Schlafendoskopie und komplett konzentrischer Weichgaumenkollaps bei CPAP-Nutzungsproblemen.

INTRODUCTION: First-line treatment for patients with obstructive sleep apnea (OSA) is continuous positive airway pressure (CPAP) therapy. However, many patients cannot use CPAP sufficiently. With drug-induced endoscopy (DISE), it is possible to assess the collapse pattern in the upper airway. The aim of this work was to evaluate a collective of patients with CPAP usage problems using DISE, in order to evaluate their usage problems and therapy recommendations. METHODS: Over a period of 5 years, all patients with an apnea-hypopnea index (AHI) of at least 15/h were retrospectively evaluated using DISE. The recommended treatment options were then analyzed. RESULTS: Data analysis of 210 patients showed that about two thirds reported mask problems as the cause of non-adherence to CPAP. A complete concentric collapse (CCC) could be excluded in 75%. These patients had a lower AHI and more frequent tonsillectomy (TE) than patients with CCC. Double the number of patients with a body mass index (BMI) > 35 kg/m2 had a CCC compared to those with a BMI < 35 kg/m2. Among patients with similar BMI and AHI, CCC was twice as likely to be found in patients without TE. CONCLUSION: The course of treatment recommended for OSA often differs, depending on CCC, BMI > 35 kg/m2, and previous TE.

Cosmic questions: an introduction.

This introductory talk at the Cosmic Questions conference sponsored by the AAAS summarizes some earlier pictures of the universe and some pictures based on modern physics and cosmology. The uroboros (snake swallowing its tail) is an example of a traditional picture. The Biblical flat-earth picture was very different from the Greek spherical earth-centered picture, which was the standard view until the end of the Middle Ages. Many people incorrectly assume that the Newtonian picture of stars scattered through otherwise empty space is still the prevailing view. Seeing Earth from space shows the power of a new picture. The Hubble Space Telescope can see all the bright galaxies, all the way to the cosmic Dark Ages. We are at the center of cosmic spheres of time: looking outward is looking backward in time. All the matter and energy in the universe can be represented as a cosmic density pyramid. The laws of physics only allow the material objects in the universe to occupy a wedge-shaped region on a diagram of mass versus size. All sizes--from the smallest size scale, the Planck scale, to the entire visible universe--can be represented on the Cosmic Uroboros. There are interesting connections across this diagram, and the human scale lies in the middle.

Assortative mating for major affective disorder.

The families of 26 married bipolar manic depressives were examined in detail. The rate of affective disorder in their spouses, and the parents and siblings of their spouses, was ascertained. The prevalence of affective disorder among the parents and siblings and of the spouses of age- and social class-matched schizophrenics and well controls was also ascertained. Finally, the prevalence of affective and other psychiatric disorders in the adult offspring of the bipolar probands was ascertained and related to the presence or absence of affective disorder in the spouse. We did not find clear evidence of assortative mating for major affective disorder, although dual mating for affective disorder had the expected result of increasing the risk for affective disorder in the adult offspring.

Brothers, sisters and antisocial behaviour.

The brothers of 73 delinquent boys were found themselves to be more antisocial than the brothers of 73 matched control boys. Further, the average antisocial score of the probands' brothers increased with the number of brothers in the family, holding the number of sisters constant, and decreased with the number of sisters, holding the number of brothers constant. These results are interpreted in terms of male potentiation and female suppression of antisocial behaviour in boys. Results are also reported for 59 pairs of matched delinquent and control girls and their siblings.

The urban emergency department: the issue of professional responsibility.

The urban emergency department is routinely asked to manage not only medical emergencies, but also a great variety of social emergencies. This situation is caused in part by budgetary constraints which prevent other agencies from providing 24-hour coverage. In an age of instant access to computerized information, these conditions often result in ethical and legal problems of extreme complexity. A case is presented which raises the issues of confidentiality and liberty in the fiduciary relationship between doctor and patient. The concept of personal care is found to be paramount.