Tapani Salmi

Early signs of critical illness polyneuropathy in ICU patients with systemic inflammatory response syndrome or sepsis

Abstract Objective: To evaluate with electromyography the incidence and the time of appearance of neuromuscular abnormality in patients with systemic inflammatory response syndrome (SIRS) and/or sepsis. Design: Follow-up study. Setting: Intensive care unit of Helsinki University Hospital, Finland. Patients: Nine mechanically ventilated patients with SIRS and/or sepsis. Interventions: Electromyography and conduction velocity measurements on the 2nd–5th day after admission to the intensive care unit. Measurements and results: In all nine patients electromyography revealed signs of neuromuscular abnormality. The means of compound muscle action potential amplitudes of the median and ulnar nerves were decreased. Fibrillation was observed in four patients out of nine. Conclusion: Because neuromuscular abnormalities seem to develop earlier than previously reported, electroneuromyography should be used more frequently as a diagnostic test.

Hypothermia-treated cardiac arrest patients with good neurological outcome differ early in quantitative variables of EEG suppression and epileptiform activity.

Objective:To evaluate electroencephalogram-derived quantitative variables after out-of-hospital cardiac arrest. Design:Prospective study. Setting:University hospital intensive care unit. Patients:Thirty comatose adult patients resuscitated from a witnessed out-of-hospital ventricular fibrillation cardiac arrest and treated with induced hypothermia (33°C) for 24 hrs. Interventions:None. Measurements and Main Results:Electroencephalography was registered from the arrival at the intensive care unit until the patient was extubated or transferred to the ward, or 5 days had elapsed from cardiac arrest. Burst-suppression ratio, response entropy, state entropy, and wavelet subband entropy were derived. Serum neuron-specific enolase and protein 100B were measured. The Pulsatility Index of Transcranial Doppler Ultrasonography was used to estimate cerebral blood flow velocity. The Glasgow-Pittsburgh Cerebral Performance Categories was used to assess the neurologic outcome during 6 mos after cardiac arrest. Twenty patients had Cerebral Performance Categories of 1 to 2, one patient had a Cerebral Performance Categories of 3, and nine patients had died (Cerebral Performance Categories of 5). Burst-suppression ratio, response entropy, and state entropy already differed between good (Cerebral Performance Categories 1–2) and poor (Cerebral Performance Categories 3–5) outcome groups (p = .011, p = .011, p = .008) during the first 24 hrs after cardiac arrest. Wavelet subband entropy was higher in the good outcome group between 24 and 48 hrs after cardiac arrest (p = .050). All patients with status epilepticus died, and their wavelet subband entropy values were lower (p = .022). Protein 100B was lower in the good outcome group on arrival at ICU (p = .010). After hypothermia treatment, neuron-specific enolase and protein 100B values were lower (p = .002 for both) in the good outcome group. The Pulsatility Index was also lower in the good outcome group (p = .004). Conclusions:Quantitative electroencephalographic variables may be used to differentiate patients with good neurologic outcomes from those with poor outcomes after out-of-hospital cardiac arrest. The predictive values need to be determined in a larger, separate group of patients.

Periodic breathing and hypoxia in snorers and controls: validation of snoring history and association with blood pressure and obesity

Abstract Fifty‐two men (aged 41–50 years) of whom 25 reported habitual and 27 of occasional or never snoring were examined clinically. Whole‐night sleep recordings of body and breathing movements, snoring and blood oxygen saturation were made. Hypoxic events exceeding 4% from the baseline were counted. Ninety‐three percent of those classified snorers by the recordings were habitual or occasional snorers, but 50% of those similarly classified non‐snorers had reported habitual or occasional snoring. Four habitual snorers had abnormal breathing indices and polysomnography established obstructive sleep apnea syndrome (OSAS) in one. Thus, self‐reported habitual snoring is a reliable OSAS‐screening method. Estimated prevalence of OSAS based on this study is 0.4–1.4%. In multivariate regression analysis, the hypoxic events were explained by obesity and apneic events. The diastolic blood pressure level was best explained by obesity, but not by hypoxic or apneic events or snoring history.

Primary Sphincter Repair: Are the Results of the Operation Good Enough?

PURPOSE: This study was designed to evaluate the clinical outcome of primary anal sphincter repair caused by obstetric tears and to analyze possible risk factors associated with sphincter rupture during vaginal delivery. METHODS: A total of 52 females with a third-degree or fourth-degree perineal laceration during vaginal delivery were examined. The symptoms of anal incontinence were obtained by a standard questionnaire. In addition to a clinical examination, endoanal ultrasound, anal manometry, and pudendal nerve terminal motor latency examinations were performed. A control group consisted of 51 primiparous females with no clinically detectable perineal laceration after vaginal delivery. RESULTS: After primary sphincter repair, 31 females (61 percent) had symptoms of anal incontinence. Fecal incontinence occurred in 10 females (20 percent). According to Hardcastle and Parks’ and Jorge and Wexner’s classifications, the study group had more severe symptoms of anal incontinence than the control group (P < 0.001 in both classification groups). In endoanal ultrasound examination, a persistent defect of the external anal sphincter was found in 39 females (75 percent) in the rupture group compared with 10 females (20 percent) in the control group (P < 0.001). Anal sphincter pressures were significantly lower in the rupture group than in the control group. An abnormal presentation was the only risk factor for anal sphincter rupture during vaginal delivery. CONCLUSIONS: After primary sphincter repair, persistent external anal sphincter defect and symptoms of anal incontinence are common in females who have had a primary sphincter repair after vaginal delivery. The means of improving the results of primary repair should be studied further.

Nasal obstruction and sleep-disordered breathing: the effect of supine body position on nasal measurements in snorers.

Objective --Nasal obstruction is considered to be a potential etiological factor in sleep-disordered breathing. However, a significant correlation between nasal measurements and obstructive sleep apnea has not been demonstrated so far. The aim of this study was to investigate the relationships between nasal resistance, nasal volumes and selected sleep parameters using nasal measurements performed in both seated and supine positions. We also investigated whether snoring patients in our clinical sample showed increased positional or decongestive nasal mucosal changes. Material and Methods --Forty-one snoring men on a waiting list for correction of nasal obstruction underwent polysomnography, anterior rhinomanometry and acoustic rhinometry. Nineteen non-snoring control subjects were also recruited. Nasal measurements were performed in a seated position, after lying down in a supine position and, after decongestion of nasal mucosa, in a seated position again. Results --In the overall patient group, nasal volume at a distance 2-4 cm from the nares in the supine position correlated inversely with apnea-hypopnea index (AHI) ( r = m 0.32, p <0.05) and oxygen desaturation index (ODI) ( r = m 0.49, p <0.05). In the non-obese patients, total nasal resistance measured in a supine position correlated with AHI ( r =0.50, p <0.05) and ODI ( r =0.58, p <0.05) and supine nasal volumes were also inversely correlated with ODI. No significant correlations were found between baseline nasal measurements performed in a seated position and sleep parameters. Postural or decongestive changes in nasal measurements were not increased in snoring patients compared with control subjects. Conclusion --The relationship found between nasal measurements and sleep parameters suggests that nasal obstruction does augment airway collapse.

Snoring and Cardiovascular Risk Factors

The association of snoring with some cardiovascular risk factors was studied cross-sectionally by a postal survey among 3750 males aged 40-59 years. In univariate analyses, snoring associated statistically significantly (P < 0.01) with hypertension, smoking, obesity, heavy alcohol use, physical inactivity, dyspnoea, hostility and morning tiredness. In a multiple logistic regression model adjusted by age, snoring associated significantly with smoking, obesity, physical inactivity, hostility and morning tiredness. When smoking was excluded from the multivariate model, alcohol use was also associated significantly with snoring. The association of snoring with smoking, and with obesity seemed to be almost independent from other studied correlates of snoring. Our results indicate that in further studies on predictive value of snoring with regard to coronary heart disease and stroke, the associations of snoring with hypertension, smoking, obesity, heavy alcohol use, physical inactivity and hostility have to be considered, as these risk characteristics may cause confounding effects.

Automatic analysis of static charge sensitive bed (SCSB) recordings in the evaluation of sleep-related apneas

Abstract An automatic analysis of Static Charge Sensitive Bed (SCSB) recordings was evaluated in the detecting periodic apneas during sleep. The results of over‐night SCSB recordings, on body movements and respiratory movements, were compared with the visually evaluated polygraphic recordings during daytime sleep. Twenty‐one patients with obstructive sleep apnea syndrome and 18 controls were studied. The periodic breathing pattern seen in all daytime recordings, was also seen in all output graphs of the over‐night SCSB analyses. The automatic analyses revealed periodic breathing in 2 control subjects. The amount was, however, small (less than 4% of the recording time) compared with the high amount observed in the patients with obstructive sleep apneas (mean 42.9% of the recording time). The high sensitivity, easy use, and low cost of the automatic SCSB method make it suitable for the quantification of the periodic breathing during night and for the screening of sleep apneas.

Quantitative electroencephalographic measures in homicidal men with antisocial personality disorder

Many symptoms of antisocial personality disorder have been proposed to be related to decreased daytime vigilance. To explore this hypothesis, quantitative analyses were conducted of the electroencephalographic (EEG) activity of drug-free and detoxified homicidal male offenders with antisocial personality disorder as the primary diagnosis. Subjects comprised 16 men recruited from a forensic psychiatric examination in a special ward of a university psychiatric hospital. Fifteen healthy age- and gender-matched controls with no criminal record or history of physical violence consisted of hospital staff and students. An overall reduction of alpha power was observed in the waking EEG of offenders. A bilateral increase in occipital delta and theta power was also found in these individuals. This study provides further support to the growing evidence of brain dysfunction in severe aggressive behavior. Homicidal offenders with antisocial personality disorder seem to have difficulties in maintaining normal daytime arousal. Decreased vigilance, together with social and psychological variables, may explain their aberrant behavior in everyday life. New studies are, however, needed to specify the vigilance problems of this patient group.

Delayed sphincter repair for obstetric ruptures: Analysis of failure

Objective  The aim of this study was to examine the clinical results after anterior anal sphincter repair in patients with obstetric trauma and to evaluate possible risk factors for poor outcome.

Spontaneous Hemodynamic Oscillations during Human Sleep and Sleep Stage Transitions Characterized with Near-Infrared Spectroscopy

Understanding the interaction between the nervous system and cerebral vasculature is fundamental to forming a complete picture of the neurophysiology of sleep and its role in maintaining physiological homeostasis. However, the intrinsic hemodynamics of slow-wave sleep (SWS) are still poorly known. We carried out 30 all-night sleep measurements with combined near-infrared spectroscopy (NIRS) and polysomnography to investigate spontaneous hemodynamic behavior in SWS compared to light (LS) and rapid-eye-movement sleep (REM). In particular, we concentrated on slow oscillations (3–150 mHz) in oxy- and deoxyhemoglobin concentrations, heart rate, arterial oxygen saturation, and the pulsation amplitude of the photoplethysmographic signal. We also analyzed the behavior of these variables during sleep stage transitions. The results indicate that slow spontaneous cortical and systemic hemodynamic activity is reduced in SWS compared to LS, REM, and wakefulness. This behavior may be explained by neuronal synchronization observed in electrophysiological studies of SWS and a reduction in autonomic nervous system activity. Also, sleep stage transitions are asymmetric, so that the SWS-to-LS and LS-to-REM transitions, which are associated with an increase in the complexity of cortical electrophysiological activity, are characterized by more dramatic hemodynamic changes than the opposite transitions. Thus, it appears that while the onset of SWS and termination of REM occur only as gradual processes over time, the termination of SWS and onset of REM may be triggered more abruptly by a particular physiological event or condition. The results suggest that scalp hemodynamic changes should be considered alongside cortical hemodynamic changes in NIRS sleep studies to assess the interaction between the autonomic and central nervous systems.