Objective evaluation of tongue base snoring after the use of an oral appliance: a prospective case series.

UNLABELLED: Oral appliances have become increasingly popular for treatment of obstructive sleep apnoea especially for patients who are not able to tolerate continuous positive airway pressure devices. For simple snoring, oral appliances have become one of the treatments of choice despite a relative lack of scientific evidence of their efficiency. OBJECTIVES: This study was designed to objectively evaluate the clinical effectiveness of oral appliance in the treatment of simple snoring. DESIGN: Prospective case series. PARTICIPANTS: Fifteen patients with confirmed simple tongue base snoring had pre- and post-oral appliance objective assessment of their snoring loudness and duration at home. MAIN OUTCOME MEASURES: The Snore Index was calculated as the number of snores per hour slept. Patients bed partners were asked to rate the snoring severity on a Spouse Dissatisfaction Scale. RESULTS: Overall there was no significant difference in the Snore Index in the pre- and post-oral appliance recordings. Subjectively, there was a statistically significant decrease in the Spouse Dissatisfaction Scale following the use of oral appliance. CONCLUSION: Tongue base snorers had no significant reduction in their snoring with the oral appliances. There is a subjective benefit which may be due to the placebo effect.

Relation of plasma oxytocin and prolactin concentrations to milk production in mothers of preterm infants: influence of stress.

Responses of oxytocin and PRL to mechanical breast pumping and the influence of physiological indicators of stress were measured at 2, 4, and 6 weeks postpartum to determine potential causes of inadequate milk production in 18 women with prematurely delivered, nonnursing (<1500 g) infants. Median milk production was similar to that reported in breastfeeding mothers, but a third of mothers were producing less than half as much by week 6. Plasma oxytocin was similar to that previously reported for breastfeeding mothers. The oxytocin area under the curve (AUC) for breast-pumping sessions (70 min) was correlated at each occasion (r = 0.37, 0.58, and 0.55, respectively) with milk yield. Unlike reports of PRL levels in breast-feeding women, PRL AUC declined between weeks 2 and 6 weeks postpartum (P = 0.03); significant increases in plasma PRL occurred in response to pumping at 2 and 4 weeks, but not at 6 weeks. Salivary amylase, a measure of alpha-adrenergic activity, was highly negatively correlated on each occasion with PRL AUC (r = -0.58, -0.68, and -0.86, respectively), but not with oxytocin. Salivary cortisol was negatively correlated to a lesser degree. We hypothesize that deficiencies in preterm lactation are mediated in part upon stress-induced suppression of PRL secretion through an adrenergic mechanism.

Audit of service to a minority client group: male to female transsexuals.

Male to female transsexual clients are a group of clients for whom there are few dedicated services in New Zealand. To examine service utilization in Wellington, New Zealand, 70 male to female transsexual clients were identified and their medical records audited for selected aspects of sexual health service delivery. Audit revealed that sexual health history is recorded incompletely and behavioural risk factors are not fully explored, sexual health examination and testing is incomplete. We conclude opportunities to expose relevant behavioural factors and to educate for sexual safety and health promotion are lost with this infrequently attending minority client group.

Serum prolactin in breastfeeding: state of the science.

Prolactin is one of two major hormones involved in lactation. While the role of infant suckling and oxytocin in the lactation process are well understood, the role of prolactin is less clear. A variety of factors related to prolactin have been investigated, and these are used as an organizing framework for this article. Factors include pregnancy, lactation, nursing frequency, prior lactation experience, milk production, and pharmacologic agents. The literature, while substantial in amount, presents inconsistencies. Implications for practice are discussed.

A simple audio data logger for objective assessment of snoring in the home.

We have developed a portable device for patient use in logging snoring loudness in the home, for guiding treatment decisions and measuring the clinical effectiveness of treatment. The device uses a free field microphone and is positioned on a bedside table. The prototype devices contain no inherently expensive components and are simple to operate (producing only 5% patient error to date). They are portable, battery powered, rugged and produce digital data which are easily and automatically analysed, and these design parameters enable the devices to be used for first line patient assessment. Of the 75 recordings made so far from 30 patients, 85% were successful, yielding clinically useful data. Because it is sound levels which are recorded and not replayable sounds, patient privacy is maintained, resulting in excellent patient acceptance (to date no patient has refused). The device has a dynamic range of 45-90 dB sound pressure level and a frequency range of 30 Hz-5 kHz. Because snoring intensities often vary significantly throughout the night the device can measure continuously over 8 h.

Palatal snoring identified by acoustic crest factor analysis.

The differentiation of palatal from non-palatal snoring is very important for ENT surgeons trying to determine whether palatal surgery would be curative. At present sleep nasendoscopy is the accepted method. Palatal vibration produces marked modulation of sound loudness at low frequency (below approximately 100 Hz). We calculate a crest factor for the sound waveform (ratio of peak to root mean square (rms) value in any given epoch), as a measure of the degree of modulation. Free-field snore sounds were recorded from 11 supine adult patients under intravenous sedation (midazolam), using a digital tape recorder. Recordings were transferred to a PC (sampling frequency 11 kHz), and analysed using code written by us. Direct visual confirmation of the site of snoring was gained from simultaneous sleep nasendoscopy, taken as the gold standard. In six patients the dominant site was the soft palate. The non-palatal group (five patients) comprised one epiglottic, two hypopharyngeal and two tongue base snorers. The crest factor was found to be significantly higher for palatal snorers (p < 0.01, Student-t or Mann-Whitney tests). Furthermore, palatal could be distinguished from non-palatal snorers on the basis of crest factor alone in all 11 cases, making this a promising non-invasive diagnostic technique.

Can bio-electrical impedance be used to measure total body water in dialysis patients?

The measurement of total body water (TBW) by bio-electrical impedance (BEI) in a group of renal patients was evaluated against the tritium dilution method. The effect of haemodialysis and the presence of peritoneal dialysate on the impedance were also investigated. The correlation between the two methods was r = 0.9, with the standard deviation of the differences being 3.66 l (TBW typically 40 l). The BEI method overestimated the actual weight loss after haemodialysis, but underestimated the volume of peritoneal dialysate in situ. The BEI method would not be appropriate for use in assessing total body water and monitoring acute volume changes in patients with renal failure who are on strict fluid restriction.

The occurrence of breast engorgement.

This study describes breast engorgement during days 1-14 postpartum of 114 first and second time vaginal- and cesarean-delivery breastfeeding mothers. Most mothers reported experiencing their most intense engorgement after hospital discharge. Previous breastfeeding experience of the mother is a more critical variable than parity in predicting engorgement. Second time breastfeeding mothers experienced engorgement sooner and more severely than did first time breastfeeding mothers, regardless of delivery method. Anticipatory guidance by the care provider is discussed in an effort to enhance the experience of the breastfeeding dyad.

The effect of sequential and simultaneous breast pumping on milk volume and prolactin levels: a pilot study.

Mothers who must express milk for a prolonged period frequently report that milk volumes decrease. The purpose of this pilot study was to assess the feasibility of having a sample of lactating mothers of preterm infants follow a specific breast pumping protocol, express milk mechanically for six weeks, and have a subsample consent to venipuncture. This pilot study compared the effects of pumping breasts sequentially or simultaneously on milk volume and prolactin levels in mothers of preterm infants. Nine lactating mothers were randomly assigned to a sequential single or simultaneous double electric breast pumping system. Prolactin levels were examined in four mothers on days 21 and 42 postpartum. The sequential single and simultaneous double groups had mean baseline prolactin levels of 50.8 ng/ml and 40.6 ng/ml, respectively on day 21, and 26.6 ng/ml and 34.5 ng/ml, respectively, on day 42 postpartum. At 9 and 12 weeks postpartum mothers were queried about their lactational status. The results suggested that milk yield may be maintained or increased with frequent use of the simultaneous double pumping system. Further study is needed to confirm results of this pilot study.

Breastfeeding and health professional encouragement.

The objective of the study was to ascertain the nature of health professional contacts related to breastfeeding for 341 women. Subjects were prospectively queried by phone or home visit over a 20-week period regarding the number and nature of contacts with health care professionals related to breastfeeding. Lactation consultants gave significantly more positive encouragement (98%) (p = .01) than either nurses (75%) or physicians (68%) did. However, of the 233 health provider contacts that included breastfeeding advice, only 21% involved lactation consultants. Primiparae were likely to decrease their level of breastfeeding if a health professional encouraged supplemental foods (39%) or weaning (86%) during the prior week. Multiparae who were experienced at breastfeeding (3+ weeks breastfeeding the previous infant) decreased their breastfeeding slowly across the weeks with the current infant, and their level of breastfeeding in general appeared independent of health care provider advice. Multiparae who lacked previous sustained breastfeeding experience (0-3 weeks) had the most rapid decrease (65%) in their breastfeeding rates even with health care provider encouragement to continue. Thus, they too appeared to act independently of health care provider advice.

Initiation and frequency of pumping and milk production in mothers of non-nursing preterm infants.

This secondary data analysis examined if time of initiation of milk expression and pumping frequency influenced milk weight weeks 2-5 postpartum. Of the 39 subjects in the convenience sample, 20 were in the early initiating (EI) group, (n = 12 high frequency [HF], n = 8 low frequency [LF]), and 19 were in the late intiating (LI) group, (n = 7 HF, n = 12 LF). The EI group initiated pumping < or = 48 hours after birth; the HF group pumped a minimum of 6.25 times daily. A two-way analysis of variance indicated that milk weight was significantly higher in the HF as compared to the LF group. While there was no significant difference in milk weight between the EI and LI groups, there was a significant interaction between frequency and initiation. Milk weight for the LF/EI group appeared to be positively influenced by the initiation of mechanical expression soon after birth.

Breast engorgement: patterns and selected outcomes.

For 14 days following birth, 114 breastfeeding mothers rated their level of breast engorgement twice daily, using a six-point engorgement scale. Individual engorgement ratings were plotted by intensity over time to provide a visual display of each subject's breast engorgement experience. Four distinct patterns of breast engorgement emerged; mothers experienced either a bell-shaped pattern, a multi-modal pattern, a pattern of intense engorgement, or a pattern of minimal engorgement. Characteristics of mothers and infants, and feeding frequency were similar across the four breast engorgement patterns.

Mothers of low birthweight infants: breastfeeding patterns and problems.

The feeding behavior and problems of mothers of low birthweight (LBW) infants following hospital discharge have not been well documented. The purpose of this paper is to report the feeding patterns of LBW infants and their mothers' reasons for a decline in breastfeeding. A convenience sample of 110 mothers and infants from eight midwestern hospitals was surveyed. Eight weeks after delivery, 28 percent of the mothers were providing mother's milk exclusively, 29 percent were providing a combination of mother's milk and artificial milk, and 43 percent had weaned their infants. An inductive analysis of the reasons for a decline in breastfeeding given by the mothers yielded two primary maternal concerns: milk production and transfer of milk to the infant. Lactation management strategies that meet the special needs of these mothers and infants should be taught during hospitalization and after hospital discharge.

Effects of pumping style on milk production in mothers of non-nursing preterm infants.

Milk production was examined in 39 lactating mothers of non-nursing preterm infants from 2 tertiary care centers. The purposes of this study were (1) to compare milk production of those using sequential single (SEQ) or simultaneous double (SIM) breast-pumping regimen, and (2) to examine the relationship of selected variables to inadequate (< 3500 g/week) and adequate (> or = 3500 g/week) milk production. In multivariate analysis, mothers using SIM produced a similar amount of milk by weight during weeks 2 to 5 postpartum compared to those using SEQ. A logistic regression model including frequency of kangaroo care, frequency of pumping, high versus low income, and previous breastfeeding experience was predictive of mothers producing adequate versus inadequate milk volume 79% of the time. All of the mothers producing > 3500 g at week 2 produced adequate amounts of milk at weeks 4 and 5. None of the mothers producing < 1700 g at week 2 reached adequate production by weeks 4 and 5. Of the remaining mothers who produced 1700 g to 3500 g at week 2, 54% achieved adequate production during weeks 4 and 5 postpartum.

Effects of heat and cold on the perineum after episiotomy/laceration.

The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool, devised to evaluate postpartum healing of the perineum following an episiotomy/laceration, was used to evaluate the effects of heat and cold on the perineum during the first 24 hours after delivery. Ninety patients were randomly assigned to one of three treatment groups. Treatment consisted of 30 subjects applying a warm perineal pack, 30 applying a cold perineal pack, and 30 taking a warm sitz bath. Analysis of variance indicated no difference in the REEDA score before or two hours after treatment. A Pearson r correlation indicated the REEDA score was associated with a laceration and not with infant weight. Although these findings do not support assumptions from the literature, this study provides baseline data and trends for future study.

Does early supplementation affect long-term breastfeeding?

The purpose of this secondary data analysis from two different samples was to examine the effect of early supplementation with manufactured milks on breastfeeding status at 20 weeks postpartum in mothers of healthy term infants. In two convenience samples of 120 and 223, respectively, breastfeeding mothers were followed up for 20 weeks postpartum or until weaning occurred. The breastfeeding rate at 20 weeks postpartum was significantly greater for mothers who reported feeding exclusively mother's milk the second week after delivery compared with mothers who breastfed and simultaneously supplemented with manufactured infant milks. Of the mothers in samples one and two who exclusively fed human milk during week 2 postpartum, 63.0% and 59.7%, respectively, were still breastfeeding at week 20, compared with 28.1% and 24.2%, respectively, who supplemented with artificial milks. There was no significant difference between these two groups of mothers and their intended duration of breastfeeding. Early introduction of supplemental bottles of artificial milks is associated with a decrease in the amount of human milk the infant receives as well as with early weaning.

Breastfeeding patterns of low-birth-weight infants after hospital discharge.

OBJECTIVE: To examine the feeding patterns of low-birth-weight infants (1,500-2,500 g) on the day of hospital discharge and 4 weeks after birth. DESIGN: Prospective, descriptive survey. SETTING: Eight hospitals in the Midwest. PARTICIPANTS: One hundred ten mothers who intended to breastfeed their low-birth-weight infants. MAIN OUTCOME MEASURES: Two different tools were used to address infant breastfeeding patterns and effectiveness of infant feeding at the breast as reported and rated by the mothers. RESULTS: At hospital discharge, 38% of the infants were exclusively fed at the breast. Only 52% of the full-term, low-birth-weight infants and 52% of the preterm low-birth-weight infants had effective vigorous feedings at the breast at hospital discharge as rated by the mothers. At 4 weeks, 40% of the infants were fed exclusively at the breast and 19% were weaned to formula. CONCLUSIONS: The several feeding patterns and modes of feeding identified with low-birth-weight infants suggest that appropriate tools be designed and tested with mothers of low-birth-weight infants. In addition, the definition of breastfeeding must be explored.

Comparison of subjects who fully versus minimally participated in a breast-feeding study.

Sampling bias occurs in research when a large percentage of subjects who are eligible for the study refuse to participate. During Phase I of a two-phase multisite Mother-Baby Feeding Project, approximately 50% of the 235 potential participants at four of five sites declined to enter the study. This report compares subjects who fully participated with those who minimally participated and explores factors related to subjects' refusal to participate. Data regarding sociodemographic data, breast-feeding experience, and reason for refusal were collected from 92 subjects who declined to enter but agreed to minimally participate. The fully participating subjects had more education than those who participated minimally. However, the breast-feeding outcomes studied were similar for both groups. This provides support for generalizing additional study findings beyond the group of fully participating subjects when considering breast-feeding outcomes. Findings lend insight into the problem of subject recruitment that is not well-addressed in the nursing literature.

Grieving responses: a comparison after home or hospital care.

This study, over a five year period in a general practice, has shown that grieving is resolved in a much more desirable way if a dying patient is nursed at home by relatives rather than by strangers in a hospital.

Intravenous disopyramide in myocardial infarction: a haemodynamic study.

Disopyramide (2 mg/kg intravenously in 10 minutes) was administered to 14 patients with myocardial infarction within 36 hours of their infarct. Heart rate (HR) increased significantly five minutes after completion of the injection, but profound tachycardia was not seen. Mean wedge pressure (WP) rose and stroke volume (SV) fell. Disopyramide therefore showed a negative inotropic effect on the heart. Systemic vascular resistance (SVR) increased but blood pressure was not significantly altered. Diastolic and mean pulmonary arterial (PA) pressure was also increased by disopyramide. Peak plasma disopyramide level was reached five minutes after injection. The implications of the haemodynamic effects of disopyramide are discussed.