Autonomic cardiovascular regulation in patients with obstructive sleep apnoea: a study based on spectral analysis of heart rate variability.

The aim of this study was to assess the function of the autonomic nervous system in patients with obstructive sleep apnoea syndrome (OSAS). The study was designed as a cross-sectional case-control study. Fifty-one patients were included, and the findings were compared with those in 66 controls. Spectral analysis of heart rate variability (HRV) during supine rest, during controlled breathing and after tilting was performed in each patient and control case. The patients performed overnight sleep recordings the night before the HRV recordings. Individuals with an apnoea-hypopnoea index (AHI) above 20 were regarded as OSAS patients and those with AHI lower than 20 as snorers. Differences in HRV and blood pressure between patients and controls were analysed by multiple linear regression with age, body mass index and sex as independent variables. During free and controlled breathing there was a significant decrease in indices reflecting vagal modulation, indicating parasympathetic dysfunction in OSAS patients compared with controls. The mid-frequency component was also significantly reduced in OSAS patients after tilting but not in the lying position. This may be related to the parasympathetic dysfunction, but could also indicate a decreased sympathetic reserve capacity. We found no significant relation between AHI and indices of vagal modulation in the patient group. Our findings show an autonomic dysfunction in patients with OSAS. The dysfunction involves the parasympathetic system, and may be related to the increased cardiovascular mortality and malignant arrhythmia described in OSAS.

The long-term outcome of retropubic urethrocystopexy (sutures and fibrin sealant) and pubococcygeal repair.

BACKGROUND: To evaluate the results of retropubic urethrocystopexy (with sutures and fibrin sealant) and pubococcygeal repair five to seven years postoperatively. MATERIALS AND METHODS: Thirty women with genuine stress urinary incontinence were subjected to retropubic urethrocystopexy (n=30) and 15 women to pubococcygeal repair (n= 15). The preoperative assessment included both subjective and objective methods. The results evaluated three months, one year and five to seven years after the surgical treatment. RESULTS: One year after surgery 71% of the women in the urethrocystopexy group reported that they were continent, compared with only 43% five to seven years after surgery. In the pubococcygeal repair group 80% were continent at one-year follow-up, compared with 60% at the long-term follow-up. According to pad test 79% of the women in the urethrocystopexy group had ceased leaking urine at minimal activity and 64% at maximal activity five to seven years after surgery. However, in the pubococcygeal repair group the corresponding percentage was 71% under both conditions. Intravesical pressure and Body Mass Index increased significantly in the whole group but urethra conductance and maximal urine flow decreased only in the urethrocystopexy group five to seven years after the surgical treatment. CONCLUSIONS: Accurate assessment of the results of any surgical treatment of stress urinary incontinence is difficult. During long term follow-up period significant changes may occur among the women, e.g. menopause and increase of Body Mass Index both predisposing to urinary incontinence.

Cold induced vasospasm in replanted digits: a comparison between different methods of arterial reconstruction.

Nineteen patients each of whom had had a single digit replanted were examined after replantation. The arterial reconstruction had been done with long grafts (n = 10) or short grafts or no graft (n = 9). The effect of local or whole body cooling on the replanted and uninjured opposite digits was monitored (9-46 months after the replantation), and the patients were given a questionnaire (9-95 months after replantation) designed to explore the development of their cold related symptoms in relation to time. All patients were troubled by cold intolerance, and improvement occurred in only 60% of the cases. Pathological (vasospastic) arterial reactions to cold measured as finger systolic pressure, were less common after replantation with long grafts. Perceived cold intolerance was significantly more pronounced in the group of patients (60%) who had evidence of cold induced arterial spasm in the replanted finger.

Arterial spasticity and cold intolerance in relation to time after digital replantation.

Cold induced arterial vasospasm was studied in ten patients with single digit replantation, by measuring finger systolic pressure at different finger temperatures. Each patient was examined three times; within 2 weeks of surgery, after 1 year and after 3 years. The replantations were performed using long arterial and venous grafts. Cold-related vasospasm is established during the first year after trauma, and thereafter seems to be persistent. It is concluded that the subjective cold tolerance, which affects all patients after digital amputation regardless of whether replantation is performed or not, is partly due to vasospasm. It is less pronounced in patients without pathological vasospasm in the replanted digit. Cold intolerance is likely to decrease during the first 2 years after replantation, but not to disappear completely.

Urodynamics in women with stress incontinence before and after surgery.

Pad test, cystometry and analysis of micturition were performed in 36 women with stress incontinence before and a year after operation with either retropubic urethrocystopexy (n = 22) or pubococcygeal repair (n = 14). There was no difference in the subjective cure rate between the two groups of women (77% and 79%, respectively). The pad test 1 year after operation showed that 59% of the women in the urethrocystopexy group and 43% of the women in the pubococcygeal repair group had stopped leaking urine. The bladder volume had increased in both groups and the intravesical pressure of the bladder filled to the maximum had increased in the pubococcygeal repair group. The functional length of the urethra, intravesical pressure at maximal urine flow, maximal urine flow rate and urethral conductance were not affected by either operation. Pad test was a more accurate test for an objective evaluation of urine leakage before operation than were the urodynamic investigation or continence tests.

Oesophageal dysfunction in familial amyloidosis with polyneuropathy.

Sixteen patients with familial amyloidosis and polyneuropathy (FAP) and 14 health subjects underwent oesophageal manometry. Six of the patients had a severe oesophageal dysmotility with almost completely abolished propulsive pressure waves on swallowing in the lower 2/3 of the oesophagus. Ten patients had moderate dysfunction with reduced propulsive pressure wave amplitudes. Neostigmine increased the pressure wave amplitudes in healthy subjects but less so in the FAP patients. Scopolamine (Scopyl)-terbutaline (Bricanyl) almost abolished the propulsive pressure waves in healthy subjects and all patients in the lower 2/3 of the esophagus. Oesophageal distensibility, tested by inflating a rubber balloon in the oesophagus, was similar in FAP patients and healthy subjects. Thus, it is unlikely that amyloid deposits in the mucosal wall increased the oesophageal stiffness. An autonomic, predominantly vagal, denervation probably explains the disturbed function.

Factors that influence the incidence of brachial oedema after treatment of breast cancer.

Six factors that may increase the likelihood of swelling of the arm after treatment of breast cancer were investigated in 136 patients who had undergone treatment. The highest incidence of oedema was among patients who had received radiotherapy in high doses with few fractions to the axilla (60%), and in patients with a history of one or more infections in the arm on the operated side (89%). Overweight, oblique surgical incision, infection in the arm, and radiotherapy correlated with arm swelling. The age of the patient and whether the operation had been done on the dominant or non-dominant side correlated less with the incidence of oedema.

Importance of time in assessing arm and hand function after treatment of breast cancer.

Ninety-three patients were examined on two occasions at 24-month intervals after surgery and irradiation for breast cancer. Stiffness of the shoulder joint, brachial oedema, pain in the arm, and the patients' subjective assessment of the degree of functional disability were registered. The results indicated that both oedema and stiffness of the shoulder joint are acceptable measures of functional impairment. We conclude, however, that such measurements should not be used as indicators of prognosis, because spontaneous improvement can occur for two years or more after treatment.

Decompression of the axillary vein for oedema of the arm caused by axillary dissection and irradiation.

Twenty women with brachial oedema after treatment for breast cancer were operated on by a standard technique, with decompression of the axillary vein and division of the irradiated portion of pectoralis major. After a mean follow-up of 32.5 months a significant improvement was noted in 14 of them. In 19 the range of movement of the shoulder had improved.

Autonomic neuropathy in familial amyloidotic polyneuropathy. A clinical study based on heart rate variability.

Familial amyloidotic polyneuropathy (FAP) is characterized by both sensimotor and autonomic dysfunction. Autonomic disturbance involving the gastrointestinal tract, the urinary bladder, the cardiac conduction system, and the peripheral circulation has been described. In this study simple, non-invasive tests of autonomic function based on heart rate variability were applied to 12 patients with FAP and 12 healthy volunteers. The heart rate variation during normal breathing, deep breathing and during tilt from recumbent to standing position was measured. All tests showed significantly less heart rate variation in patients than in controls and the heart rate variation decreased with increasing severity of neurological disability, but the small number of patients in our study does not allow any further comparison between subgroups. Our study thus indicates impaired cardiovascular autonomic function in patients with FAP and we believe that these findings might also be of importance in other forms of systemic amyloidosis.

Reassessment of valve area determinations in mitral stenosis by the pressure half-time method: impact of left ventricular stiffness and peak diastolic pressure difference.

Estimation of the orifice area is of major importance in the timing of valve dilation or surgery in patients with mitral stenosis. Determination of the area has traditionally been accomplished at cardiac catheterization by the Gorlin equation. The valve area can also be estimated noninvasively with Doppler echocardiographic measurements of the pressure half-time, which is inversely proportional to the area. This method has gained widespread acceptance, but its accuracy has recently been questioned and factors other than reduction of orifice area appear to modify the pressure half-time. In the present study, the influence of left ventricular stiffness (defined as diastolic pressure rise per milliliter of mitral flow) and peak atrioventricular pressure difference on the pressure half-time was examined both in a hydraulic model and by review of data from 35 patients with mitral stenosis. Left ventricular stiffness less than 0.13 mm Hg/ml was considered normal. In the model study, the orifice area correlated only moderately with inverted pressure half-time (1/PHT) (r = 0.67). By multiple linear regression, inverted pressure half-time was shown to be dependent on valve area, chamber stiffness and peak pressure difference (R = 0.89), area and stiffness being most important (R = 0.85). In the clinical study, an increased ventricular stiffness was found in 22 of the 35 patients. The pressure half-time method overestimated the Gorlin-derived area by an average of 72% in these patients compared with only 10% in 13 patients with normal stiffness (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous and stepwise cystometry through suprapubic catheters--effect of infusion pattern and infusion rate on the cystometrogram of the normal human bladder.

Continuous cystometry at two filling rates (50 and 100 ml min-1) and stepwise cystometry (successive rapid volume infusions followed by bladder wall relaxation) were performed in 12 healthy subjects. Suprapubic catheters were used for infusion and recording of perivesical and intravesical pressures. The continuous cystometrograms obtained at filling rates of 50 and 100 ml min-1, respectively, did not differ with respect to desire to void, transmural pressure increase or bladder capacity. Stepwise cystometry allowed the bladders to be filled to a slightly larger volume than during continuous cystometry, but with comparatively lower transmural pressures only at very large distension of the bladder. There was considerable inter-individual variation in transmural pressure at both continuous and stepwise cystometry. Stepwise cystometry did not appear to provide any important additional information about pressure-volume relationship in the normal human bladder than could be obtained at routine clinical cystometry.

Viscoelastic properties of the normal human bladder.

Continuous and stepwise cystometry were performed through suprapubic catheters in 12 healthy young subjects in order to assess passive viscoelastic variables of the normal human bladder during the collection phase. Elastic contants increased non-linearly with bladder distension. Relative elastic modulus and relaxation time of the bladder wall increased or tended to increase with bladder distension and infusion rate. There was considerable interindividual variation in all variables suggesting that discrimination between normal and abnormal bladder wall viscoelasticity may be difficult in routine clinical practice.

Pre- and postoperative respiratory muscle strength in primary hyperparathyroidism.

Muscle function in ten hyperparathyroid patients and six patients with benign thyroid disease was assessed by measuring maximal expiratory (Pe max) and inspiratory (Pi max) pressures before and 6-12 months after neck surgery. Pe max was improved in all the hyperparathyroid patients postoperatively (p less than 0.002), while the median value of Pi max was unchanged. In the control (thyroid) group there was no significant postoperative change in either Pe max or Pi max. It is concluded that normalization of hypercalcemia improves respiratory muscular capacity, which can be quantified by measuring maximal expiratory pressure.

Lung function abnormalities in patients with primary biliary cirrhosis.

Twenty-five patients with primary biliary cirrhosis (PBC) in different stages were investigated with respect to pulmonary function abnormalities. The results were compared with a reference sample of 17 sex- and age-matched healthy subjects. A high prevalence of lung function impairment was found in the PBC patients (14/25 [56%]). Bronchial asthma was present in three patients, and severe lung emphysema in one. These four patients had an abnormal lung function, mainly of obstructive type. There was a statistically significant difference between the remaining 21 PBC patients without chronic obstructive lung disease and the reference subjects with respect to diffusion capacity. Almost all abnormal lung function data were found in the symptomatic PBC patients (i.e. symptoms of pruritus, xanthoma, xanthelasmata, jaundice, hyperpigmentation, hepatosplenomegaly), 13 out of 18 (72%), whereas only one out of seven asymptomatic patients was affected. Nine patients (36%) had reduced diffusion capacity compared with none of the reference subjects. The lung function abnormalities in PBC patients are similar to those found in sarcoidosis, another granulomatous disease.

Bladder wall relaxation and its dependency on transmural pressure and infusion rate during cystometry--in vivo studies in the rat.

Cystometry at different infusion rates was performed in 7 rats in vivo. The bladders were furthermore allowed to relax from different transmural pressures. When distension of the bladder was moderate, relative relaxation was small and almost independent of transmural pressure and infusion rate. When distended to large volumes, however, there was a marked increase in bladder wall relaxation and the relaxation increased with increasing infusion rates. These findings indicate the importance of standardization of the cystometric procedure.

Non-invasive assessment of the presence and severity of cardiac amyloidosis. A study in familial amyloidosis with polyneuropathy by cross sectional echocardiography and technetium-99m pyrophosphate scintigraphy.

Twelve patients with familial amyloidosis with polyneuropathy were examined both by cross sectional echocardiography and by technetium-99m pyrophosphate scintigraphy to assess involvement of the heart non-invasively. All 12 patients had echocardiographic abnormalities. The most prominent findings were highly refractile myocardial echoes, thickened heart valves, and increased thickness of the heart walls. Four patients had abnormal myocardial uptake of technetium-99m pyrophosphate. The remaining eight had equivocal or no myocardial uptake and were considered to have normal scintigrams. A certain amount of amyloid is probably required to produce an abnormal scintigram, although lesions with less amyloid can evidently be identified by echocardiography. Neither the duration of polyneuropathy nor its severity showed any relation to the echocardiographic or scintigraphic findings. It is concluded that cross sectional echocardiography is superior to technetium-99m pyrophosphate scintigraphy in detecting cardiac involvement in familial amyloidosis with polyneuropathy and that these results may also be applicable to other forms of amyloidosis.

Disturbances of cardiac rhythm and conduction in familial amyloidosis with polyneuropathy.

Sixteen consecutive patients with familial amyloidosis with polyneuropathy of varying duration and severity underwent 24 hour ambulatory electrocardiographic monitoring. A high incidence of sinus node dysfunction, supraventricular and ventricular arrhythmias, and disturbances of atrioventricular conduction was found. Considerably more arrhythmias and disturbances of conduction were detected by long term electrocardiographic monitoring than by conventional 12 lead electrocardiograms. During a follow up period of three to 14 months five patients needed treatment by a pacemaker, three of them because of symptomatic complete heart block, one because of second degree heart block with heart failure, and one because of symptomatic dysfunction of the sinus node. The tachyarrhythmias did not require specific treatment. Long term electrocardiographic monitoring is a useful adjunct in the evaluation of patients with familial amyloidosis with polyneuropathy as it may detect otherwise unrecognised symptomatic disturbances of heart rhythm. The results may be valid also for other forms of amyloidosis involving the heart.

Hemodynamic and angiocardiographic observations in familial amyloidosis with polyneuropahy.

Eleven patients with familial amyloidosis with polyneuropathy were studied by heart catheterization; eight of them also by right and left ventriculography and selective coronary angiography. Signs of congestive heart failure, often reported as typical of cardiac amyloidosis, were found in only one patient. The systolic function was relatively unimpaired, but in several patients hemodynamic data suggested restrictive cardiomyopathy. Six patients showed signs of right or left ventricular outflow tract obstruction. Thus, no uniform hemodynamic pattern could be identified, but the changes found indicate impaired diastolic function.

Renal function in familial amyloidosis with polyneuropathy.

The renal function is assumed to be normal in most patients with familial amyloidosis with polyneuropathy (FAP) type 1. In the present study of 24 patients with FAP type 1, estimation of the urinary concentrating capacity and 51Cr-EDTA clearance demonstrated that the glomerular clearance and the concentrating capacity were imparied in most patients. The concentrating capacity was significantly correlated with the clearance values. Urine electrophoresis indicated a glomerular cause for the proteinuria. It is suggested that the renal dysfunction should be attributed to deposition of amyloid substance in the glomeruli.