Sleep disorders include sleep disturbance and sleep-disordered breathing (SDB). Especially, SDB has been gathering much attention as sleep apnea syndrome (SAS) in clinical physicians last three decades. SAS is characterized with heavy snoring, excessive daytime sleepiness, and obesity. Pathophysiology of SAS is repeated obstructions of upper airway (pharyngeal sites) during sleep, so that marked hypoxemia and arousals occur. When SAS is severe and hypoxemia continues for long time, cardiovascular systems are much affected. Recent studies demonstrate that SAS is directly associated with hypertension, stroke, cardiac failure, and cardiac death. Another important clinical problem in patients with SAS is excessive daytime sleepiness that occurs due to repeated arousals during sleep. It has been reported that patients with SAS have more traffic car accidents. SAS impairs not only physical conditions but also mental and social conditions. Sleep disturbances, such as sleep loss, insomnia, and hypersomnia are also major health problem. Recent epidemiological studies demonstrated that sleep disturbances are common in general population. To understand the pathophysiology, diagnosis and treatment of sleep disturbances are clinically important and useful for general physicians.
Sleep disturbance is a risk factor for various physical and mental disorders, and also for industrial and traffic accidents. Therefore, sleep disturbance is considered to be a serious public health issue. Nationwide epidemiological studies of sleep have been conducted in various countries using samples representative of the general population. In Japan, epidemiological sleep study has been increasing in recent years. The accumulated epidemiological evidence of Japanese sleep behavior or sleep disturbances are as follows: (1) sleep duration gradually became shortened, (2) being female, of younger age, living in an urban environment, unemployed, and having an unhealthy lifestyle were associated with short sleep duration, (3) sleep duration exhibited a U-shaped association with symptoms of depression, (4) sleep duration is closely associated with glucose intolerance and dyslipidemia, (5) the prevalence of insomnia among the adult population was 21.4%, (6) the prevalence of excessive daytime sleepiness among the adult population was 15%, (7) excessive daytime sleepiness is associated with disagreeable sensations in the legs and interruption of sleep by snoring or dyspnea, (8) sleep duration of the Japanese adult population is shorter than that of Europeans, and (9) the prevalence of insomnia among adolescents was 23.5%. These epidemiological findings will contribute toward the development of health promotion activities in the future. Further epidemiological studies are required to clarify the sleep characteristics of the Japanese population.
Epidemiologic studies have clearly shown that sleep problems are common in the general population. A survey, conducted in Japan, reported that 21.4% of adults had complaints of insomnia and that 14.9% complained of hypersomnia (excessive daytime sleepiness). In the primary care setting, however, few patients present with overt sleep complaints but rather generally present with symptoms of fatigue, excessive sleepiness, and impaired waking. Therefore, it is important for physicians to understand how to differentiate and manage the sleep complaints of the patient. Herein, the author reviewed the clinical management of insomnia and hypersomnia, together with recent pathophysiological findings on these disorders. Insomnia is currently defined as an inability to obtain an adequate amount of sleep, to feel restored and refreshed in the morning, and to function adequately in the daytime. The differential diagnosis of difficulty in sleeping includes psychophysiological, neurological and circadian causes. Pharmacological and non-pharmacological interventions are combined in the treatment of insomnia. Sleep deprivation is the most frequent cause of excessive daytime sleepiness. Narcolepsy is the most prevalent type of hypersomnia with sleep attack and cataplexy. Recent studies have indicated the pathogenetic importance of orexin/hypocretin (a peptide hormone produced in the lateral hypothalamus) dysfunction in narcolepsy.
Considerable progress has been made in both the basic research and clinical areas over the last several decades in our understanding of the pathogenesis of obstructive sleep apnea-hypopnea syndrome (OSAHS). This brief review highlights the potential mechanisms of repetitive collapse of the pharyngeal airway during sleep in patients with OSAHS.
Polysomnography (PSG) is the single most important laboratory technique for the assessment of sleep and its disorders. In addition, portable monitoring (PM) using a limited number of bioparameters has been proposed as an alternative to PSG in the diagnosis of sleep apnea. This paper focuses on the different approaches in the diagnosis of sleep disorders.
Continuous positive airway pressure (CPAP) is the treatment of choice for patients with moderate-to-severe obstructive sleep apnea (OSA). CPAP can effectively reduce the risk of cardiovascular events and improve both sleep quality and quality of life in OSA. Our goal is to highlight some important concepts and recent developments that may be relevant to CPAP treatment in OSA.
In recent years, progress has been made in multidisciplinary investigations of sleep medicine, and many health disorders caused by respiratory disturbances during sleep, have been clarified. In sleep-disordered breathing (SDB), treatment for obstructive sleep apnea (OSA) has been evaluated scientifically, and guidelines have been provided. Oral Appliance (OA) therapy has been recognized as one treatment method that improves upper-airway obstruction of the pharyngeal region by its usage during sleep. However, this adaption is for cases of mild to moderate obstructive respiratory disturbances and an Apnea-Hypopnea Index AHI < 20 is determined by the dentist according to the doctors′ request while diagnosing obstructive sleep-disordered breathing, and regular dental management is required. OAs come in two types, mandibular repositioning appliances (MRA) and tongue retaining devices (TRD). MRA is distributed worldwide and is considered effective in improving airway obstruction during sleep. MRA is prepared by applying an Occlusal Splint in the treatment of temporomandibular disorders (TMD). MRA can improve depression of the root of the tongue and attempts to expand the upper airway by seeking an attachment source in the teeth, and pulling the lower jaw forward. Since OA therapy is noninvasive, has good compliance for continued use, is portable, and is covered by health insurance, distribution of this treatment method is expected to expand in future. Potential obstructive sleep apnea patients are said to number in the millions, even in Japan, and dentists will play an important role in the treatment and prevention of various health disorders caused by sleep-disordered breathing. However, coordination of medical department and dental department is considered to be essential.
Among sleep disorders of breathing (SDB), obstructive sleep apnea syndrome (OSAS) sometimes indicates the need for surgical treatment. Despite the use of uvulopalatopharyngoplasty (UPPP), which has been mainly utilized to date, it has become clear that diet control is also necessary to prevent recurrence of the symptoms. Other recent operative methods, including laser assisted uvulopalatoplasty (LAUP), radiofrequency volumetric tissue reduction (RFVTR), etc., have not yet revealed their detailed outcome and prognosis. However, the combined procedures of pharyngeal surgery and nasal surgery could be valuable. In order to achieve a better outcome, three points appear to be necessary for surgical strategy for OSAS; 1) To diagnose the precise obstructive portion and select appropriate cases for the indication to improve both the pharyngeal and nasal obstruction, 2) To reduce the body weight and maintain diet control, 3) To reduce the risk factors of surgical side effects and negative social medical factors.
In Japan, the incidence of breast cancer is increasing every year, and the necessity for breast reconstruction using silicone implants is thus increasing. Such reconstructions result in a foreign body response, with formation of a fibrous capsule and thickening, resulting in capsular contracture during shrinkage, which are often accompanied by marked transformation and pain. The mechanisms underlying this phenomenon are unclear, although one report has described decreased capsular contracture following the use of an implant with a processed surface displaying enhanced ruggedness. The present study examined whether capsular contracture would be decreased by changing the outer structure of the silicone implant. Smooth- and textured-type implants were implanted dorsally in rats. Gross and histopathological examinations (hematoxylin and eosin staining, Masson′s trichrome staining, transforming growth factor (TGF)-β -staining, a-smooth muscle actin (α-SMA) staining, and collagen I and III staining) were performed at weeks 1, 2, 4 and 8 after implantation to examine capsule thickness. The textured-type implant showed a thinner capsule than the smooth type at weeks 4 and 8. The fibrous layer of the capsule was particularly thin. Moreover, TGF-β-positive cells decreased gradually with the smooth-type implant, while TGF-β -positive cells remained evident upon histopathological examination of the textured-type implant. For textured-type implants, α-SMA-positive cells gradually decreased and type III collagen fibers predominated, while smooth-type implants showed a gradual increase in α-SMA-positive cells and a predominance of type I collagen fibers. Based on these findings, the characteristics of the capsule for textured implants with irregular surfaces can be summarized as follows: 1) during the early stage after implantation, stronger inflammatory reactions are induced compared with the smooth type, and because the inflammation becomes chronic, remodeling from type III collagen to type I collagen is decreased, resulting in a type III collagen-dominant capsule; and 2) as irregular structures buffer the tension applied to the capsule due to body movement, the degree of increase in α-SMA-positive cells is lower compared with the smooth type. As a result, a thin capsule that is less likely to contract is formed. These factors are mostly responsible for reducing capsular contracture for textured implants.
It is important to understand the definitive and stereotaxic vascular anatomy of the external carotid artery (ECA) in order to apply effective and safe transcatheter intraarterial infusion chemotherapy for head and neck cancer. We analyzed the branching patterns of the superior thyroid, lingual, facial, occipital and ascending pharyngeal arteries based on 105 digital subtraction external carotid arteriograms from patients with various head and neck cancers (82 males and 23 females; mean age, 65.8 years; age range, 26-88 years old ). The superior thyroid, lingual, facial, occipital or ascending pharyngeal arteries most often arose directly from the ECA in 46%, 67%, 72%, and 46% of subjects, respectively. The linguofacial, thyrolingual or thyrolinguofacial common trunks were more frequently noticed compared with previous reports. Branching of the superior thyroid artery toward the ventral direction was most often observed in 52% of the cases and the proximal portion of the artery showed obtuse, downward angulation in 58% of the cases. The occipital artery arose from between the facial and lingual arteries of the ECA in 50% of the cases. In the cases with linguofacial common trunk, the occipital artery arose from the distal portion of the common trunk branching in 73%. These angiographic analyses of the branching ECA are clinically useful to effectively and safely advance intra-arterial infusion chemotherapy for head and neck cancers.
A 71-year-old man with rheumatoid arthritis was admitted to our hospital because of fever and dyspnea. He had been treated with infliximab (260 mg) for rheumatoid arthritis every month for one year. He had severe hypoxemia, and his chest X-ray revealed bilateral diffuse infiltrative opacities. He was intubated and required mechanical ventilation for severe respiratory failure from the first hospital day. Since he exhibited elevated serum β -1→ 3 D-glucan and typical radiographic findings of geographic ground-glass opacities on HRCT, we diagnosed Pneumocystis pneumonia (PCP). After administration of Co-Trimoxazole (Sulfamethoxazole/trimethoprim), his clinical condition improved dramatically. Immunosuppressed patients during treatment with MTX and infliximab may often develop acute lung injury with infectious pneumonia and drug-induced pneumonia. Differential diagnosis and prophylaxis for PCP during the administration of long-term immunosuppression therapy should be considered for high-risk patients. It is necessary to investigate the administration of Co-Trimoxazole as part of the critical prevention.