Secundino Fernandez

Increased Sympathetic and Decreased Parasympathetic Cardiac Tone in Patients with Sleep Related Alveolar Hypoventilation

OBJECTIVE To assess autonomic function by heart rate variability (HRV) during sleep in patients with sleep related alveolar hypoventilation (SRAH) and to compare it with that of patients with obstructive sleep apnea (OSA) and control patients. DESIGN Cross-sectional study. SETTING Sleep Unit, University Hospital of University of Navarra. PATIENTS Fifteen idiopathic and obesity related-SRAH patients were studied. For each patient with SRAH, a patient with OSA, matched in age, sex, body mass index (BMI), minimal oxygen saturation (SatO2), and mean SatO2 was selected. Control patients were also matched in age, sex, and BMI with patients with OSA and those with SRAH, and in apnea/hypopnea index (AHI) with patients with SRAH. INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Time- and frequency-domain HRV measures (R-R, standard deviation of normal-to-normal RR interval [SDNN], very low frequency [VLF], low frequency [LF], high frequency [HF], LF/HF ratio) were calculated across all sleep stages as well as during wakefulness just before and after sleep during a 1-night polysomnography. In patients with SRAH and OSA, LF was increased during rapid eye movement (REM) when compared with control patients, whereas HF was decreased during REM and N1-N2 sleep stages. The LF/HF ratio was equally increased in patients with SRAH and OSA during REM and N1-N2. Correlation analysis showed that LF and HF values during REM sleep were correlated with minimal SatO2 and mean SatO2. CONCLUSIONS Patients with SRAH exhibited an abnormal cardiac tone during sleep. This fact appears to be related to the severity of nocturnal oxygen desaturation. Moreover, there were no differences between OSA and SRAH, supporting the hypothesis that autonomic changes in OSA are primarily related to a reduced nocturnal oxygen saturation, rather than a consequence of other factors such as nocturnal respiratory events.

Sleeve Gastrectomy Reduces Hepatic Steatosis by Improving the Coordinated Regulation of Aquaglyceroporins in Adipose Tissue and Liver in Obese Rats

BackgroundGlycerol constitutes an important metabolite for the control of lipid accumulation and glucose homeostasis. Our aim was to investigate the potential role of aquaglyceroporins, which are glycerol channels mediating glycerol efflux in adipocytes (AQP3 and AQP7) and glycerol influx (AQP9) in hepatocytes, in the improvement of adiposity and hepatic steatosis after sleeve gastrectomy in an experimental model of diet-induced obesity (DIO).MethodsMale Wistar DIO rats (n = 161) were subjected to surgical (sham operation and sleeve gastrectomy) or dietary interventions [fed ad libitum a normal diet (ND) or a high-fat diet (HFD) or pair-fed to the amount of food eaten by sleeve-gastrectomized animals]. The tissue distribution and expression of AQPs in biopsies of epididymal (EWAT) and subcutaneous (SCWAT) white adipose tissue and liver were analyzed by real-time PCR, Western blot, and immunohistochemistry.ResultsFour weeks after surgery, DIO rats undergoing sleeve gastrectomy showed a reduction in body weight, whole-body adiposity, and hepatic steatosis. DIO was associated with a tendency towards an increase in EWAT AQP3 and SCWAT AQP7 and a decrease in hepatic AQP9. Sleeve gastrectomy downregulated AQP7 in both fat depots and upregulated AQP3 in EWAT, without changing hepatic AQP9. Aqp7 transcript levels in EWAT and SCWAT were positively associated with adiposity and glycemia, while Aqp9 mRNA was negatively correlated with markers of hepatic steatosis and insulin resistance.ConclusionOur results show, for the first time, that sleeve gastrectomy, a widely applied bariatric surgery procedure, restores the coordinated regulation of fat-specific AQP7 and liver-specific AQP9, thereby improving whole-body adiposity and hepatic steatosis.

Characterizing the phenotypes of obstructive sleep apnea: Clinical, sleep, and autonomic features of obstructive sleep apnea with and without hypoxia

OBJECTIVE The pathophysiological basis of obstructive sleep apnea (OSA) is not completely understood and likely varies among patients. In this regard, some patients with OSA do not exhibit hypoxemia. We aimed to analyze the clinical, sleep, and autonomic features of a group of patients with severe OSA without hypoxia (OSA-h) and compare to OSA patients with hypoxia (OSA+h) and controls. METHODS Fifty-six patients with OSA-h, 64 patients with OSA+h, and 44 control subjects were studied. Clinical and sleep features were analyzed. Besides, time- and frequency-domain heart rate variability (HRV) measures comprising the mean R-R interval, the standard deviation of the RR intervals (SDNN), the low frequency (LF) oscillations, the high frequency (HF) oscillations, and the LF/HF ratio, were calculated across sleep stages during a one-night polysomnography. RESULTS OSA-h patients had a lower body mass index, a lower waist circumference, lower apnea duration, and a higher frequency of previous naso-pharyngeal surgery when compared to OSA+h patients. In terms of heart rate variability, OSA+h had increased LF oscillations (i.e., baroreflex function) during N1-N2 and rapid eye movement (REM) sleep when compared to OSA-h and controls. Both OSA+h and OSA-h groups had decreased HF oscillations (i.e., vagal inputs) during N1-N2, N3 and REM sleep when compared to controls. The LF/HF ratio was increased during N1-N2 and REM sleep, only in patients with OSA+h. CONCLUSIONS Patients with OSA-h exhibit distinctive clinical, sleep, and autonomic features when compared to OSA with hypoxia. SIGNIFICANCE OSA is a heterogeneous entity. These differences must be taken into account in future studies when analyzing therapeutic approaches for sleep apnea patients.

Sound analysis of catathrenia: a vocal expiratory sound

PurposeCatathrenia (nocturnal groaning) is a rare and relatively little-understood parasomnia. The characteristics of the sound and the recordings are not similar in all the relevant research papers. Indeed, there is currently some discussion regarding whether or not this is a single entity. For some authors, catathrenia is a particular form of parasomnia; for others, it may be a variant of snoring or a respiratory problem. The goal is to establish whether or not catathrenia may be regarded as an expiratory vocal sound. An attempt was made to classify the origin of this sound according to its sound structure.MethodsWe present the sound analysis of two patients, a man and a woman, with clinically diagnosed catathrenia and we compared them with the analysis of snoring. We use the spectrogram and the oscillogram. We classified the sounds according to the Yanagihara criteria.ResultsThe vocal nature of the sound was confirmed, and several significant differences to some snoring sounds were discovered. The analysis of the catathrenia samples demonstrated that these signals are type II according to Yanagihara classification; these signals had a very short jitter, and had formants and harmonics. However, snoring is a type III, very irregular and had formants but not harmonics.ConclusionsThe oscillogram and the spectrogram in these patients show that the origins of the sounds are clearly different: catathrenia is laryngeal, while snoring is guttural. Catathrenia cannot be considered as expiratory snoring.

Catathrenia: respiratory disorder or parasomnia?

BACKGROUND The International Classification of Sleep Disorders-Third Edition (ICSD-3) classifies catathrenia among the respiratory disorders and not as a parasomnia as in ICSD-2. Few patients have been reported during these years, and the clinical description of the sound is different from group to group. In fact, there is no full agreement about its nature, origin, meaning, and treatment. METHODS AND RESULTS In this paper we review the literature on catathrenia focusing on the characteristics of the sound, demographics of the patients, aetiology, response to treatment, etc., in order to support its classification as a respiratory disorder or a parasomnia. We also discuss the possibility of Catathrenia being not one disorder but two variants or two different disorders.

Hyperfunctional Voice Disorder in Children With Attention Deficit Hyperactivity Disorder (ADHD). A Phenotypic Characteristic

OBJECTIVE The purpose of this study was to detect specific vocal aerodynamic patterns in attention deficit hyperactivity disorder (ADHD) patients and to define a possible new phenotypic feature of this disorder that must be diagnosed and treated. STUDY DESIGN This is a prospective study. METHODS Seventy-nine children aged 5-13 years were recruited: 44 children with ADHD diagnosis and 35 children, as a control group, matched according to age and gender. All children were evaluated in the voice laboratory. Each subject repeated sustained vowels, syllables, words, and sentences several times. Intraoral pressure, transglottal airflow, microphone, and electroglottograph results were recorded and analyzed. Children affected by ADHD, with adequate tolerance, were evaluated endoscopically and by the speech therapist. RESULTS The aerodynamic analysis shows that the subglottal pressure is higher and transglottal airflow is lower in ADHD children compared with the children of the control group. Those differences are statistically significant. The endoscopic physical examination showed vocal nodules in 25 children (78.125%) and hyperfunctional vocal behavior in all ADHD children studied. CONCLUSIONS We proposed that every child with ADHD disorder must be evaluated from a laryngeal point of view (otolaryngologist and speech therapist) as an important part of the diagnosis and global treatment. It could be considered as a new phenotypic characteristic of this disorder.

Pharyngo-laryngoscopic video-recording in obstructive sleep apnea during natural N2 sleep. A case report of a non-complete obstructive mechanism

OBJECTIVES This is a video case report of a 58-year-old male patient with severe obstructive sleep apnea (OSA) who underwent a pharyngo-laryngoscopy during non-drug-induced sleep. METHODS The pharyngo-laryngoscopy was performed transnasally during a 30-minute nap, in the afternoon, with a flexible endoscope in supine position. During the procedure, the patient was monitored with polysomnography. RESULTS The patient slept for 20 minutes in supine position, reaching N2 sleep stage. During the sleep, 15 respiratory events (apneas or hypopneas) were recorded. The video-recording showed that, during apneas, the obstruction at the pharyngeal level was never complete, although the nasal sensor showed a total stop in the nasal airflow. CONCLUSIONS This case highlights that OSA could not be as obstructive as generally thought, at least during N2 sleep; moreover, it suggests that apneic episodes are not a totally passive and monomorphic phenomenon, but a rather complex event.

Controlling the variability of air-pulses to determine the thresholds of laryngeal-pharyngeal reflexes using a novel device

Factors determining the variability of air-pulse pressure to determine the thresholds of laryngeal-pharyngeal reflexes, which are related to swallowing and airway protection, were explored. Potential factors affecting the reproducibility of air-pulses were experimentally evaluated and included in a multiple linear regression model. A novel device controlling these factors and minimizing variability was designed. Its reproducibility was assessed by the coefficient of variation (CV) of the pressures and duration of air-pulses, and its validity was assessed by comparing obtained pressures and durations with desired pressures and durations. Differences in the pressures of airpulse categories were assessed by a one-way ANOVA of repeated measures, a Tukey test and a box and whisker plot. The distance and angle between the exit of the tube conducting the pulses and the surface to be impacted, the diameter of the tube, the feeding pressure of the system, and the duration of air-pulses significantly affected the accuracy of air-pulses. The novel device incorporated electronic valves and a telemeter for use during the fiberoptic endoscopic evaluation of swallowing. The differences between the desired and obtained pressures and durations were below 3%. The CV of the air-pulse pressures of the novel device was 0.02. The CV of air-pulse duration was 0.05. The oneway ANOVA, Tukey test and box and whisker plot showed that the outlet pressures of air-pulse categories had statistically significant differences between them without overlap between categories, which helps to obtain an accurate threshold.

Stratus Relieva: Treatment for Chronic Rhinosinusitis

Objective: Patients with chronic rhinosinusitis resistant to systemic treatment have as an alternative endoscopic nasal surgery. The Relieva Stratus system has allowed local treatment in paranasal cavities, avoiding an aggressive surgery and high corticoesteroids systemic treatment. We describe our experience with the system in the first six patients. Method: Four patients suffering ethmoid and 2 with frontal chronic rhinosinusitis have been included. The Stratus catheter was implanted endoscopically under general anesthesia in combination with balloon sinuplasty technique for either the maxillary or the frontal sinus. Triamcinolone was used for local delivery. Stratus was removed in office 4 week later. Results: Stratus Relieva was implanted in patients with chronic inflammation of the ethmoid or frontal sinus. No major complications were observed. Four catheters were implanted in the ethmoid bulla and 2 in the frontal sinus. They were removed in office under local anesthesia. Intraoperaory bleeding was minimal. Patients described no foreign object sensation after surgery. We observed good evolution in all patients but one, in which Stratus Relieva was performed. This patient persisted with chronic inflammation of the maxillary and ethmoid sinus and functional endoscopy surgery was performed as alternative for definitive treatment. Conclusion: Results with this device are promising although longer observation period is needed. It is possible that the patient that did not show an improvement of disease may have not been an adequate candidate for this surgery. Therefore, we consider that appropriate selection of patients is necessary for a good outcome.

Muscle Tension Dysphonia: Which Laryngoscopic Features Can We Rely on for Diagnosis?

OBJECTIVES Muscle tension dysphonia (MTD) is generally diagnosed through clinical history and physical examination. Several diagnostic or classification systems exist, such as those of Van Lawrence, Morrison-Rammage, and Koufman, that delineate MTD and distinguish subtypes on the basis of laryngoscopic features. The aim of this study is to determine which of the clinical features included in these classifications are most related to the aerodynamic profile of MTD. STUDY DESIGN This is an analytic retrospective study. MATERIAL AND METHODS This study evaluates a series of 30 consecutive patients, all over 18 years old, who attended the voice clinic consult of our department and were diagnosed with MTD. All subjects underwent fiberoptic nasal endoscopy, acoustic voice assessment, and aerodynamic voice assessment. The study only includes patients with a pathological aerodynamic profile. Presence or absence of each laryngoscopic feature in the full range of features in the Van Lawrence, Morrison-Rammage, and Koufman classification systems was evaluated independently by three experts. Cohens kappa coefficient was calculated to indicate the degree of concordance between the experts. The chi-squared test was used to determine the degree of association between clinical features and mean value of the subglottic pressure peak (mmH2O). RESULTS Clinical parameters that were found to have a statistically significant association (P < 0.05) with an alteration in mean subglottic pressure peak were those related to anteroposterior and lateral compression of the larynx in Van Lawrence, Morrison-Rammage, and Koufman classification systems. CONCLUSIONS While several studies have sought to clarify the laryngoscopic features of MTD, the current study is the first to evaluate these features in subjects who have been objectively diagnosed by means of aerodynamic voice assessment. The laryngoscopic features most strongly related to an aerodynamic profile of MTD were anteroposterior compression of the larynx, lateral compression of the larynx, and vestibular fold contribution to phonation.