Expiratory Velopharyngeal Obstruction: Sleep Endoscopy-Guided Treatment Strategies to Prevent Oral Breathing During Sleep.

OBJECTIVE: Obstructive sleep apnea (OSA) is a prevalent disorder, with oral breathing influencing its severity. Expiratory velopharyngeal obstruction (EVO), observed during drug-induced sleep endoscopy (DISE), may contribute to oral breathing in OSA patients. EVO results in obstruction between the pharynx and nasal cavity during expiration. This study aims to identify factors associated with positive EVO during DISE. STUDY DESIGN: Case series. SETTING: Tertiary Medical Center. METHODS: Seventy-two OSA patients underwent clinical evaluation, polysomnography, and DISE, utilizing interventions like intraoral negative airway pressure (iNAP), mouth closure, and oral appliances (OAs) in supine positions with head rotation. The findings, classified under velopharynx, oropharynx, tongue base, epiglottis, included the presence of EVO. RESULTS: The results demonstrated that interventions including mouth closure and iNAP were associated with increased observation of EVO (43.1% and 34.7%) compared to OA (20.1%). However, head rotation was associated with decreased presence of EVO during DISE compare to supine (26% vs 35.8%). Noticeably, per 1 year increase of age was associated with an increased odds of EVO (odds ratio: 1.03, 95% confidence interval: 1.01-1.06). However, no other baseline characteristics were significantly associated the odds of EVO. CONCLUSION: Our study reveals the effectiveness of head rotation and OA in reducing EVO and improving mouth breathing in OSA patients, offering valuable insights for future treatment strategies.

Potential Treatments for Epiglottic Collapse in Obstructive Sleep Apnea: How Modified Drug-Induced Sleep Endoscopy Help?

OBJECTIVE: In patients with obstructive sleep apnea (OSA), epiglottic collapse (EC) constitutes a major factor in the failure of continuous positive airway pressure therapy and uvulopalatopharyngoplasty. This study explored treatments that can improve EC in patients with OSA through drug-induced sleep endoscopy with target-controlled infusion (TCI-DISE). STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary center. METHODS: This study screened 352 OSA patients who underwent TCI-DISE between 2016 and 2022. Fifty-four patients with EC were included in the final analysis. EC severity was assessed multiple times through TCI-DISE with different interventions. RESULTS: The application of these interventions in patients with anteroposterior epiglottic collapse (apEC) led to a significant decrease in apEC severity from total to partial or no obstruction in 60.0% of patients by head rotation, in 53.6% by mouth closure, in 47.4% who received oral appliances (OA), and in 28.0% who received intermittent negative airway pressure (iNAP). With simultaneous head rotation, apEC severity decreased more significantly from total to partial or no obstruction in 77.8% of patients by mouth closure, in 70.3% who received OA, and in 68.0% who received iNAP. Lateral epiglottic collapse (latEC) severity decreased in 53.8% of patients after OA use and in 61.5% of patients with OA use and head rotation. CONCLUSION: This study identified head rotation with mouth closure as the most effective treatment for apEC through TCI-DISE. Patients with latEC had higher weight, apnea-hypopnea index, and body mass index compared with patients with apEC. OA use with head rotation appeared more effective in latEC through TCI-DISE.

Nociception Effect on Frontal Electroencephalogram Waveform and Phase-Amplitude Coupling in Laparoscopic Surgery.

BACKGROUND: Electroencephalographic pattern changes during anesthesia reflect the nociception-analgesia balance. Alpha dropout, delta arousal, and beta arousal with noxious stimulation have been described during anesthesia; however, data on the reaction of other electroencephalogram signatures toward nociception are scarce. Analyzing the effects of nociception on different electroencephalogram signatures may help us find new nociception markers in anesthesia and understand the neurophysiology of pain in the brain. This study aimed to analyze the electroencephalographic frequency pattern and phase-amplitude coupling change during laparoscopic surgeries. METHODS: This study evaluated 34 patients who underwent laparoscopic surgery. The electroencephalogram frequency band power and phase-amplitude coupling of different frequencies were analyzed across 3 stages of laparoscopy: incision, insufflation, and opioid stages. Repeated-measures analysis of variance with a mixed model and the Bonferroni method for multiple comparisons were used to analyze the changes in the electroencephalogram signatures between the preincision and postincision/postinsufflation/postopioid phases. RESULTS: During noxious stimulation, the frequency spectrum showed obvious decreases in the alpha power percentage after the incision (mean ± standard error of the mean [SEM], 26.27 ± 0.44 and 24.37 ± 0.66; P < .001) and insufflation stages (26.27 ± 0.44 and 24.40 ± 0.68; P = .002), which recovered after opioid administration. Further phase-amplitude analyses showed that the modulation index (MI) of the delta-alpha coupling decreased after the incision stage (1.83 ± 0.22 and 0.98 ± 0.14 [MI × 10 3 ]; P < .001), continued to be suppressed during the insufflation stage (1.83 ± 0.22 and 1.17 ± 0.15 [MI × 10 3 ]; P = .044), and recovered after opioid administration. CONCLUSIONS: Alpha dropout during noxious stimulation is observed in laparoscopic surgeries under sevoflurane. In addition, the modulation index of delta-alpha coupling decreases during noxious stimulation and recovers after the administration of rescue opioids. Phase-amplitude coupling of the electroencephalogram may be a new approach for evaluating the nociception-analgesia balance during anesthesia.

Dietary profile of pediatric obstructive sleep apnea patients, effects of routine educational counseling, and predictors for outcomes.

Background: Dietary behavior is a main contributing yet modifiable factor to the body weight status of children and may be involved in the pathophysiology of childhood obstructive sleep apnea (OSA). This study aimed to investigate the dietary profile of pediatric OSA patients, effects of educational counseling after adenotonsillectomy, and predictor for disease resolution. Methods: This observational study included 50 pediatric OSA patients undergoing adenotonsillectomy with routine educational counseling (Group 1), 50 pediatric OSA patients undergoing adenotonsillectomy without formal educational counseling (Group 2), and 303 healthy children without OSA (Control). The three groups were matched by age. The consumption frequency of 25 food items/groups was assessed by the Short Food Frequency Questionnaire. Quality of life was evaluated by the OSA-18 questionnaire. Sleep architecture and OSA severity were measured by standard polysomnography. Between- and within-group comparisons were analyzed by non-parametric approaches and generalized estimating equations. Prediction of disease recovery was performed by multivariable logistic regression models. Results: Group 1 children consumed fruit drinks with sugar, vegetables, sweets, chocolate, rice, and noodles more frequently than Control Group children. At baseline, the distributions of sex, weight status, OSA-18 scores, and polysomnographic variables were comparable between Group 1 and Group 2. After a 12-month follow-up, Group 1 had better improvements in physical suffering, caregiver concerns, sleep architecture, and mean peripheral oxygen saturation compared to Group 2. Furthermore, Group 1 no longer had excessive consumption of fruit drinks with sugar, chocolate, and noodles; however, food consumption frequencies did not change significantly. Notably, younger age and reduced intake of butter/margarine on bread and noodles were independent predictors of cured OSA in Group 1. Conclusion: The present study preliminarily characterized an unhealthy dietary profile among pediatric OSA patients and suggested that routine educational counseling in addition to adenotonsillectomy yielded some clinical benefits. Certain items/groups of food frequencies may be associated with disease recovery and further investigations are warranted.

Upper Airway Surgery or Weight Control? Modified Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea.

OBJECTIVE: To identify the value of head rotation in the supine position and oral appliance (OA) use in drug-induced sleep endoscopy (DISE). STUDY DESIGN: Eighty-three sleep apnea adults undergoing target-controlled infusion-DISE (TCI-DISE) were recruited from a tertiary academic medical center. SETTING: During DISE, 4 positions were utilized: supine position (position 1), head rotation (position 2), mandibular advancement using an OA (position 3), and head rotation with an OA (position 4). METHODS: Polysomnography (PSG) data and anthropometric variables during DISE were analyzed. RESULTS: Eighty-three patients (65 men and 18 women; mean [standard deviation, SD], 48.5 [11.0] years) who underwent PSG and TCI-DISE were included. The mean (SD) apnea-hypopnea index (AHI) was 35.5 (22.4) events/h. Twenty-three patients had persistent complete concentric velopharyngeal collapse in the supine position, even with concurrent head rotation and OA (position 4). Their mean (SD) AHI was 54.7 (24.6) events/h, significantly higher than that of the 60 patients without such collapse in position 4 (p < .001). Their mean (SD) body mass index (BMI) was 29.0 (4.1) kg/m2 , also significantly higher (p = .005). After adjustment for age, BMI, tonsil size, and tongue position, the degree of velum and tongue base obstruction was significantly associated with sleep apnea severity in positions 2, 3, and 4. CONCLUSION: We showed the feasibility, safety, and usefulness of using simple edge-to-edge, reusable OA in DISE. Patients who are not responsive to head rotation and OA during TCI-DISE may need upper airway surgery and/or weight control.

Using sleep heart rate variability to investigate the sleep quality in children with obstructive sleep apnea.

Background: Obstructive sleep apnea (OSA) is associated with impaired sleep quality and autonomic dysfunction. Adenotonsillectomy significantly improves subjective and objective sleep quality in children with OSA. However, the postoperative changes in heart rate variability (HRV) indices (indicators of cardiac autonomic function) and their importance remain inconclusive in childhood OSA. This retrospective case series aimed to investigate the association of sleep HRV indices, total OSA-18 questionnaire score (a subjective indicator of sleep quality) and polysomnographic parameters (objective indicators of sleep quality), and effects of adenotonsillectomy on HRV indices, total OSA-18 questionnaire score and polysomnographic parameters in children with OSA. Methods: Seventy-six children with OSA were included in baseline analysis, of whom 64 (84%) completed at least 3 months follow-up examinations after adenotonsillectomy and were included in outcome analysis. Associations between baseline variables, and relationships with treatment-related changes were examined. Results: Multivariable linear regression models in the baseline analysis revealed independent relationships between tonsil size and obstructive apnea-hypopnea index (OAHI), adenoidal-nasopharyngeal ratio and very low frequency (VLF) power of HRV (an indicator of sympathetic activity), and normalized low frequency power (an indicator of sympathetic activity) and OAHI. The outcome analysis showed that adenotonsillectomy significantly improved standard deviation of all normal-to-normal intervals, and high frequency power, QoL (in terms of reduced total OSA-18 questionnaire score), OAHI and hypoxemia. Using a conceptual serial multiple mediation model, % change in OSA-18 questionnaire score and % change in VLF power serially mediated the relationships between change in tonsil size and % change in OAHI. Conclusions: The improvement in OAHI after adenotonsillectomy was serially mediated by reductions in total OSA-18 questionnaire score and VLF power. These preliminary findings are novel and provide a direction for future research to investigate the effects of VLF power-guided interventions on childhood OSA.

Adenotonsillectomy-related changes in systemic inflammation among children with obstructive sleep apnea.

BACKGROUND: Adenotonsillar hypertrophy is the most common cause of pediatric obstructive sleep apnea (OSA). Although adenotonsillectomy considerably reduces OSA and systemic inflammation, whether and how systemic inflammation influences the effects of adenotonsillectomy on OSA has yet to be determined. METHODS: This study investigated the associations between changes in anatomical variables, % changes in subjective OSA-18 questionnaire scores, % changes in 11 polysomnographic parameters, and % changes in 27 systemic inflammatory biomarkers in 74 children with OSA. RESULTS: Fifty-six (75.6%) boys and 18 (24.4%) girls with the mean age of 7.4 ± 2.2 years and apnea-hypopnea index (AHI) of 14.2 ± 15.9 events/h were included in the statistical analysis. The mean period between before and after adenotonsillectomy was 5.6 ± 2.6 months. After adenotonsillectomy, the OSA-18 score, eight of 11 polysomnographic parameters, and 20 of 27 inflammatory biomarkers significantly improved (all p < 0.005). Notably, there were significant associations between change in tonsil size and % change in AHI ( r = 0.23), change in tonsil size and % changes in interleukin-8 (IL-8) ( r = 0.34), change in tonsil size and % change in and IL-10 ( r = -0.36), % change in IL-8 and % change in C-C chemokine ligand 5 (CCL5) ( r = 0.30), and % change in CCL5 and % change in AHI ( r = 0.38) (all p < 0.005). Interestingly, % change in IL-8 and % change in CCL5 serially mediated the relationship between change in tonsil size and % change in AHI (total effect: ß = 16.672, standard error = 8.274, p = 0.048). CONCLUSION: These preliminary findings suggest that systemic inflammation is not only a complication of OSA but also that it mediates the surgical effects, which may open avenues for potential interventions to reduce tonsil size and OSA severity through the regulation of IL-8 and CCL5.

Mouth puffing phenomena of patients with obstructive sleep apnea when mouth-taped: device's efficacy confirmed with physical video observation.

PURPOSE: This study aimed to design a device to monitor mouth puffing phenomena of patients with obstructive sleep apnea when mouth-taped and to employ video recording and computing algorithms to double-check and verify the efficacy of the device. METHODS: A mouth puffing detector (MPD) was developed, and a video camera was set to record the patients' mouth puffing phenomena in order to make ensure the data obtained from the device was appropriate and valid. Ten patients were recruited and had polysomnography. A program written in Python was used to investigate the efficacy of the program's algorithms and the relationship between variables in polysomnography (sleep stage, apnea-hypopnea index or AHI, oxygen-related variables) and mouth puffing signals (MPSs). The video recording was used to validate the program. Bland-Altman plot, correlations, independent sample t-test, and ANOVA were analyzed by SPSS 24.0. RESULTS: Patients were found to mouth puff when they sleep with their mouths taped. An MPD was able to detect the signals of mouth puffing. Mouth puffing signals were noted and categorized into four types of MPSs by our algorithms. MPSs were found to be significantly related to relative OSA indices. When all participants' data were divided into minutes, intermittent mouth puffing (IMP) was found to be significantly different from non-mouth puffing in AHI, oxygen desaturation index (ODI), and time of oxygen saturation under 90% (T90) (AHI: 0.75 vs. 0.31; ODI: 0.75 vs. 0.30; T90: 5.52 vs. 1.25; p < 0.001). Participants with severe OSA showed a higher IMP percentage compared to participants with mild to moderate OSA and the control group (severe: 38%, mild-to-moderate: 65%, control: 95%; p < 0.001). CONCLUSIONS: This study established a simple way to detect mouth puffing phenomena when patients were mouth-taped during sleep, and the signals were classified into four types of MPSs. We propose that MPSs obtained from patients wearing the MPD can be used as a complement for clinicians to evaluate OSA.

Snoring Sound Characteristics are Associated with Common Carotid Artery Profiles in Patients with Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) and snoring have been reported to be modifiable risk factors for thick carotid intima-media thickness (CIMT) and carotid atherosclerosis, which are closely linked to cardiovascular disease. METHODS: This cross-sectional study prospectively recruited 70 participants with OSA and without a history of carotid artery disorder, who primarily sought surgical Intervention. OSA and snoring were assessed with the Epworth Sleepiness Scale, Snore Outcomes Survey, polysomnography, and snoring sound recording. The carotid arteries were evaluated with ultrasonography and divided into three types of carotid artery profiles (normal carotid artery, thick CIMT, or significant carotid atherosclerosis). Multivariate linear/logistic/categorical regressions were performed with the forward selection approaches/logistic least absolute shrinkage and selection operator, as appropriate. RESULTS: Normalized snoring sound energy (301-850 Hz) was independently associated with the carotid intima-media thickness (regression coefficient [ß] = 0.01, standard error [SE] = 0.004, P = 0.03; R 2 = 0.067) and type of carotid profile (ß = 0.40, SE = 0.09, P < 0.001; R 2 = 0.156). Normalized snoring sound energy (4-300 Hz) (ß = -0.10, SE = 0.04, P = 0.01) and female sex (ß = 1.90, SE = 0.94, P = 0.04) were independently related to the presence of carotid stenosis (R 2 = 0.159). The optimal regression model of the type of carotid artery profile included normalized snoring sound energy (301-850 Hz) (ß = 0.33, SE = 0.14, P = 0.03), snoring time (ß = 0.26, SE = 0.13, P = 0.047), female sex (ß = 0.26, SE = 0.13, P = 0.047), and increased age (ß = 0.20, SE = 0.10, P = 0.04) under the control of the Snore Outcomes Survey score, 3% oxygen desaturation index, snoring sound energy (4-1500 Hz), normalized snoring sound energy (851-1500 Hz), cigarette smoking, and hyperlipidemia (R 2 = 0.427). CONCLUSION: Our findings suggested that snoring sound characteristics are associated with carotid artery profiles among early OSA patients who cannot be noticed by ultrasound because organic changes of the carotid artery have not yet started. Future studies are warranted to verify the clinical significance of the results.

Screening Severe Obstructive Sleep Apnea in Children with Snoring.

Efficient screening for severe obstructive sleep apnea (OSA) is important for children with snoring before time-consuming standard polysomnography. This retrospective cross-sectional study aimed to compare clinical variables, home snoring sound analysis, and home sleep pulse oximetry on their predictive performance in screening severe OSA among children who habitually snored. Study 1 included 9 (23%) girls and 30 (77%) boys (median age of 9 years). Using univariate logistic regression models, 3% oxygen desaturation index (ODI3) ≥ 6.0 events/h, adenoidal-nasopharyngeal ratio (ANR) ≥ 0.78, tonsil size = 4, and snoring sound energy of 801-1000 Hz ≥ 22.0 dB significantly predicted severe OSA in descending order of odds ratio. Multivariate analysis showed that ODI3 ≥ 6.0 events/h independently predicted severe pediatric OSA. Among several predictive models, the combination of ODI3, tonsil size, and ANR more optimally screened for severe OSA with a sensitivity of 91% and a specificity of 94%. In Study 2 (27 (27%) girls and 73 (73%) boys; median age, 7 years), this model was externally validated to predict severe OSA with an accuracy of 76%. Our results suggested that home sleep pulse oximetry, combined with ANR, can screen for severe OSA more optimally than ANR and tonsil size among children with snoring.

The Impact of Estrogen Supplementation to Autonomic and Sleep Modulations in Free-Moving Spontaneously Hypertensive Rats.

Sleep and estrogen levels have an impact on neural regulation and are associated with cardiovascular (CV) events. We investigated the effects of estrogen on heart rate variability (HRV) and circadian cycle in spontaneously hypertensive rats (SHRs). Polysomnographic recording was performed in seven male and seven female SHRs during sleep. The electroencephalogram (EEG) and electromyogram (EMG) were evaluated to define active waking (AW), quiet sleep (QS), and paradoxical sleep (PS) stages. Cardiac activities were measured by RR interval of the electrocardiogram (ECG), mean arterial pressure (MAP), and power spectrum of HRV.In ECG, estrogen prolonged the RR interval in total sleep when compared with that at baseline in male SHRs (203.74 ± 6.61 versus 181.30 ± 8.06 ms, P < 0.001) and in female SHRs (169.21 ± 6.43 versus 160.76 ± 10.66 ms, P < 0.05). In HRV, the estrogen increased the high frequency (HF) in total sleep when compared with that at baseline in male SHRs (1.03 ± 0.28 versus 0.60 ± 0.43 ln (ms2), P < 0.001) and in female SHRs (0.71 ± 0.26 versus 0.42 ± 0.19 ln (ms2), P < 0.05).In male SHRs, estrogen increased the frequency of QS (26.50 ± 4.85 versus 20.79 ± 5.07, P < 0.01) and PS (25.64 ± 5.18 versus 20.14 ± 4.75, P < 0.05) stages when compared with baseline. In female SHRs, estrogen increased the percentage of delta waves in total sleep (79.87% ± 3.10% versus 76.71% ± 2.74%, P < 0.05) when compared with that at baseline.In HRV, estrogen leads to neuromodulation by increased parasympathetic tone in all SHRs, suggesting a lower risk to CV events. In sleep analyses, estrogen in male SHRs caused poor sleep quality. In contrast, estrogen in female SHRs demonstrated improved quality of sleep and decreased risk of hypertension.

Incorporation of Mobile Application (App) Measures Into the Diagnosis of Smartphone Addiction.

OBJECTIVE: Global smartphone expansion has brought about unprecedented addictive behaviors. The current diagnosis of smartphone addiction is based solely on information from clinical interview. This study aimed to incorporate application (app)-recorded data into psychiatric criteria for the diagnosis of smartphone addiction and to examine the predictive ability of the app-recorded data for the diagnosis of smartphone addiction. METHODS: Smartphone use data of 79 college students were recorded by a newly developed app for 1 month between December 1, 2013, and May 31, 2014. For each participant, psychiatrists made a diagnosis for smartphone addiction based on 2 approaches: (1) only diagnostic interview (standard diagnosis) and (2) both diagnostic interview and app-recorded data (app-incorporated diagnosis). The app-incorporated diagnosis was further used to build app-incorporated diagnostic criteria. In addition, the app-recorded data were pooled as a score to predict smartphone addiction diagnosis. RESULTS: When app-incorporated diagnosis was used as a gold standard for 12 candidate criteria, 7 criteria showed significant accuracy (area under receiver operating characteristic curve [AUC] > 0.7) and were constructed as app-incorporated diagnostic criteria, which demonstrated remarkable accuracy (92.4%) for app-incorporated diagnosis. In addition, both frequency and duration of daily smartphone use significantly predicted app-incorporated diagnosis (AUC = 0.70 for frequency; AUC = 0.72 for duration). The combination of duration, frequency, and frequency trend for 1 month can accurately predict smartphone addiction diagnosis (AUC = 0.79 for app-incorporated diagnosis; AUC = 0.71 for standard diagnosis). CONCLUSIONS: The app-incorporated diagnosis, combining both psychiatric interview and app-recorded data, demonstrated substantial accuracy for smartphone addiction diagnosis. In addition, the app-recorded data performed as an accurate screening tool for app-incorporated diagnosis.

The effects of bilateral stimulation of the subthalamic nucleus on heart rate variability in patients with Parkinson's disease.

The beneficial effects of subthalamic nucleus deep brain stimulation (STN-DBS) on motor symptoms and quality of life in Parkinson's disease (PD) are well known, but little is known of the effects on autonomic function. Diffusion of current during stimulation of the STN may simultaneously involve the motor and nonmotor, limbic and associative areas of the STN. The aims of this study were to examine whether STN stimulation affects functions of the autonomic nervous system and, if so, to correlate the effects with the active contacts of electrodes in the STN. Eight PD patients with good motor control and quality of sleep after STN-DBS surgery were recruited. All patients had two days of recordings with portable polysomnography (PSG) (first night with stimulation "on" and second night "off"). From the PSG data, the first sleep cycle of each recording night was defined. Heart rate variability (HRV) was analyzed between the same uninterrupted periods of the two sleep nights. In addition, the optimal electrode positions were defined from postoperative MRI studies, and the coordinates of active contacts were confirmed. HRV spectral analysis showed that only low-frequency (LF)/high-frequency (HF) power was significantly activated in the stimulation "on" groups (P = 0.011). There was a significant negative correlation between power change of LF/HF and electrode position lateral to the midcommissural point (ρ = 0.857, P = 0.007) These results demonstrate that STN-DBS can enhance sympathetic regulation; the autonomic response may be due to electrical signals being distributed to limbic components of the STN or descending sympathetic pathways in the zona incerta.

Suppressing cardiac vagal modulation and changing sleep patterns in rats after chronic ischemic stroke injury.

Chronic autonomic function and sleep architecture changes in patients post-stroke are not well understood. Using wireless polysomnographic recordings, this study aimed to investigate the long-term effects on sleep patterns and autonomic function in free moving rats after middle cerebral artery occlusion (MCAO). The sleep pattern and heart rate variability (HRV) of Wistar-Kyoto rats (WKY) were analyzed. After 7-10days, the rats were divided into two groups: an MCAO group (n=8) and a sham surgery group (n=8). Compared with shams, MCAO rats showed decreased accumulated quiet sleep (QS) time over 24h during the 3rd week. The time percentage, duration and delta power of QS were also significantly decreased in the MCAO group during the dark period. Compared with baseline, there were significant increases in the parasympathetic-associated HRV measures in the sham group, including the total power (TP), high frequency power (HF) and lower frequency power (LF), throughout the post-operative weeks (primarily the 2nd and 3rd weeks), reflecting a developmental increase of parasympathetic modulation; the normalized LF and the LF-HF ratio were unaffected. In great contrast, however, most of the HRV measures in the MCAO group were not significantly changed. Therefore, this study showed that the long-term effects of ischemic stroke injury involve retardation of the establishment of parasympathetic enhancement and disturbance of the normal sleep-wake cycle.

Methadone-mediated autonomic functioning of male patients with heroin dependence: the influence of borderline personality pattern.

BACKGROUND: We hypothesize that the population with borderline personality shows different autonomic response to methadone compared to individuals with other personalities. This study applies heart rate variability (HRV) measurements and the Tridimensional Personality Questionnaire (TPQ) to examine this hypothesis. METHODOLOGY/PRINCIPAL FINDINGS: Forty-four male patients with heroin dependence were recruited from a methadone maintenance treatment program. Eight personality patterns were classified according to the TPQ norm used in Taiwan. The borderline pattern (BP, composed of high novelty seeking, high harm avoidance and low reward dependence) and the other personality patterns (OP) were separated into two groups. We compared the HRV profiles between the BP and OP groups. Correlation and regression analysis were performed to clarify relationship between HRV differences and the borderline index (BI, a new concept defined by us, which is calculated as novelty seeking + harm avoidance - reward dependence). The HRV targets investigated included low frequency (LF) power, high frequency (HF) power, total power (TP), normalized LF (LF%), and LF/HF. No baseline HRV parameters showed any inter-group difference. The BP group had a significantly lower ΔHF and a higher ΔLF/HF than the OP group. The personality dimension, reward dependence, showed a negative correlation with ΔLF/HF and ΔLF%. BI was negatively correlated with ΔHF and positively correlated with ΔLF/HF and ΔLF%. CONCLUSIONS/SIGNIFICANCE: Borderline personality individuals show increased sympathetic activity and decreased parasympathetic activity compared to other personalities after taking methadone. The results support the hypothesis that there is an interaction between borderline personality and autonomic modulation.

Cardiac autonomic modulation during methadone therapy among heroin users: a pilot study.

BACKGROUND: Methadone therapy benefits heroin users in both the medical and psychosocial dimensions. However, both heroin and methadone have cardiac toxicity. Only limited information is available describing the changes in cardiac autonomic function of heroin users and effects of methadone therapy. We conduct the current study to explore the cardiac vagal function in heroin users as well as the impact of lapse and methadone therapy. METHODS: 80 heroin users from a methadone therapy clinic were distributed into 31 compliant and 49 incompliant patients according to whether they lapsed into heroin use within 10 days. 40 healthy control subjects were recruited from the community. Participants underwent electrocardiographic recordings and the heroin users were further investigated before and after methadone therapy. Spectral analysis of heart rate variability (HRV) was computed for cardiac parasympathetic modulation (high-frequency power, HF) and cardiac sympathetic modulation (normalized low-frequency power, LF%). RESULTS: The baseline HRV parameters found lower HF values for heroin users and lower RR interval values for patients with a recent lapse compared with the healthy control subjects. After 1h of methadone administration, heroin users who had lapsed showed a significant increase in HF but the heroin users who had not lapsed did not. CONCLUSION: Our findings suggest that heroin users show decreased cardiac vagal activity and that methadone therapy immediately facilitates vagal regulation in patients with a recent lapse. The differential patterns of autonomic alteration under methadone between those with and without lapse might offer an objective measure of lapse.

Association of heart rate variability with clinical outcome in parkinsonian patients after subthalamic deep brain stimulation: a retrospective cohort study.

BACKGROUND/PURPOSE: Lower sympathetic and parasympathetic function increases the morbidity in Parkinsonian patients. We conducted this retrospective study to elucidate the effect of subthalamic deep brain stimulation (STN-DBS) on autonomic cardiovascular regulation of patients with Parkinson's disease. METHODS: Twelve men and four women with advanced Parkinson's disease (mean age: 63 years) who underwent bilateral STN-DBS were followed up for 9-32 months. Daytime electrocardiography for 5 minutes and rating scores were recorded before and after surgery. Good response was defined as improvement >50% in the Unified Parkinson's Disease Rating Scale (UPDRS), and a fair response as improvement between 10% and 50% after surgery. Digitalized electrocardiography signals such as high-frequency power [HF; 0.15-0.45 Hz, to reflect vagal (parasympathetic) regulation], low-frequency power (LF; 0.04-0.15 Hz, contributed from mixed sympathetic and parasympathetic divisions), and the fraction of LF/(HF + LF) in normalized units (LF%, to reflect sympathetic regulation) were transformed with fast Fourier transformation to power spectrum and heart rate variables. RESULTS: Six male and two female patients were good responders and the others were fair responders. There were no significant differences in height, weight, duration of disease, levadopa equivalent daily dose, preoperative and postoperative UPDRS, and DBS-off and levodopa-off UPDRS between the good and fair response groups. There were no significant differences between the good and fair response groups for preoperative heart rate interval, LF values, LF% values, and HF values. Compared with preoperative values, the good response group showed a significant increase in LF but not in heart rate, LF%, and HF after surgery. In contrast, the fair response group showed no significant change in all heart rate variables postoperatively. CONCLUSION: Our study showed an improvement in autonomic cardiovascular regulation in Parkinsonian patients with >50% improvement in rating scale after STN-DBS, which implied morbidity reduction in nonmotor symptoms among such patients.

Reactive oxygen species are the cause of the enhanced cardiorespiratory response induced by intermittent hypoxia in conscious rats.

This study was carried out to investigate the role of reactive oxygen species (ROS) in the elevation of cardiorespiratory responses during the development of intermittent hypoxia (IH)-induced hypertension. Rats were exposed to either 30 days of IH [(30s N2)+(45 s room air (RA)] or RA for 6 h/day. After 5 days of exposure, stable mean arterial pressure, normalized low-frequency power of pulses interval spectrogram (a marker of cardiac sympathetic outflow), and minute ventilation (an index for arterial chemoreflex activation) were significantly increased throughout the observation period in IH-exposed rats, but not in RA-exposed rats. FosB expression in rostral ventrolateral medulla was elevated after IH exposure for 5 days. Intraperitoneal injection of MnTMPyP (a superoxide scavenger) or N-acetylcysteine (an antioxidant) prevented IH-induced elevation of the cardiorespiratory responses and lipid peroxidation of lung tissues. These results suggest that ROS are essential for IH-induced elevation of arterial chemoreflex activation and sympathetic outflow, which may, in turn, contribute to IH-induced hypertension.

Cardiac neural regulation oscillates with the estrous cycle in freely moving female rats: the role of endogenous estrogens.

Both estrogens levels and sleep/wakefulness states have been separately reported to affect cardiac autonomic regulation. In this study, we examined the integrated effects of the estrous and sleep cycles on cardiac autonomic activity in freely moving adult female rats. Cardiac autonomic activities were measured by analyzing the power spectrum of heart rate variability. High-frequency power (HF) and low-frequency power to HF ratio are closely correlated with cardiac parasympathetic and sympathetic activity, respectively. Ten days after electrodes were implanted, electroencephalogram, electromyogram, and electrocardiogram were recorded 6 h daily for 12 consecutive days to cover at least two estrous cycles. Estrous-cycle stages were determined using vaginal smears. Sleep cycle-related heart rate variability parameter oscillations were seen in all rats. However, the estrous cyclicity and estrous-cycle-related changes were only observed in the control rats and not in ovariectomized or the estrogen receptor antagonist, tamoxifen, treatment rats. A significantly higher HF was observed in estrous rats compared with diestrous rats or ovariectomized rats no matter whether the rats were asleep or awake. However, a significantly low-frequency power to HF ratio was only observed in quiet sleep (QS) during estrus. All these differences disappeared after treatment with tamoxifen. Our results suggest that estrous-cycle-related changes in cardiac neural regulations can be mainly attributed to endogenous estrogens, and these effects are most obviously manifest during QS. Estrous rats during QS would be equivalent to the late follicular phase of the women menstrual cycle and involve strong vagal tone but weak sympathetic activity.

Cardiac autonomic regulation differentiates reflux disease with and without erosive esophagitis.

OBJECTIVE: Impaired autonomic function has been observed in patients with gastroesophageal reflex disease (GERD), but little is known about autonomic function in patients with non-erosive reflux disease (NERD). The objective of this study was to investigate potential differences in autonomic function by means of heart rate variability in GERD patients with and without erosive esophagitis. MATERIAL AND METHODS: Thirty-five GERD patients and 20 healthy controls participated in the study. Seventeen subjects with NERD and 18 patients with erosive reflux disease (ERD) were identified based on typical reflux symptoms, endoscopic findings, and 24-h esophageal pH. Spectral analysis of heart rate variability was performed to calculate the low-frequency (LF) band, the high-frequency (HF) band, and the LF/HF ratio. RESULTS: No significant differences were found in age, gender, body mass index, or current tobacco use among the reflux patients and controls. The Helicobacter pylori status and severity of reflux symptoms were similar between the two groups. The HF band power was significantly lower in patients with ERD than in NERD patients (p < 0.01) and controls (p < 0.05). LF band power (%) and LF/HF ratio were significantly lower in the NERD patients compared with ERD patients (p < 0.05) and controls (p < 0.05). There was no statistically significant correlation between any heart rate variability parameter and symptom severity score in either the ERD or NERD group. CONCLUSIONS: Patients with ERD and NERD display a similar degree of symptom severity, but the pattern of autonomic function appears to differ between NERD and ERD.