Ivar Ringqvist

A Prospective Randomized Study Comparing Two Different Degrees of Mandibular Advancement with a Dental Appliance in Treatment of Severe Obstructive Sleep Apnea

The objective of this study was to compare the effect of two different degrees of mandibular advancement (MA), 75% versus 50%, on somnographic variables after 6 months of dental appliance treatment in patients with severe obstructive sleep apnea (OSA). A further purpose was to compare the number of adverse events on the stomatognathic system and the effects of dental appliance treatment on the presence of daytime sleepiness.Eighty-six males with severe OSA (apnea index ≥ 20) were randomly allocated to either 75% or 50% MA. Forty patients in the 75% MA group and 37 patients in the 50% MA group completed the 6-month follow-up.The effectiveness of treatment in terms of normalization (apnea index < 5 and apnea/hypopnea index < 10) with 75% MA was 52%, which was significantly higher (p = 0.04) than the 31% achieved with 50% MA. The dental appliance had few adverse events on the stomatognathic system regardless of group, and the number of adverse events did not differ between the two groups. Finally, the mean value of Epworth Sleepiness Scale scores decreased significantly from 11.6 at baseline to 8.0 at follow-up (p < 0.001). No significant difference was observed between the two groups. The results indicate that a dental appliance could be an alternative treatment for some patients with severe OSA.

A prospective randomized study of a dental appliance compared with uvulopalatopharyngoplasty in the treatment of obstructive sleep apnoea.

The enthusiasm for uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnoea (OSA) has declined in recent years, partly because of a lower success rate over time and partly because of adverse effects. Reports on the beneficial effects of dental appliances exist, but only one prospective randomized study has been published comparing dental appliances with nasal continuous positive airway pressure (CPAP) treatment. No study has been published comparing dental appliance treatment with UPPP. Ninety-five male patients with confirmed OSA, subjective daytime sleepiness and an apnoea index (AI) > 5 were randomized for subsequent treatment with either a dental appliance or UPPP. There were 49 patients in the dental appliance group and 46 in the UPPP group. Thirty-seven patients in the dental appliance group and 43 in the UPPP group completed the 12-month follow-up. The success rate (rate of patients with at least a 50% reduction in AI) for the dental appliance group was 95%, which was significantly higher (p < 0.01) than the 70% success rate for the UPPP group. According to the criteria for OSA (apnoea index > or = 5 or apnoea/hypopnoea index > or = 10), 78% of the dental appliance group and 51% of the UPPP group were normalized after 12 months. The difference between the groups was significant (p < 0.05). These findings suggest that the dental appliance technique is useful in the treatment of mild to moderate OSA.

Raynaud's Phenomenon in a Female Population: Prevalence and Association with Other Conditions

In a random sample of 3000 women of ages eighteen to fifty-nine years in the city of Västerås, Sweden, 19% of the 2705 responders to a questionnaire com plained of cold and white fingers with or without numbness. On the basis of interview and examination, 79% of these women were diagnosed as having Ray nauds phenomenon (RP), giving a prevalence of 15.6%. A significantly higher rate of family members with cold, white fingers was found only in the group of women with pronounced RP (p < 0.001). A significantly higher frequency of women with pronounced RP than of the control group had a history of recur rent muscle/joint pain (p < 0.05). Laboratory tests that might indicate an active connective tissue disease did not, however, confirm a diagnosis of rheumatoid arthritis. All three subgroups differed significantly from the control group in terms of recurrent chest pains; subgroups 2 and N differed significantly from controls in terms of recurrent headaches.

Dental and skeletal changes after 4 years of obstructive sleep apnea treatment with a mandibular advancement device : a prospective, randomized study.

The aim of this prospective, randomized study was to analyze dental and skeletal side effects after 4 years of treating obstructive sleep apnea (OSA) patients with a mandibular advancement device (MAD) compared with uvulopalatopharyngoplasty (UPPP). With the appliance in position, the mandible was advanced 50% of maximum protrusion capacity (ie, 4-6 mm); the vertical opening between the incisal edges was, on average, 3 mm. Thirty patients in the MAD group and 37 in the UPPP group completed the 4-year follow-up. There were no differences between the MAD and the UPPP groups in any of the dental or skeletal variables measured after the 4-year treatment period. In the MAD group, small but statistically significant changes were found: there was a posterior rotation of the mandible (mandibular line [ML]/nasion-sella line [NSL]) (mean 0.5 degrees [95% confidence interval (CI) 0.1-0.8 degrees ]). Correlated to the posterior rotation of the mandible, the distances incision superius ML, incision superius-NSL, and incision inferius-NSL increased by means (95% CI) of 0.7 (0.5-1.2), 0.8 (0.4-1.1), and 1.3 (0.8-1.8) mm, respectively. Overjet and overbite did not change significantly, nor was there a significant change in the mandibular length. The observed changes were considered clinically insignificant because overbite and overjet stayed within normal limits. Only the vertical position of the maxillary incisors in relation to ML changed to the extent that the 95% CI of the mean for the change was outside that of the mean of the change in the UPPP group and measurement error. Treatment of OSA with a dental appliance is probably a lifelong process, and long-term follow-up studies should therefore be undertaken to control both the treatment effect on OSA and the side effects on the masticatory system.

Conversion from laparoscopic to open appendicectomy : A possible drawback of the laparoscopic technique?

OBJECTIVE To analyse the reasons for, and outcome of, conversion from laparoscopic to open appendicectomy and to identify factors that may predict the need for conversion. DESIGN Subgroup analysis from a randomised multicentre study. SETTING One university hospital and four county hospitals, Sweden. SUBJECTS A total of 500 patients were randomised to laparoscopic (n = 244) or open (n = 256) appendicectomy. Thirty operations (12%) were converted to open appendicectomy. MAIN OUTCOME MEASURES Reasons for conversion, outcome, and preoperative predictive variables. RESULTS Difficult anatomy or the presence of an abscess were the main reasons for conversion (25/30). The incidence of perforated appendicitis was higher among patients who required conversion compared with both the open and laparoscopic group. Operating time, anaesthetic time, and duration of hospital stay were longer after conversion. Time to full recovery and length of sick leave were also longer, except for patients with perforated appendicitis. There was no difference in the complication rate. No predictive factors were identified. CONCLUSION The main reasons for conversion were difficult anatomy and the presence of an abscess. After conversion patients recovered more slowly than those operated on laparoscopically or by primary open operation.

Mortality and Morbidity in Patients with Intermittent Claudication in Relation to the Location of the Occlusive Atherosclerosis in the Leg

Mortality and morbidity from cerebrovascular and coronary arterial disease over a period of six years were studied in 224 non-diabetic patients with inter mittent claudication. Patients with multiple arterial stenoses in the leg had a lower six-year survival than patients with single stenoses (55% versus 77%), with a higher mortality from cardiac deaths. These differences were still signifi cant after adjustment for differences in clinical characteristics at the initial ex amination. This might indicate that patients with multiple arterial stenoses in the legs have a more widespread and more progressive atherosclerotic disease.

Time delays in ultrasound systems can result in fallacious measurements

Even short time delays (less than 30 ms) in cardiac motion pattern may have clinical relevance. These delays can be measured with echocardiography, using techniques such as flow and tissue Doppler and M-mode together with external signals (e.g., ECG and phonocardiography). If one or more of these signals are delayed in relation to the other signals (asynchronous), an incorrect definition of cardiac time intervals can occur, the consequence of which is invalid measurement. To determine if this time delay in signal processing is a problem, we tested three common ultrasound (US) systems using the ECG as the reference signal. We used a digital ECG simulator and a Doppler string phantom to obtain test signals for flow and tissue pulsed Doppler, M-mode, phonocardiography, auxiliary and ECG signals. We found long time delays of up to 90 ms in one system, whereas delays were mostly short in the two other systems. The time delays varied relative to system settings. Consequently, to avoid these errors, precise knowledge of the characteristics of the system being used is essential.

Echocardiographic doppler assessments of left ventricular filling and ejection during upright exercise in endurance athletes

Doppler echocardiography was used to describe left ventricular filling and ejection during upright bicycle exercise in 24 healthy male endurance athletes. The transmitral pressure gradient was estimated and isovolumetric relaxation, filling and ejection time and transmitral and aortic flow velocities were measured at rest and during exercise. From rest to peak exercise (at a heart rate of 160 bpm), the mean left ventricular filling time was shortened by 73%, the ejection time by 31%, while the isovolumetric relaxation time was shortened by 62%. At peak exercise, the maximum aortic flow velocity almost doubled and the maximum transmitral flow velocity more than doubled, with a tenfold increase in the mean transmitral pressure gradient. The increase was significant (P<0·001) at each level of exercise. The left ventricular filling rate measured as volume per time was 185 ± 62 ml s−1 at rest and it increased to 986 ± 192 ml s−1 at peak exercise. This study demonstrates large changes in diastolic filling indices during upright exercise and it shows that the heart is able to increase its filling rate five times from rest to peak exercise.

Effect of menopause on left ventricular filling in 50-year-old women

Abstract In conclusion, our study shows menopause-related changes in Doppler indexes of LV filling, suggesting impaired LV filling in postmenopausal women.

The effect of isradipine, a new calcium-channel antagonist, in patients with primary Raynaud's phenomenon: A single-blind dose-response study

SummaryIsradipine is a new potent calcium-channel blocking agent with highly selective action on peripheral vessels. In this single-blind study, its dose-related effect on cold-induced changes in finger systolic pressure (FSP) was investigated in ten female patients with primary Raynauds phenomenon, and the side effects of isradipine treatment were evaluated. The patients were studied during 9 weeks of treatment. After 3 weeks of placebo, isradipine was given in doses of 1.25 mg b. i. d. and 2.5 mg b. i. d. for 3 weeks each. FSP was measured on local finger cooling to 10°C. FSP at 10°C expressed in percent of the value of 30°C increased from 21±16% (M±SD) after placebo to 42±28% (p<0.05) and 62±25% (p<0.001) after treatment with isradipine 1.25 mg and 2.5 mg b. i. d., respectively. The subjective efficacy of the treatment was assessed with a visual analogue scale (VAS). The VAS rating increased from 17 (range 0–66) after placebo to 39 (range 12–88) (NS) and 68 (range 25–99) (p<0.001) after isradipine treatment with 1.25 mg and 2.5 mg b.i.d., respectively. Adverse effects of isradipine therapy were few and did not differ from those reported after the placebo period. This single-blind dose-response study showed that isradipine in doses of 1.25 mg and 2.5 mg b.i.d had favorable objective and subjective effects in patients with primary Raynauds phenomenon and had no serious side effects.