Daytime hypoventilation in obstructive sleep apnoea syndrome

Chronic alveolar hypoventilation is a classic feature of the "pickwickian syndrome" (i.e. obesity-hypoventilation syndrome) but in fact hypercapnia is observed in a minority of obstructive sleep apnoea syndrome (OSAS) patients. Most recent studies having included large numbers of unselected, consecutive OSAS patients agree on a prevalence of 10-20% of alveolar hypoventilation. The mechanisms of hypercapnia in OSAS are not fully understood but the determining factors of daytime respiratory insufficiency are probably the presence of a marked obesity, leading to the obesity hypoventilation syndrome and, principally, the association of OSAS with chronic obstructive pulmonary disease. This association (the so-called "overlap syndrome") is observed in >10% of OSAS patients. Bronchial obstruction is generally mild to moderate and may be asymptomatic. The severity of the nocturnal events (apnoeas, hypopnoeas) and a (possible) diminished chemosensitivity to hypercapnic and hypoxic stimuli do not appear to be determining factors of hypercapnia. The most important consequence of chronic alveolar hypoventilation is pulmonary hypertension which is only observed in patients with daytime arterial blood gases disturbances, and which can lead to right heart failure. When nasal continuous positive airway pressure fails to correct sleep-related hypoxaemia, supplementary O, must be given or another way of assisted ventilation (BIPAP) must be considered. In the most severe patients (diurnal PaO(2) <55 mmHg) conventional O(2) therapy (>or=16h/24h) is required in addition to nocturnal ventilation.

Prostatitis unplugged? Prostatic massage revisited

Repetitive prostatic massage is not a new tool in the urologists' armatarium. Once the most popular therapeutic maneuver used to treat prostatitis, it was abandoned as primary therapy almost 3 decades ago. Based on experience reported outside North America and anecdotal experiences of some patients and their physicians, it may be making a comeback. Unfortunately, there are almost no prospective data that would substantiate a claim as to its effectiveness. This article discusses the historic aspects of prostatic massage, suggests possible mechanisms of action, and describes the opinions of North American urologists who are associated with academic clinical research centers and are universally acknowledged as experts in the diagnosis and treatment of prostatitis. At this time, the science of prostatic massage must rely on anecdotal experiences, small, uncontrolled studies, and perhaps somewhat biased opinions of the major thought leaders in the field of chronic prostatitis/chronic pelvic pain syndrome.

Identification of a cyclic nucleotide- and voltage-activated ion channel from insect antennae

From an antennal cDNA library of Heliothis virescens a clone has been isolated encoding a polypeptide of 678 amino acids. Data base comparisons and primary structure analysis of the deduced protein sequence (HvCNG) indicated significant homology to cyclic nucleotide and voltage-activated ion channels including six putative membrane spanning domains, a putative cyclic nucleotide binding site, a pore region and a voltage-sensor motif. Heterologous expression of the cloned cDNA in Sf9 cells resulted in a polypeptide of the predicted molecular mass. Patch clamp analysis allowed to record the activity of the identified HvCNG channels; they were activated by cAMP but also by hyperpolarization. The channel displayed in potassium solution a conductance of 30 pS; the ion selectivity was calculated as PK/PNa approximately 3. Northern blot analysis revealed that the channel is highly expressed in the antennae; weaker signal were detected in heads and legs. In situ hybridization of tissue sections through the antennae showed a spatial distribution of reactive cells; they are located beneath sensillar hairs. Thus, a novel channel type has been identified which may play an important role in antennal cells.

Actigraphy and leg movements during sleep: a validation study

A study comparing actigraphy and polysomnography in the detection of leg movements was performed in a group of 35 patients with sleep disorders. Visual scoring used epochs of 5-second duration, and in each epoch, electromyographic activity of tibialis anterior muscle was classified in eight types on the basis of its duration and amplitude. Activity levels of the actigraphic data were logged in 5-second intervals and stored in memory for computer retrieval. To assess the reproducibility of actigraphic detection scoring, in 10 patients actigraphic and polysomnographic data were compared during two consecutive nights. Despite a high correlation between polysomnography and actigraphy in the detection of muscular activity (r = 0.78; P = 0.001), no agreement was obtained between the two analyses according to the Bland and Altman method of concordance (mean bias: -117.5). The greater agreement was found for electromyographic activity lasting more than 3 seconds and with an amplitude of more than 50 microV. In the group of patients examined during two consecutive nights the scoring error did not differ significantly. The results demonstrated that (1) despite a significant correlation between actigraphic and polysomnographic data, actigraphy substantially underestimated leg electromyographic activity and therefore could not be used routinely for diagnostic purposes; and (2) because error scoring did not undergo significant changes across the two nights, actigraphy may be used for follow-up evaluation.

Selective activation of G protein subtypes in the vomeronasal organ upon stimulation with urine-derived compounds

Chemosensory neurons in the vomeronasal organ (VNO) detect pheromones related to social and reproductive behavior in most terrestrial vertebrates. Current evidence indicate that the chemoelectrical transduction process is mediated by G protein-coupled second messenger cascades. In the present study, attempts were made to identify the G protein subtypes which are activated upon stimulation with urinary pheromonal components. G protein-specific antibodies were employed to interfere specifically with inositol 1,3,4-trisphosphate formation induced by urinary stimuli and to immunoprecipitate Galpha-subunits, activation dependently labeled with [alpha-32P]GTP azidoanilide. The results of both experimental approaches indicate that stimulation of female VNO membrane preparations with male urine samples induces activation of Gi as well as Go subtypes. Experiments using different fractions of urine revealed that upon stimulation with lipophilic volatile odorants, only Gi proteins were activated, whereas Go activation was elicited by alpha2u-globulin, a major urinary protein, which is a member of the lipocalin superfamily. Since each G protein subtype is stereotypically coexpressed with one of the two structurally different candidate pheromone receptors (V1R and V2R), the results provide the first experimental evidence that V1Rs coexpressed with Gi may be activated by lipophilic probably volatile odorants, whereas V2Rs coexpressed with Go seem to be specialized to interact with pheromonal components of proteinaceous nature.

Arousal threshold to respiratory stimuli in OSA patients: evidence for a sleep-dependent temporal rhythm

It has recently been described that the maximal respiratory effort developed at the end of an apnea (Pesmax)--which is regarded as an index of arousal threshold in patients with obstructive sleep apnea syndrome (OSA)--increases progressively during the night, probably as a consequence of associated sleep fragmentation. In order to find out whether the nocturnal trend of Pesmax may be more influenced by a sleep-dependent circadian rhythm than by sleep fragmentation, we revised the polygraphic recordings of 37 patients in whom obstructive apneas were recorded for at least 7 hours. In 15 of these patients, analysis was made for eight hours of the night. During each hour we analyzed at least 7 obstructive apneas, in which we measured the minimal esophageal pressure at the start of the apnea, the maximum value recorded at the end of the apnea (Pesmax), the difference from the minimum to the maximum (delta Pes), and the rate of increase in esophageal pressure (RPes). As indices of sleep fragmentation, we defined the number of arousals, awakenings and sleep state transitions. In the group of patients as a whole, we found a trend toward a gradual increase for apnea duration (F = 98.8, p < 0.001) and Pesmax F = 31.6, p < 0.001) which was significant from the first to the last hour. The time-dependent evolution of apnea duration and Pesmax showed that the rise in these two variables peaked during the first 3 hours of sleep, followed by a plateau and a decrease in the last hour of the night. This temporal profile was more evident when the analysis was available for 8 hours. No significant changes across the night were found for nocturnal hypoxemia and number of arousals. Considering the slope of Pesmax changes across the night, we saw that neither the apnea+hypopnea index nor the indices of sleep fragmentation affected the nocturnal trend. The present data demonstrate the presence of a nocturnal trend in arousal threshold in OSA patients independent of sleep fragmentation. The biphasic evolution of the arousal threshold may be caused by factors that influence the circadian and homeostatic processes.

Pharyngeal critical pressure in patients with obstructive sleep apnea syndrome. Clinical implications

Current evidence suggests that patients with obstructive sleep apnea (OSA) may have greater pharyngeal critical pressure (Pcrit), which reflects the increase in upper airway collapsibility. The contribution of Pcrit to the severity of OSA and to the efficacious continuous positive pressure (nCPAPeff) therapy has never been extensively described and no data are available about the interaction of Pcrit, age, and anthropometric variables. To determine the relationship between Pcrit, severity of the disease, nCPAPeff, and anthropometric variables we measured Pcrit in a group of 106 patients with OSA. Pharyngeal critical pressure was derived from the relationship between maximal inspiratory flow and nasal pressure, Pcrit representing the extrapolated pressure at zero flow. Upper airway resistance (Rus) was determined as the reciprocal of the slope (DeltaPn/DeltaVImax cm H2O/L/s) in the regression equation. In a subgroup of 68 patients, during the diagnostic night, we measured as indices of respiratory effort, the maximal inspiratory esophageal pressure (Pes) at the end of apnea (Pesmax), the overall increase from the minimum to the maximum (DeltaPes), and the rate of increase of Pes during apnea (RPes). As a group, the mean Pcrit was 2.09 +/- 0.1 cm H2O (range, 0 to 4.5) and the mean Rus was 11.1 +/- 0.5 cm H2O/L/s. Although men have greater Pcrit, pharyngeal collapsibility was influenced neither by neck size nor by body mass index (BMI). Although there was a significant relationship between Pcrit and apnea plus hypopnea index (AHI) (r = 0.23, p = 0.02), neck circumference was the stronger predictor of apnea frequency, with Pcrit contributing only to the 3% of the variance. In the group of patients as a whole, a model including AHI, BMI, Rus, and Pcrit explained the 36% of the variance in nCPAPeff, with a greater contribution of AHI, Pcrit accounting for only 3% of the variation. In patients for whom the measure of respiratory effort was obtained, 42% of the variance in nCPAPeff was explained by RPes (33%) and BMI. From these results we conclude that Pcrit alone does not yield a diagnostically accurate estimation of OSA severity and nCPAPeff. Although individual collapsibility may predispose to pharyngeal collapse, upper airway occlusion may require the combination of several factors, including obesity, upper airway structure, and abnormalities in muscle control.

In vivo migration and function of transferred HIV-1-specific cytotoxic T cells

The persistence of HIV replication in infected individuals may reflect an inadequate host HIV-specific CD8+ cytotoxic T lymphocyte (CTL) response. The functional activity of HIV-specific CTLs and the ability of these effector cells to migrate in vivo to sites of infection was directly assessed by expanding autologous HIV-1 Gag-specific CD8+ CTL clones in vitro and adoptively transferring these CTLs to HIV-infected individuals. The transferred CTLs retained lytic function in vivo, accumulated adjacent to HIV-infected cells in lymph nodes and transiently reduced the levels of circulating productively infected CD4+ T cells. These results provide direct evidence that HIV-specific CTLs target sites of HIV replication and mediate antiviral activity, and indicate that the development of immunotherapeutic approaches to sustain a strong CTL response to HIV may be a useful adjunct to treatment of HIV infection.

[Short-duration nocturnal hypoxemia and persistent pulmonary hypertension]

Can daily short-duration hypoxemia (4-8 hours) induce pulmonary hypertension and right ventricular hypertrophy? A clinical model of this type of hypoxemia does exist: isolated nocturnal hypoxemia in patients with obstructive sleep apnea syndrome (OSAS) or chronic obstructive pulmonary disease (COPD). By investigating the pulmonary hemodynamics of these patients, it should be possible to determine whether nocturnal hypoxemia alone can induce pulmonary hypertension. Although nocturnal hypoxemia (in OSAS as well as in COPD) can induce acute episodes of pulmonary hypertension, it would not appear that nocturnal hypoxemia alone would be sufficient to provoke permanent diurnal pulmonary hypertension. This is the conclusion of recent studies concerning diurnal pulmonary hemodynamics in OSAS and COPD patients exhibiting minimal hypoxemia during the day but significant nocturnal desaturation. The therapeutic consequences of these data, particularly in COPD are important: current evidence is insufficient to treat with nocturnal oxygen therapy COPD patients who have minimal diurnal hypoxemia but significant nocturnal desaturation.

[Starling resister and stability of sleep ventilation]

The upper airway can be described as a collapsible segment (the pharynx) interposed between two rigid bony (the cavum) or cartilaginous (the trachea) segments. Due to this structure, the pharynx behaves as a collapsible tube, in which airflow does not depend on the downstream pressure, but is limited to a maximum value which depends only on the upstream pressure and on the pressure surrounding the collapsible segment; this behavior, known as a Starling resistor can be modeled by the waterfall effect. Thus, the upper airways can be in three different conditions: an occluded condition, in which no flow is possible, a patent condition, in which flow depends on the difference between upstream and downstream pressures (according to Poiseuille's law), and a situation in which flow is limited. The behavior of the upper airway is largely dependent on its anatomic structure, but functional factors play a critical role. Among these sleep state is both a determinant of the collapsibility of the pharynx, and determined by the simulation of upper airway mechanoreceptors whose activity depends on the activity of respiratory muscles. Thus the interplay of three factors: ventilatory drive, upper airway collapsibility, and arousal threshold can predict most of the situations of stable and unstable ventilatory behavior during sleep. The level of the arousal threshold governs the stability of the ventilatory pattern, as it determines whether a combination of slow, respiratory effort, and blood gases can be maintained or is interrupted by an arousal.

Nocturnal evolution of respiratory effort in obstructive sleep apnoea syndrome: influence on arousal threshold

It has been recently described that the overnight increase in maximal end-apnoeic oesophageal pressure (P(oes,max)), considered as an index of the arousal threshold to occlusion, mostly contributes to apnoea lengthening during the night. However, the rise in apnoea duration could also be caused by changes in hypoxaemia, chemosensitivity and upper airway resistance. To better define the relative contributions of each of these factors, we examined the recordings of nine patients. Before apnoea, the mean pulmonary resistance at peak inspiratory flow (RPIF) was computed. During apnoea, all swings in oesophageal pressure (P(oes)) were measured to define the P(oes,max), the increase from the minimum to the maximum (deltaP(oes)), the rate of increase in P(oes) (RP(oes)) and the P(oes) at the first occluded breath (P(oes,1)). A gradual and significant increase in apnoea duration (p=0.02), P(oes,max) (p=0.02) and deltaP(oes) (p=0.006) was present across the night without any changes in oxygen saturation, RPIF, and P(oes,1). The slope of increase in P(oes,max), apnoea duration and deltaP(oes) was correlated with the apnoea/hypopnoea index. We conclude that in obstructive sleep apnoea, the nocturnal rise in apnoea duration is attributable more to an increase in the arousal threshold related to apnoea recurrence than to changes in chemosensitivity and upper airway resistance.

Expression and functional analysis of olfactory receptors

The olfactory system recognizes and discriminates myriads of odorants of diverse molecular structure. This task is supposed to be accomplished by a large array of seven-transmembrane domain receptors encoded by a multigene family. Although circumstantial evidence suggests that the identified genes encode odorant receptors, unequivocal proof requires demonstration that the resulting proteins should be able to interact with odorous molecules and couple via G proteins onto second messenger cascades. This goal can be achieved by heterologous expression of receptor proteins in surrogate eucaryotic cells, although the task is complicated by the diversity of putative odorous ligands and the large size of the receptor family. Employing the baculovirus/Sf9 cell system it was found that receptor proteins can be expressed at high levels. Stimulating receptor-expressing Sf9 cells with a mixture of numerous odorous compounds elicited a significant and dose-dependent second messenger response, which was never observed in control cells. Assaying a large panel of odorous compounds, including representatives of different odor classes and compounds of different chemical classes revealed that distinct receptor subtypes respond to certain odorants but not to others. Graded responses to only a subset of odorants indicate that the heterologous expressed receptor types have a selective but relatively broad ligand specificity. The easily manipulated bacterial system was employed to produce olfactory receptor proteins in large quantities. It was solubilized from inclusion bodies and upon reconstitution in liposomes displayed specific interaction with odor ligands.

[Hypersomnia. Investigational strategy for evaluating hypersomnia]

CLINIC AND HISTORY: Expression of hypersomnia can take on several forms: long period of nocturnal sleep, excessive diurnal somnolence or both. History taking is essential. Useful tools include standardized questionnaires and a diary of sleeping habits. Not only do they provide evidence of the hypersomnia, but also information on possible eccentric origin(s). A pathological hypothesis can then be put forward: sleep apnea syndrome, narcolepsy, idiopathic hypersomnia, or periodic movements during sleep. POLYGRAPHY: Different recording protocols have been designed to determine sleep patterns, often depending on the clinical setting. The goal is to obtain an objective confirmation of hypersomnia and demonstrate a cause. The type of recording (hour and duration of the recording, parameters monitored) depends on the information desired. Because captors themselves sometimes perturb sleep, polygraphic explorations must be adapted to each individual situation.

Simplified diagnostic procedure for obstructive sleep apnoea syndrome: lower subsequent compliance with CPAP

The aim of this study was to investigate whether a simplified diagnostic procedure based on ambulatory monitoring with MESAM IV altered subsequent compliance with continuous positive airway pressure (CPAP) in obstructive sleep apnoea (OSA) patients. During a period of 16 months, 60 patients with symptoms evocative of OSA and positive MESAM recording were prescribed CPAP after titration with standard polysomnography. Compliance was followed during 2 yrs based on built-in time counters and was compared with the compliance in two comparison groups: an equal number of equally severely affected patients diagnosed with standard polysomnography during the 18 months (8 months before and 8 months after) preceding and following the study period and a group of 48 patients with an estimated similar apnoea/hypopnoea index but less typical clinical and/or MESAM features, diagnosed as having OSA based on polysomnography during the study period. The three groups were not different by age, body mass index, or sleepiness score. Patients diagnosed with the ambulatory procedure had higher drop-out rates (21.7% versus 10% and 6.25%; p<0.05) and lower rates of use of their CPAP (43+/-0.3 h x night(-1)) than any of the control groups (53+/-0.2 and 5.6+/-0.2 h x night(-1), p<0.05). In conclusion, there is a risk that ambulatory diagnostic procedures alter the relationship of patients to their disease and/or the medical staff so that subsequent compliance with treatment may be decreased. The greatest care concerning compliance should be taken before an ambulatory-based diagnostic procedure is implemented.

New frontiers in the management of obstructive sleep apnoea syndrome

This paper is the text of a talk given at the European Respiratory Society meeting in Berlin in September 1997 in a symposium organized by the Sleep Disorders Working Group. It covers new treatments for obstructive sleep apnoea which are not established as standard treatments. Although postural treatment was proposed a long time ago, few studies have investigated its efficacy in clinical practice. However, in view of the data concerning postural sleep apnoea, it certainly deserves more consideration. Oral appliances appear to have become more popular as an alternative to continuous positive airway pressure (CPAP) when surgery is not desired or not desirable. A few controlled studies have been undertaken to establish its efficacy, which is less constant and less predictable than with CPAP. Other experimental approaches include nerve and muscle stimulation, for which preliminary results are promising. In the area of drug treatment, there is nothing new. Finally, the questions of what to do when treatment does not work and who should receive treatment are addressed.

Subtypes of odorant-binding proteins--heterologous expression and ligand binding

Odorant-binding proteins (OBP) in the mucus of the olfactory epithelium are thought to transfer the hydrophobic odorous compounds through the aqueous barrier towards the chemo-sensory cells. To evaluate their binding properties, two distinct OBP subtypes of the rat were expressed as N-terminal His-tagged fusion proteins in Escherichia coli, thus allowing an efficient purification. Based on gel chromatography and CD spectroscopy analysis the recombinant OBP subtypes seem to share several structural features with other members of the lipocalin family. Approaches to elucidate whether heterologous expressed OBPs interact with odorous compounds revealed that OBP1 specifically binds 2-[3H]-isobutyl-3-methoxypyrazine whereas OBP2 did not shown any specific binding to this compound. In contrast, the chromophore 1-anilinonaphthalene 8-sulfonic acid (1,8-ANS) specifically interacted with OBP2 but not with OBP1. Displacement experiments monitored by the relative fluorescence intensity revealed that fatty acids with appropriate chain length act as efficient competitors. Some odorous compounds, notably lilial (p-tert-butyl-alpha-methyl dihydrocinnamic aldehyde) and citralva (3,7-dimethyl-2,6-octadienenitrile), also displaced efficiently the chromophore, whereas pyrazine derivatives including 2-isobutyl-3-methoxypyrazine and other odorants did not. These results indicate that rat OBPs have distinct ligand specificities.

Cloning and expression of odorant-binding proteins Ia and Ib from mouse nasal tissue

We had previously reported the purification and partial characterisation of four distinct odorant-binding proteins from male mouse nasal epithelium. One of these, named OBP-I appeared to be a heterodimer, whose subunits, Ia and Ib showed significant similarity in their N-terminal amino acid sequences with hamster aphrodisin. In this paper, we report the complete amino acid sequences of these two polypeptide chains, as deduced from nucleotide sequences of their relative cDNA. These data confirm the high similarity of both proteins with hamster aphrodisin. A comparison with the sequences of other known OBPs indicate that they are more closely related to members of class I, including bovine OBP, rat OBP-I and pig OBP-I. A putative odorant-binding site is indicated by the presence of amino acid residues conserved with respect to the bovine protein, whose three-dimensional structure has been recently resolved. In-situ hybridisation has revealed identical expression patterns for the two proteins, further supporting the heterodimeric structure of these proteins in the nasal mucus.

Time course of pulmonary artery pressure during sleep in sleep apnoea syndrome: role of recurrent apnoeas

Recent results in animals have suggested that repetition of hypoxaemic stimuli may result in a progressive increase in pulmonary arterial pressure (Ppa). The purpose of the present study was to investigate the effects of recurrent obstructive apnoeas on Ppa. We have, therefore, examined the nocturnal trend of Ppa in seven obstructive sleep apnoea syndrome (OSAS) patients and in five snorers. Mean Ppa was measured before, at the start, at the end and after the selected apnoeas. The analysis was performed for each 1 h period for at least 7 h throughout the night on at least 10 randomly selected apnoeas per hour. In snorers, 100 randomly chosen values were measured during every hour of the night. In the morning after the nocturnal study, the Ppa responses to acute hypoxia and hypercapnia were measured. No Ppa changes throughout the 7 h were found during sleep in snorers [Ppa slope:-0.002+/-0.10 mmHg x h(-1)]. In OSAS patients a small but significant increase in Ppa throughout the night was noted, affecting the values before [Ppa slope: 0.7+/-0.16 mmHg x h(-1)], at the start of apnoea [Ppa slope: 0.530.1 mmHg x h(-1)] as well as at the end [Ppa slope: 0.44+/-0.08 mmHg x h(-1)] and in the postapnoeic period [Ppa slope: 0.55+/-0.1 mmHg x h(-1)]. When we limited the analysis to nonrapid eye movement (NREM) sleep, a trend in progressive Ppa was also present, irrespective of changes in apnoea duration and apnoea desaturation. The Ppa rise during the night was not affected by diurnal Ppa pulmonary vascular response to hypoxia and hypercapnia or indices of sleep apnoea severity. We conclude that in obstructive sleep apnoea, pulmonary artery pressure progressively increases during the night, reflecting the cumulative effects of apnoeas and nocturnal hypoxaemia.