Obstructive Sleep Apnea: The Effect of Bariatric Surgery After Five Years-A Prospective Multicenter Trial.

BACKGROUND: The prevalence of obstructive sleep apnea (OSA) is high among the bariatric surgery candidates. Obesity is the most important individual risk factor for OSA. The aim of this study was to investigate the effect of a laparoscopic Roux-en-Y gastric bypass (LRYGB) on OSA 5 years after the surgery. PATIENTS AND METHODS: In this prospective multicenter study, standard overnight cardiorespiratory recording was conducted to 150 patients at baseline prior to bariatric surgery. A total of 111 (73.3%) patients of those had OSA. Cardiorespiratory recordings at 5 years after surgery were available for 70 OSA patients. The changes in anthropometric and demographic measurements including age, weight, body mass index (BMI), and waist and neck circumference were evaluated. Also, a quality of life (QoL) questionnaire 15D administered in a baseline was controlled at 5-year follow-up visit. RESULTS: At 5-year OSA was cured in 55% of patients, but moderate or severe OSA still persisted in 20% of patients after operation. Mean total AHI decreased from 27.8 events/h to 8.8 events/h (p < 0.001) at 5-year follow-up. A clinically significant difference in QoL was seen in mobility, breathing, sleeping, usual activities, discomfort and symptoms, vitality and sexual activity. The QoL total score improved more in OSA patient at 5-year follow-up. CONCLUSIONS: LRYGB is an effective treatment of OSA in obese patients and the achieved beneficial outcomes are maintained at 5-year follow-up.

The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline.

BACKGROUND: Overweight/obesity is a common, reversible risk factor for obstructive sleep apnea severity (OSA). The purpose of this guideline is to provide evidence-based recommendations for the management of overweight/obesity in patients with OSA. METHODS: The Grading of Recommendations, Assessment, Development and Evaluation approach was used to evaluate the literature. Clinical recommendations were formulated by a panel of pulmonary, sleep medicine, weight management, and behavioral science specialists. RESULTS: Behavioral, pharmacological, and surgical treatments promote weight loss and can reduce OSA severity, reverse common comorbidities, and improve quality of life, although published studies have methodological limitations. After considering the quality of evidence, feasibility, and acceptability of these interventions, the panel made a strong recommendation that patients with OSA who are overweight or obese be treated with comprehensive lifestyle intervention consisting of 1) a reduced-calorie diet, 2) exercise or increased physical activity, and 3) behavioral guidance. Conditional recommendations were made regarding reduced-calorie diet and exercise/increased physical activity as separate management tools. Pharmacological therapy and bariatric surgery are appropriate for selected patients who require further assistance with weight loss. CONCLUSIONS: Weight-loss interventions, especially comprehensive lifestyle interventions, are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. The American Thoracic Society recommends that clinicians regularly assess weight and incorporate weight management strategies that are tailored to individual patient preferences into the routine treatment of adult patients with OSA who are overweight or obese.

Health-related correlates of psychological well-being among girls and boys 6-8 years of age: The Physical Activity and Nutrition in Children study.

AIM: Due to limited knowledge on the differences in the correlates of psychological well-being (PSWB) between girls and boys, we compared the correlates of PSWB between primary school girls and boys. METHODS: A population sample of 412 children participated in the Physical Activity and Nutrition in Children study. Parents completed a questionnaire that included 19 questions on the components of PSWB, and a PSWB score was computed. We assessed correlates of PSWB, including physical activity, sedentary behaviour, cardiorespiratory fitness, diet quality, body fat content, sleep duration, sleep disordered breathing, prevalent diseases and parental characteristics. We used logistic regression to analyse the risk of being in the lowest third of the PSWB scores. RESULTS: Low parental education was associated with increased risk (odds ratio (OR) 2.34, P = 0.039) and high cardiorespiratory fitness with decreased risk (OR 0.26, P = 0.006) of poor PSWB in girls. At least 2 h of screen-based sedentary behaviour per day (OR 1.93, P = 0.037), daily parental smoking (OR 2.10, P = 0.034) and sleep disordered breathing (OR 4.24, P = 0.003) were related to increased risk of poor PSWB in boys. CONCLUSIONS: There are large differences in the correlates of PSWB between girls and boys. Most of these correlates are modifiable and related to the health behaviour of children and their parents.

Endoscopic dacryocystorhinostomy as treatment for lower lacrimal pathway obstructions in adults: Review article.

Obstruction of the lacrimal pathway is manifested by epiphora, infection, and blurred vision as well as ocular and facial pain. Conservative treatments only achieve temporary relief of symptoms, thus surgery is the treatment of choice. Dacryocystorhinostomy (DCR) is recognized as the most suitable treatment for patients with obstructions of the lacrimal system at the level of the sac or in the nasolacrimal duct. The aim of this operation is to create a bypass between the lacrimal sac and the nasal cavity. During the past 2 decades, advances in rigid endoscopic equipment and other instruments have made it possible to obtain more information about the anatomic landmarks of the nasolacrimal system, which led to the development of less-invasive and safer endoscopic techniques. However, many parts of the treatment process related to endoscopic endonasal dacryocystorhinostomy (EN-DCR) still remain controversial. This article reviews the published literature about the technical issues associated with the success of EN-DCR, and clarifies the pros and cons of different pre- and postoperative procedures in adults with lower lacrimal pathway obstructions.

Upregulation of inflammatory genes in the nasal mucosa of patients undergoing endonasal dacryocystorhinostomy.

BACKGROUND: Epiphora is a common complaint of nasolacrimal duct obstruction (NLDO) in adults. The precise pathogenesis of NLDO is still unknown, but inflammatory processes are believed to be predisposing factors. Endoscopic dacryocystorhinostomy (EN-DCR) is an effective surgical technique for treating symptomatic NLDO. The purpose of the procedure is to relieve the patient's symptoms by creating an opening, ie, a rhinostoma, between the lacrimal sac and the nasal cavity. Although the success rates after EN-DCR are high, the procedure sometimes fails due to onset of a fibrotic process at the rhinostomy site. The aim of this prospective comparative study was to investigate inflammation-related gene expression in the nasal mucosa at the rhinostomy site. METHODS: Ten participants were consecutively recruited from eligible adult patients who underwent primary powered EN-DCR (five patients) or septoplasty (five controls). Nasal mucosa specimens were taken from the rhinostomy site at the beginning of surgery for analysis of gene expression. Specimens were taken from the same site on the lateral nasal wall for controls. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed for the inflammatory genes interleukin (IL)-6, IL-1ß, and CCL2, and because of a clear trend of increased inflammation in the EN-DCR samples, a wider PCR array was performed to compare inflammation-related gene expression in EN-DCR subjects and corresponding controls. RESULTS: Our qRT-PCR results revealed a clear trend of increased transcription of IL-6, IL-1ß, and CCL2 (P=0.03). The same trend was also evident in the PCR array, which additionally revealed notable differences between EN-DCR subjects and controls with regard to expression of several other inflammation-related mediators. At 6-month follow-up, the success rate after primary EN-DCR was 60%, ie, in three of five patients. CONCLUSION: The present study demonstrates that there is an intense inflammation gene expression response in the nasal mucosa of patients undergoing EN-DCR.

The health-related quality-of-life impact of nocturnal awakenings in the middle-aged and older Finnish population.

PURPOSE: The aim of the study is to examine the health-related quality-of-life (HRQOL) impact of the nocturnal awakenings and the duration of the sleep in the Finnish middle-aged and older population. METHODS: Cross-sectional sample consisted of 823 community-dwelling persons aged 55-75 living in a single municipality in a rural area of Eastern Finland. Frequency of the nocturnal awakenings was dichotomized as reporting "frequent," if the participant reported subjectively awakening "often" or "very often," and "infrequent" if the participant reported awakening "sometimes" or less frequently. HRQOL was measured with a preference-based HRQOL-index instrument, 15D. Analyses were adjusted for gender, BMI, morbidities, depression, employment and marital status, current smoking and drinking, exercise, recommendation to exercise from a health care professional, and subjective opinion about own exercise habits. RESULTS: Frequent nocturnal awakenings had statistically and clinically significant negative impact on HRQOL, the mean (SE) adjusted marginal HRQOL impact being -0.0416 (0.006). More than 10 and less than 6.5 h of daily sleep were associated with higher probability of having low HRQOL, adjusted odd ratios (95 % CI) being 2.65 (1.11-6.33) and 2.65 (1.55-4.52), respectively. However, the changes in daily sleep duration did not have noticeable influence on the significance or magnitude of the negative HRQOL impact of the frequent nocturnal awakenings. CONCLUSIONS: Nocturnal awakenings displayed a strong independent association with decreased HRQOL. The findings suggest that both clinicians and researchers should pay closer attention to nocturnal awakenings and other sleep problems in order to find ways to improve the quality of life in individuals with such conditions.

Obesity and obstructive sleep apnea--clinical significance of weight loss.

Obesity is a major health burden that contributes to increased morbidity and mortality. Obesity is also the most important risk factor for obstructive sleep apnea (OSA); at least 70% of patients are obese. OSA as such, has been linked with increased cardiovascular morbidity and mortality, and OSA patients often display metabolic syndrome. The exact underlying mechanisms behind these associations are complex and not fully understood. In obese individuals, weight reduction and increased physical activity form cornerstones for the prevention and treatment of metabolic syndrome, and recent controlled intervention trials strongly suggest that weight reduction together with a healthy diet and increased physical activity may correct or at least improve the symptoms of OSA. However, regardless of promising results in terms of symptoms of OSA and the undoubted metabolic benefits of changing lifestyles, weight reduction as a treatment of OSA is still underrated by many clinicians. Based on the current knowledge, clinicians should revise their previous attitudes, including suspicions about weight reduction as an effective treatment for OSA patients. Nevertheless, we also need large well-controlled trials on the effects of different weight reduction programs among OSA patients to determine the overall efficacy of different treatment modalities and their long-term success.

[Surgery for lower nasolacrimal duct obstructions in adults]. / Aikuisten alakyyneltietukosten kirurginen hoito.

Epiphora and purulent discharge are common and irritating clinical manifestations of nasolacrimal duct obstruction (NLDO). If conservative treatment fails, dacryocystorhinostomy (DCR) has proven an efficient surgical method. The aim of DCR is to bypass the obstruction by creating a stoma between the lacrimal sac and the nasal cavity. External DCR has been the gold standard for decades. In recent years with the development of nasal endoscopes, less invasive surgical techniques, such as endonasal endoscopic DCR have become an increasingly popular procedure in the treatment of patients with NLDO. In such patients, the success rates for both external and endonasal DCR are about 90% and a successful procedure has a significant impact on the quality of life.

Mitomycin C in revision endoscopic dacryocystorhinostomy: a prospective randomized study.

BACKGROUND: Endoscopic dacryocystorhinostomy (EN-DCR) is an effective and safe procedure when treating saccal and postsaccal nasolacrimal duct obstruction. However, sometimes scarring of the rhinostomy site caused by fibrosis may occur, particularly in revision operations. The application of intraoperative mitomycin C (MMC), an antiproliferative agent, has been introduced as one possible technique to improve the outcome. We conducted a prospective, randomized study to evaluate if the use of MMC improves the success in endonasal revision DCR procedure. METHODS: Thirty revision EN-DCR procedures were performed during 2004-2010. The patients were randomized into two study groups, according to whether the intraoperative MMC was used or not. The technique of EN-DCR procedure in both groups was the same, but in the MMC group, at the end of the procedure a piece of tampon soaked in MMC (0.4 mg/mL) was placed into the rhinostoma for 5 minutes. No silicone stents were inserted. The surgical outcome at the 6-month follow-up visit was considered successful if the lacrimal sac irrigation succeeded and if the patients' symptoms were relieved. RESULTS: The success rate after revision EN-DCR with MMC was 93% and without MMC was 60%. The overall success rate was 77%. The difference between the two groups was not statistically significant (p = 0.08). The relief of the symptoms between groups in both the Nasolacrimal Duct Obstruction Symptom Score and ocular symptoms was statistically significant (p = 0.007 and p = 0.02, respectively). CONCLUSION: The results of our study indicate that the application of intraoperative mitomycin C may improve the outcome in revision EN-DCR.

Impaired nasal breathing may prevent the beneficial effect of weight loss in the treatment of OSA.

BACKGROUND: Weight loss is considered an effective treatment for obstructive sleep apnoea (OSA) in overweight patients. Some patients, however, do not benefit from weight loss. It has been postulated that nasal obstruction may act as an independent risk factor for OSA. OBJECTIVE: The aim of our study was to evaluate whether impaired nasal airflow might explain the missing effect of weight reduction on OSA. METHODOLOGY: Fifty-two overweight adult patients with mild OSA were recruited. After the 12-month lifestyle intervention, all patients who achieved more than 5% weight loss were divided into two groups based on whether they still had OSA or not. Change in nasal resistance measured by rhinomanometer and AHI were the main outcome variables. RESULTS: A total of 26/52 patients achieved 5% weight reduction. Of those 26 patients, 16 were objectively cured from OSA and 10 patients did not benefit from weight loss. Nasal resistance reduced significantly more in patients who had been cured from OSA. Smoking had a negative impact on both nasal resistance and improvement of AHI. CONCLUSIONS: Impaired nasal breathing and smoking may prevent the beneficial effects of weight reduction in the treatment of OSA.

Strong expression of HSP47 in metaplastic nasal mucosa may predict a poor outcome after primary endoscopic dacryocystorhinostomy: a prospective study.

PURPOSE: Dacryocystorhinostomy (DCR) is an effective and safe procedure for patients with post-saccal obstruction of the nasolacrimal pathway. The aim of DCR is to relieve symptoms by creating a bypass between the lacrimal sac and the nasal cavity. The most common reason for failure is stenosis caused by a fibrotic process at the rhinostomy site. In this prospective study we assessed the expression of heat shock protein 47 (HSP47), a regulator of fibrosis, in the biopsies of nasal mucosa isolated from patients undergoing primary endoscopic DCR (EN-DCR). METHODS: Thirty consecutive primary EN-DCR procedures in 30 patients were performed using the powered instrumentation technique. The nasal mucosa specimens over the rhinostomy site were collected for histological analysis at the beginning of the operation and the expression of HSP47 was evaluated by immunohistochemistry. The outcome of EN-DCR was estimated in follow-up visits at 1 week, 2 months and 6 months after surgery. RESULTS: At the 6-month follow-up, the overall success rate after primary EN-DCR was 83%. A metaplastic change and strong expression of HSP47 in nasal mucosa were associated with EN-DCR failure (p = 0.009). CONCLUSIONS: HSP47 may be regarded as a novel marker to predict impaired EN-DCR outcome.

Sustained improvement in mild obstructive sleep apnea after a diet- and physical activity-based lifestyle intervention: postinterventional follow-up.

BACKGROUND: Obesity is the most important risk factor for obstructive sleep apnea (OSA). Weight-reduction programs have been observed to represent effective treatment of overweight patients with OSA. However, it is not known whether beneficial changes remain after the end of the intervention. OBJECTIVE: The aim of the study was to assess the long-term efficacy of a lifestyle intervention based on a healthy diet and physical activity in a randomized, controlled, 2-y postintervention follow-up in OSA patients. DESIGN: Eighty-one consecutive overweight [body mass index (in kg/m(2)): 28-40] adult patients with mild OSA were recruited. The intervention group completed a 1-y lifestyle modification regimen that included an early 12-wk weight-reduction program with a very-low-calorie diet. The control group received routine lifestyle counseling. During the second year, no dietary counseling was offered. Change in the apnea-hypopnea index (AHI) was the main objective outcome variable, and changes in symptoms were used as a subjective measurement. RESULTS: A total of 71 patients completed the 2-y follow-up. The mean (± SD) changes in diet and lifestyle with simultaneous weight reduction (-7.3 ± 6.5 kg) in the intervention group reflected sustained improvements in findings and symptoms of OSA. After 2 y, the reduction in the AHI was significantly greater in the intervention group (P = 0.049). The intervention lowered the risk of OSA at follow-up; the adjusted odds ratio for OSA was 0.35 (95% CI: 0.12-0.97; P = 0.045). CONCLUSION: Favorable changes achieved by a 1-y lifestyle intervention aimed at weight reduction with a healthy diet and physical activity were sustained in overweight patients with mild OSA after the termination of supervised lifestyle counseling. This trial was registered at clinicaltrials.gov as NCT00486746.

Symptom score questionnaire for nasolacrimal duct obstruction in adults--a novel tool to assess the outcome after endoscopic dacryocystorhinostomy.

BACKGROUND: The incidence of nasolacrimal pathway obstruction increases with age, and dacryocystorhinostomy (DCR) is a commonly applied surgical technique to treat severe cases. However, no disease-specific tools to assess the symptoms and the subjective outcome after DCR have been established. We have developed a specific Nasolacrimal Duct Obstruction Symptom Score (NLDO-SS) questionnaire to evaluate the outcome, and tested it in a prospective clinical trial. STUDY DESIGN: Prospective clinical follow-up study. METHODS: Sixty-eight consecutive primary endoscopic dacryocystorhinostomy (EN-DCR) procedures were performed in 64 patients during 2004-2008. Preoperatively and during the three follow-up visits (at 1 week, 2 and 6 months), the patients filled in the NLDO-SS, and at the second and third follow-up visits they also filled in the Glasgow Benefit Inventory (GBI) questionnaire. At one year after the operation, a GBI questionnaire was sent to the patients. RESULTS: The surgical success rate of EN-DCR was 93 %. EN-DCR resulted in a significant reduction in all of the eight symptoms scores of the NLDO-SS (p= 0.001). The GBI scores indicated a significant benefit at 2 months (+37 (SD; 28) and an even higher benefit at 6 months after surgery (+52 (SD; 29), p= 0.001), but no further improvement was found between 6 and 12 months (+52 vs +52, p= 1.0). The correlation between the total GBI and NLDO-SS was significant (p=0.001). CONCLUSIONS: EN-DCR significantly improves the quality of life as measured by the GBI. The NLDO-SS correlated with the GBI and gave more information about the benefits after EN-DCR than GBI alone. The NLDO-SS proved to be an effective tool to evaluate lacrimal obstructions and EN-DCR benefits. Further studies to validate NLDO-SS are needed.

The activation of the inflammatory cytokines in overweight patients with mild obstructive sleep apnoea.

It is widely accepted that obstructive sleep apnoea (OSA) is linked with cardiovascular diseases. The relationship is complex and remains still poorly understood. The presence of chronic systemic inflammation has been connected with pathogenesis of both OSA and cardiovascular diseases. While atherogenesis is believed to be a process of many years, little is known about the potential impact of the largest OSA subgroup, mild OSA, on the development of cardiovascular diseases. The aim of the present study was to assess whether untreated mild OSA is associated with an activation of inflammatory cytokine system. The adult study population consisted of two groups: 84 patients with mild OSA [apnoea-hypopnoea index (AHI) 5-15 h(-1)] and 40 controls (AHI <5 h(-1)). Serum concentrations of pro- and anti-inflammatory cytokines were measured before any interventions. After adjustments for age, sex, body mass index, fat percentage, most important cardiometabolic and inflammatory diseases, and non-steroidal anti-inflammatory medication, the mean level of tumour necrosis factor-alpha was significantly elevated (1.54 versus 1.17 pg mL(-1), P = 0.004), whereas the level of interleukin-1 beta (IL-1 beta) was reduced (0.19 versus 0.23 pg mL(-1), P = 0.004) in patients with mild OSA compared with controls. The concentrations of the protective anti-inflammatory cytokines, interleukin-10 (1.28 versus 0.70 pg mL(-1), P < 0.001) and interleukin-1 receptor antagonist (478 versus 330 pg mL(-1), P = 0.003) were elevated in the OSA group. The concentrations of C-reactive protein increased, but IL-1 beta decreased along with the increase of AHI. Mild OSA was found to be associated not only with the activation of the pro-inflammatory, but also with the anti-inflammatory systems.

Sleep duration, lifestyle intervention, and incidence of type 2 diabetes in impaired glucose tolerance: The Finnish Diabetes Prevention Study.

OBJECTIVE: Both short and long sleep duration have frequently been found to be associated with an increased risk for diabetes. The aim of the present exploratory analysis was to examine the association between sleep duration and type 2 diabetes after lifestyle intervention in overweight individuals with impaired glucose tolerance in a 7-year prospective follow-up. RESEARCH DESIGN AND METHODS: A total of 522 individuals (aged 40-64 years) were randomly allocated either to an intensive diet-exercise counseling group or to a control group. Diabetes incidence during follow-up was calculated according to sleep duration at baseline. Sleep duration was obtained for a 24-h period. Physical activity, dietary intakes, body weight, and immune mediators (C-reactive protein and interleukin-6) were measured. RESULTS: Interaction between sleep duration and treatment group was statistically significant (P = 0.003). In the control group, the adjusted hazard ratios (HRs) (95% CI) for diabetes were 2.29 (1.38-3.80) and 2.74 (1.67-4.50) in the sleep duration groups 9-9.5 h and >or=10 h, respectively, compared with for that of the 7-8.5 h group. In contrast, sleep duration did not influence the incidence of diabetes in the intervention group; for sleep duration groups 9-9.5 h and >or=10 h, the adjusted HRs (95% CI) were 1.10 (0.60-2.01) and 0.73 (0.34-1.56), respectively, compared with that in the reference group (7-8.5 h sleep). Lifestyle intervention resulted in similar improvement in body weight, insulin sensitivity, and immune mediator levels regardless of sleep duration. CONCLUSIONS: Long sleep duration is associated with increased type 2 diabetes risk. Lifestyle intervention with the aim of weight reduction, healthy diet, and increased physical activity may ameliorate some of this excess risk.

Evaluation of a novel ambulatory device for screening of sleep apnea.

The gold standard for diagnosis of obstructive sleep apnea (OSA) is the sleep laboratory polysomnography, which is technically demanding, labor-intensive, and time-consuming. Thus, screening of large undiagnosed population for OSA may be cost efficient only by means of ambulatory devices suitable for home recordings. The aim of our study was to evaluate the diagnostic and technical reliability of a novel ambulatory device (APV2, Remote Analysis Oy) introduced for sleep apnea diagnostics. APV2 records breathing movements, nasal and oral air flow, position, snore, blood oxygen saturation, and heart rate. The evaluation was done by comparing 10 simultaneous polygraphic recordings with APV2 and with commonly used clinical reference instrumentation (Embla, Embla Co.) at a sleep laboratory. Furthermore, the technical reliability of measurements was evaluated by analyzing the fraction of clinical APV2 and Embletta (Embla Co.) home recordings (n = 149 and n = 169, respectively) that were technically of diagnostically unacceptable quality. Similar diagnostic sensitivity in detecting OSA was found with the APV2 compared to the simultaneous reference recording with the Embla. Apnea-hypopnea indices and oxygen desaturation indices, recorded with APV2 and Embla, were closely correlated (r = 0.996-0.997, p < 0.0001). The quality of 90.0% of home recordings with APV2 was technically perfect and 96.0% of recordings were of diagnostically acceptable quality. As a comparison, the clinical evaluation of a widely used ambulatory polygraphy device (Embletta) showed that 77.2% of home recordings were technically perfect and 80.8% of recordings were diagnostically acceptable. In conclusion, the novel device was found clinically applicable, technically reliable, and sensitive for the diagnostics of OSA.

Lifestyle intervention with weight reduction: first-line treatment in mild obstructive sleep apnea.

RATIONALE: Obesity is the most important risk factor for obstructive sleep apnea (OSA). However, although included in clinical guidelines, no randomized controlled studies have been performed on the effects of weight reduction on mild OSA. OBJECTIVES: The aim of this prospective, randomized controlled parallel-group 1-year follow-up study was to determine whether a very low calorie diet (VLCD) with supervised lifestyle counseling could be an effective treatment for adults with mild OSA. METHODS: Seventy-two consecutive overweight patients (body mass index, 28-40) with mild OSA were recruited. The intervention group (n = 35) completed the VLCD program with supervised lifestyle modification, and the control group (n = 37) received routine lifestyle counseling. The apnea-hypopnea index (AHI) was the main objectively measured outcome variable. Change in symptoms and the 15D-Quality of Life tool were used as subjective measurements. MEASUREMENTS AND MAIN RESULTS: The lifestyle intervention was found to effectively reduce body weight (-10.7 +/- 6.5 kg; body mass index, -3.5 +/- 2.1 [mean +/- SD]). There was a statistically significant difference in the mean change in AHI between the study groups (P = 0.017). The adjusted odds ratio for having mild OSA was markedly lowered (odds ratio, 0.24 [95% confidence interval, 0.08-0.72]; P = 0.011) in the intervention group. All common symptoms related to OSA, and some features of 15D-Quality of Life improved after the lifestyle intervention. Changes in AHI were strongly associated with changes in weight and waist circumference. CONCLUSIONS: VLCD combined with active lifestyle counseling resulting in marked weight reduction is a feasible and effective treatment for the majority of patients with mild OSA, and the achieved beneficial outcomes are maintained at 1-year follow-up.

Repeated early debridement does not provide significant symptomatic benefit after ESS.

OBJECTIVE: Postoperative debridement is considered essential after endoscopic sinus surgery (ESS), however, its effect on postoperative symptoms is largely unexplored. METHODS: In the present study 90 patients undergoing ESS were randomized to debridement of the nasal cavities either three times during the first postoperative week (intervention group), or once on the 7th postoperative day (control group). Postoperative saline douching was used in both groups. The primary outcome measure was the postoperative Lund-MacKay Symptom Score. RESULTS: The patients in the intervention group reported less severe symptoms on all domains of the Lund-MacKay Score compared with the patients in the control group both at one and four weeks. The difference between the groups was statistically significant in discharge at one week (4.1 +/- 2.3 in the intervention group and 5.4 +/- 2.6 in the control group, p = 0.0025). At four weeks, significantly fewer nasal cavities presented with nasal secretions in the intervention group compared with the control group (14/84 vs. 38/93). CONCLUSIONS: Repeated debridement during the first postoperative week produced minor symptomatic benefit in patients recovering from ESS. Therefore, in terms of subjective recovery and health care costs repeated debridement is not justified during the first postoperative week after ESS.

Etoricoxib for pain management during thyroid surgery--a prospective, placebo-controlled study.

OBJECTIVE: To assess the efficacy of etoricoxib in pain treatment during thyroid surgery. DESIGN: Double-blind, placebo-controlled, randomized trial. SETTING: A secondary-level central hospital in Finland. PATIENTS: Sixty-nine consecutive patients (59 women) aged 18 to 70 years who underwent thyroid surgery. INTERVENTIONS: Patients were randomized to receive etoricoxib 120 mg (n = 34) or placebo (n = 35) by mouth 60 minutes before surgery. After surgery oxycodone 2 mg administered intravenously was provided for rescue analgesia. MAIN OUTCOME MEASURES: Oxycodone consumption during the first 6 (primary) and the 7 to 24 hours (secondary) after surgery. RESULTS: During the first 6 hours, all patients in the placebo group and 31 of 34 patients in the etoricoxib group were given oxycodone for rescue analgesia (P = 0.072). In the 7 to 24 postsurgical hours, 25 of 35 patients in the placebo group versus 16 of 34 patients in the etoricoxib group needed rescue analgesics (mean difference 24%, 95% CI -1 to 47%, P = 0.039). CONCLUSION: Etoricoxib 120 mg reduced pain in the 7 to 24 postsurgical time period but did not have opioid-sparing effect during the first 6 hours after surgery.

Headache induced by an arachnoid cyst of the sphenoid sinus: a rare diagnosis problem?

We describe a diagnostic problem in a young adult with a long history of frequently occurring headache episodes. The cause for these episodes was traced to a rare condition, extensive arachnoid cyst of sphenoid sinus. Extensive lesions of the sphenoid sinus are relatively rare and can cause non-specific symptoms. Thus they can represent a major pre-operative diagnosis dilemma even with access to advanced imaging techniques.