Obstructive sleep apnea therapy.

In clinical practice, oral appliances are used primarily for obstructive sleep apnea patients who do not respond to continuous positive airway pressure (CPAP) therapy. We hypothesized that an oral appliance is not inferior to CPAP in treating obstructive sleep apnea effectively. We randomly assigned 103 individuals to oral-appliance or CPAP therapy. Polysomnography after 8-12 weeks indicated that treatment was effective for 39 of 51 persons using the oral appliance (76.5%) and for 43 of 52 persons using CPAP (82.7%). For the difference in effectiveness, a 95% two-sided confidence interval was calculated. Non-inferiority of oral-appliance therapy was considered to be established when the lower boundary of this interval exceeded -25%. The lower boundary of the confidence interval was -21.7%, indicating that oral-appliance therapy was not inferior to CPAP for effective treatment of obstructive sleep apnea. However, subgroup analysis revealed that oral-appliance therapy was less effective in individuals with severe disease (apnea-hypopnea index > 30). Since these people could be at particular cardiovascular risk, primary oral-appliance therapy appears to be supported only for those with non-severe apnea.

[18 years experience with mechanical ventilation in patients with Duchenne muscular dystrophy]. / 18 jaar ervaring met chronische beademing bij patiënten met spierdystrofie van Duchenne.

OBJECTIVE: To find out which patients with Duchenne muscular dystrophy are eligible for starting home mechanical ventilation and what the survival rate is. DESIGN: Retrospective. METHOD: In 48 patients with Duchenne muscular dystrophy who were treated with home ventilation from 1987, the results were assessed in the follow-up visit in February 2005. Initially, ventilation was only given through a tracheotomy (TPPV), but after starting up a multidisciplinary neuromuscular consultation, non-invasive ventilation (NIPPV) was offered in an earlier stage of the disease. The following data were derived from the outpatient medical record: indication for ventilation, vital capacity (VC), arterial blood gas values, duration of ventilation up to February 2005, survival and causes of death. RESULTS: 15 patients died. The 5-year survival rate was 75% from the start of mechanical ventilation and 67% (18/27) of the patients were still living at home at the time of the follow-up visit. The most important causes of death were cardiomyopathy (5/15) and tracheal bleeding (3/15). The group of patients who started ventilation before 1995 (n = 17) had a significantly smaller VC than the group (n = 31) who started after the neuromuscular consultation was set up. The PaCO2 during daytime was significantly higher in the group that started ventilation before 1995 compared to the group that started later. CONCLUSION: Home mechanical ventilation can be implemented effectively in patients with Duchenne dystrophy, with a 5-year survival of 75%.

[From the poliomyelitis epidemic to the founding of artificial respiration centres, intensive care units and centres for home mechanical ventilation]. / Van de poliomyelitisepidemie naar de oprichting van beademingscentra, intensivecareafdelingen en centra voor thuisbeademing.

In 1952, Copenhagen was confronted with a poliomyelitis epidemic that involved the respiratory musculature in large numbers of patients. The anaesthetist B. Ibsen, who established carbon dioxide intoxication due to severe hypoventilation as the cause of death, proposed that the patients be treated by tracheostomy and positive pressure respiration in order to achieve better ventilation than with an iron lung. In the Netherlands, it was decided to organise the control ofthe epidemics on a nationwide basis. Various hospitals were asked to set up artificial respiration centres. In addition, the Beatrix Fund was set up in order to collect money for combating poliomyelitis. The epidemic reached the Netherlands in 1956. In Groningen University Medical Centre, 74 patients were admitted, of whom 36 had to be ventilated. In two cases, the mechanical ventilation could not be stopped and one of these was ultimately discharged home with chronic ventilation in 1960, thus becoming the first patient in the Netherlands to be given mechanical ventilation at home. The mechanical ventilation centres developed into the intensive care units as we know them today. Most of the forms of treatment now in use are based on the techniques thought up and elaborated by the pioneers working in the mechanical ventilation centres. The latest development in this series is the development of centres for home mechanical ventilation.

Pneumatosis intestinalis and active cytomegaloviral infection after lung transplantation. Groningen Lung Transplant Group.

Pneumatosis intestinalis occurred in a patient with a primary cytomegaloviral (CMV) infection with pneumonitis 6 weeks after single lung transplantation for primary pulmonary hypertension. The possible causal relationship between pneumatosis intestinalis, an uncommon disorder with an obscure pathogenesis, and active CMV infection has been observed before; however, to our knowledge, this is the first report of this combination after lung transplantation. The patient had no abdominal complaints, and after treatment of the CMV infection, the pneumatosis intestinalis resolved spontaneously. The early diagnosis of active CMV infection and the prevention of unnecessary abdominal surgery were essential in this case.

Acid maltase deficiency: treatment of respiratory insufficiency with cuirass respirator.

Three patients with the late-onset form of acid maltase deficiency showed a gradual weakening of proximal limb and trunk muscles leading to severe respiratory insufficiency. Considerable deterioration of pulmonary function occurred owing to a vicious cycle of hypoventilation and exhaustion. Treatment by nocturnal cuirass ventilation with tailor-made shells was successful. The muscle weakness still progressed very slowly but there were no more respiratory problems.

Cell growth inhibitory effects of caulerpenyne, a sesquiterpenoid from the marine algae Caulerpa taxifolia.

Caulerpa taxifolia (Vahl) C. Agardh (Ulvophyceae, Caulerpales) is an algae of tropical origin that was accidentally introduced into the Mediterranean in 1984. Caulerpenyne (Cau) is the major metabolite present in Caulerpa taxifolia. This metabolite has previously been shown to be cytotoxic against cell lines in culture as in KB cells and fibroblasts from hamsters. Cau along with 6 other drugs representative of the major classes of anticancer products was tested against 8 cancer cell lines of human origin. Cau demonstrated growth-inhibitory effects in all cases with some variability between cell lines; this inter-cell variability was, however, less marked than that observed with the anticancer drug tested. Cells of colorectal cancer origin were the most sensitive to the presence of Cau with IC50 values of 6.1 and 7.7 microM. Increasing the duration of contact between Cau and the cells from 75 min to 29.5 hr did not improve the cytotoxic efficacy of this compound. When Cau was pre-incubated in the culture medium for from 7 to 83 min before being exposed to CAL 27 cells (head and neck cancer origin), there was a constant loss of cytostatic action of Cau as a function of Cau pre-incubation time. As the bovine serum albumin concentration increased in the culture medium, the concentration-response curves showed a constant shift towards the right, indicating a loss of cytostatic activity of Cau. In the presence of Cau, cells in culture clearly exhibited an early and marked shift into S phase followed by a blockade into the premitotic G2 M phase. Possible targets for CAU remain to be identified. Cau needs to be tested on tumor bearing animals to confirm this promising antiproliferative activity.

Stimulation of lymphocytes in vitro by Bacteroides intermedius and Bacteroides (Porphyromonas) gingivalis sonicates.

The present study was designed to assess whether the in vitro stimulation of lymphocytes by sonicates of Bacteroides intermedius and Bacteroides (Porphyromonas) gingivalis is antigen specific or non-specific. In addition, the role of T and B lymphocytes in these responses was assessed. Peripheral blood lymphocytes obtained from healthy volunteers were cultured in the presence of these bacterial preparations and the proliferative response was measured. In similar experiments the response of umbilical cord blood lymphocytes did not exceed background values. In limiting dilution experiments only 1:4000, 1:6800, and 1:8200 of the lymphocytes initially reacted to B. intermedius, which strongly argues for the antigen-specificity of the response. Purified T cells, in the presence of monocytes, proliferated when stimulated with B. intermedius and B. gingivalis. As for B cell stimulation, the bacterial extracts were capable of inducing IgM production, which appeared to be T cell dependent. These findings support the notion that B. intermedius and B. gingivalis induce specific T cell activation; secondarily, a T cell dependent, polyclonal B cell activation may occur.

CD4 to CD8 ratio and in vitro lymphoproliferative responses during experimental gingivitis in pregnancy and post-partum.

The absolute numbers and percentages of peripheral T, B, and NK cells were assessed in 7 women, both during the second trimester of pregnancy and 6 months post-partum. Furthermore, the in vitro responses of peripheral blood lymphocytes (PBL) to several mitogens and a preparation of Prevotella intermedia were compared in a period of experimentally-induced gingivitis during pregnancy and post-partum. Clinically, the periodontal pocket bleeding index (PPBI) was found to be higher during pregnancy than post-partum. The absolute numbers of CD3, CD4, and CD19 positive cells appeared to be decreased during pregnancy as compared to post-partum. However, the results did not indicate any evidence for a reduced in vitro PBL response to several mitogens and a preparation of P. intermedia during pregnancy.

[Risk of respiratory insufficiency caused by thoracic rigidity]. / Gevaar voor respiratoire insufficiëntie door starre thorax.

Three patients, a man aged 71 and two women aged 47 and 54, were admitted for chronic obstructive pulmonary disease and cardiac failure. All three had thoracic deformities, owing to earlier pneumonectomy with thoracoplasty because of pulmonary tuberculosis, congenital kyphoscoliosis, and infant poliomyelitis respectively. Such patients are at risk of developing chronic respiratory insufficiency because of chronic alveolar hypoventilation: muscle power decreasing with age gradually fails to meet the increased respiratory labour. Often, the respiratory insufficiency is not noticed because the problems are ascribed to secondary chronic obstructive pulmonary disease or cardiac failure. The first sign of imminent respiratory insufficiency is nocturnal carbon dioxide accumulation. Therapy consists of respiratory assistance at night by positive air pressure ventilation via a nose mask.

[Treatment of the obstructive sleep-apnea syndrome in adults]. / Behandeling van het obstructieve slaapapneusyndroom bij volwassenen.

When treating the obstructive sleep-apnoea syndrome (OSAS), conservative management and the correction of treatable stenoses in the upper airway should be considered first. If these measures are neither effective nor applicable, then continuous positive airway pressure (CPAP) is the preferred treatment. Surgical interventions should only be considered after failure of non-surgical treatment modalities. Pharmacological management of OSAS is usually only indicated as a form of supplementary treatment in specific patients. Oral-appliance therapy appears to be of value in the management of OSAS and, in specific groups of patients, seems likely to offer a good alternative to CPAP in the future.

[Dyspnea caused by bullae in a muscular dystrophy patient on chronic intermittent ventilatory support]. / Dyspneu door bullae bij een chronisch intermitterend beademde patiënt met spierdystrofie.

A 65-year-old patient, ex-smoker, with facioscapulohumeral muscular dystrophy (FSHD) had been on home non invasive ventilatory support for three years when he experienced gradual increase of dyspnoea. The chest radiograph showed large bullae occupying most of the right hemithorax, with compression of lung tissue, mediastinal shift, and compression of the left lower lobe. Bullectomy resulted in rapid clinical and radiographic improvement. This is the first report of beneficial effects of emergency bullectomy in FSHD. Bullectomy has proved most successful in patients with localized bullae and compression of surrounding lung tissue. Patients with respiratory infections and bronchiectasis benefit less.

[Orthopnea: not always of cardiac origin]. / Orthopneu: niet altijd cardiaal bepaald.

Respiratory insufficiency developed in a man aged 68 after cardiac surgery and in a man aged 60 with COPD and a history of cigarette smoking after an attack of 'flu', while in a woman aged 70 with non insulin-dependent diabetes mellitus it had been present for years. All three had bilateral diaphragmatic paralysis. The diagnosis is based on the triad orthopnoea, paradoxical abdominal movements during respiration in the recumbent position and a decrease of the vital capacity in the horizontal as compared with the sitting position. The patients' physical condition could be improved with the aid of (noninvasive) ventilatory support.

Tracing sewage and natural freshwater input in a northwest Mediterranean Bay: evidence obtained from isotopic ratios in marine organisms.

Elemental carbon and nitrogen levels and isotope ratios were assessed in different biological compartments of a Northwest (NW) Mediterranean bay to trace the various sources of nutrient input from natural (river runoffs) and anthropogenic (harbor outflows, fish farms and urban sewage outfall) sources. Samples from transplanted mussels and natural sea grass communities (Posidonia oceanica leaves and epiphytes) were harvested from different locations throughout the bay during the touristic summer and rainy seasons. The results from the nitrogen analysis revealed that sewage and harbor outflow promote higher nitrogen levels, enrichment of (15)N in the tissues, and a higher seasonal variability in sea grass and epiphytes. In mussel tissues, the delta(15)N was also influenced by sewage and harbor outflow, whereas delta(13)C was influenced by terrestrial inputs. These results suggest that natural and anthropogenic nutrient inputs have a temporary and localized influence and affect the sensitivity of natural isotopic ratios to changes in hydrologic conditions, especially to rain and tourism.