Supine Time Research Articles

In-Laboratory Polysomnography Worsens Obstructive Sleep Apnea by Changing Body Position Compared to Home Testing.

(1) Background: Home sleep apnea testing, known as polysomnography type 3 (PSG3), underestimates respiratory events in comparison with in-laboratory polysomnography type 1 (PSG1). Without head electrodes for scoring sleep and arousal, in a home environment, patients feel unfettered and move their bodies more naturally. Adopting a natural position may decrease obstructive sleep apnea (OSA) severity in PSG3, independently of missing hypopneas associated with arousals. (2) Methods: Patients with suspected OSA performed PSG1 and PSG3 in a randomized sequence. We performed an additional analysis, called reduced polysomnography, in which we blindly reassessed all PSG1 tests to remove electroencephalographic electrodes, electrooculogram, and surface electromyography data to estimate the impact of not scoring sleep and arousal-based hypopneas on the test results. A difference of 15 or more in the apnea-hypopnea index (AHI) between tests was deemed clinically relevant. We compared the group of patients with and without clinically relevant differences between lab and home tests (3) Results: As expected, by not scoring sleep, there was a decrease in OSA severity in the lab test, similar to the home test results. The group of patients with clinically relevant differences between lab and home tests presented more severe OSA in the lab compared to the other group (mean AHI, 42.5 vs. 20.2 events/h, p = 0.002), and this difference disappeared in the home test. There was no difference between groups in the shift of OSA severity by abolishing sleep scoring in the lab. However, by comparing lab and home tests, there were greater variations in supine AHI and time spent in the supine position in the group with a clinically relevant difference, either with or without scoring sleep, showing an impact of the site of the test on body position during sleep. These variations presented as a marked increase or decrease in supine outcomes according to the site of the test, with no particular trend. (4) Conclusions: In-lab polysomnography may artificially increase OSA severity in a subset of patients by inducing marked changes in body position compared to home tests. The location of the sleep test seems to interfere with the evaluation of patients with more severe OSA.

Analysing the impact of body position shift on sleep architecture and stage transition: A comprehensive multidimensional study using event-synchronised polysomnography data.

Although understanding the physiological mechanisms of obstructive sleep apnea (OSA) is important for treating OSA, limited studies have examined OSA patients' sleep architecture at the epoch-by-epoch level and analysed the impact of sleep position and stage on OSA pathogenesis. The epoch-labelled polysomnogram was analysed multidimensionally to investigate the effect of sleep position on the sleep architecture and risk factors of apnea in patients with OSA. This retrospective multicentric case-control study reviewed full-night diagnostic polysomnography of 6983 participants. The difference in the proportion of time spent supine during non-rapid eye movement (NREM) and REM stages, and the mean duration of respiratory events per body position were evaluated. The frequency of sleep stage transition per body position shift type was computed. Further subgroup analysis was performed based on OSA severity and positional dependency. Supine time in patients with OSA varied across sleep stages, with lower proportions in N3 and REM, and shorter durations with severity. Patients with OSA spent less time in supine positions during N3 and REM, and experienced longer apnea events in both positions compared to the control group. The frequency of all sleep stage transitions increased with OSA severity and was higher among non-positional OSA than positional OSA and the control group, regardless of body position shift type. The sleep stage transition from N3 and REM to wakefulness was notably heightened during position shift. Understanding the sleep architecture of patients with OSA requires analysing various sleep characteristics including sleep position simultaneously, with future studies focusing on position detection to predict sleep stages and respiratory events.

Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing.

Night-to-night variability of obstructive sleep apnea severity is considerable and may depend on the diagnostic modality used. We investigated the night-to-night variability using peripheral arterial tonometry (PAT). Home sleep apnea testing was performed in 51 patients during 3 consecutive nights using PAT. Patients referred to our sleep clinic were screened and prospectively recruited for this study. All recordings were automatically and manually scored according to the PAT scoring guidelines. No systematic differences in PAT-derived apnea-hypopnea index (pAHI) were found between the nights. The night-to-night variability was comparable between manually and automatically scored data. pAHI varied in 35% of patients more than 10 events/h between the nights. The obstructive sleep apnea severity of 24% of patients was misclassified when using 1 night compared to the average of all nights. On average, pAHI varied by 57% from night to night. The variability of pAHI could partially be explained by the variability of time spent in the supine position with more time supine leading to a higher pAHI. On measuring a subsequent night, 12-14% of patients spontaneously fulfilled the commonly accepted criteria for treatment success without any intervention. With repeated recordings of PAT, we found no first night effect. However, there is considerable night-to-night variability similar to values found for polysomnography, which can partially be explained by the variability of time spent in the supine position. Obstructive sleep apnea severity was frequently misclassified due to the night-to-night variability. Our findings make a strong case for multiple testing in the diagnostic work-up of obstructive sleep apnea patients. Tschopp S, Wimmer W, Caversaccio M, Borner U, Tschopp K. Night-to-night variability in obstructive sleep apnea using peripheral arterial tonometry: a case for multiple night testing. J Clin Sleep Med. 2021;17(9):1751-1758.

Sleep time and efficiency in patients undergoing laboratory-based polysomnography.

Sleep quality in patients studied with laboratory-based polysomnography may differ from sleep quality in patients studied at home but remains clinically relevant and important to describe. We assessed objective sleep quality and explored factors associated with poor sleep in patients undergoing laboratory-based polysomnography. We reviewed diagnostic polysomnography studies from a 10-year period at a single sleep center. Total sleep time (TST) and sleep efficiency (SE) were assessed as markers of sleep quality. Poor sleep was defined as TST ≤ 4 hours or SE ≤ 50%. Multivariable analysis was performed to determine associations between objective sleep quality as an outcome and multiple candidate predictors including age, sex, race, body mass index, comorbidities, severity of obstructive sleep apnea, and central nervous system medications. Among 4957 patients (age 53 ± 15 years), average TST and median SE were 5.8 hours and 79%, respectively. There were 556 (11%) and 406 (8%) patients who had poor sleep based on TST and SE, respectively. In multivariable analysis, those who were older (per 10 years: 1.48 [1.34, 1.63]), male (1.38 [1.14,1.68]), and had severe obstructive sleep apnea (1.76 [1.28, 2.43]) were more likely to have short sleep. Antidepressant use was associated with lower odds of short sleep (0.77 [0.59,1.00]). Older age (per 10 years: 1.48 [1.34, 1.62]), male sex (1.34 [1.07,1.68]), and severe obstructive sleep apnea (2.16 [1.47, 3.21]) were associated with higher odds of poor SE. We describe TST and SE from a single sleep center cohort. Multiple demographic characteristics were associated with poor objective sleep in patients during laboratory-based polysomnography. Harrison EI, Roth RH, Lobo JM, et al. Sleep time and efficiency in patients undergoing laboratory-based polysomnography. J Clin Sleep Med. 2021;17(8):1591-1598.

Use of a Sleep Positioning Device Significantly Reduces Esophageal Acid Exposure in Lung Transplant Recipients: 2017 Presidential Poster Award

Introduction: Despite advancements in surgical techniques and medical management, lung transplantation remains one of the highest risk solid organ transplants. Patients with lung disease and those who undergo transplantation have been found to display a greater prevalence of gastroesophageal reflux disease (GERD). While the exact pathophysiologic mechanism remains unknown, GERD has been established as an independent and modifiable risk factor for the development of transplant rejection. Additional studies have also displayed a benefit of using an incline wedge pillow in patients with GERD. The goal of this study is to evaluate if a sleep-positioning device (SPD) decreases esophageal acid exposure in patients who have undergone lung transplantation. Methods: This is a single center IRB approved restrospective study designed to evaluate the effect of GERD on patients who have undergone lung transplantation. Patients were identified upon referral to a subspecialty-swallowing center, at which point were provided a SPD for persistent symptoms of GERD or had undergone a positive ambulatory esophageal pH study. Their medical records were then evaluated for esophageal pH study results in addition to markers of pulmonary function. Results: A total of twenty-seven patients were provided a SPD, twenty-four of who had previously undergone formal pH testing. Of this cohort, 96% had already been prescribed a proton pump inhibitors which were held for seven days prior to pH testing. Following the initiation of nightly SPD use, nine individuals had repeat pH tests used for comparison. Significant improvements in percentage of total time spent below a pH of four (Pre 12.4% to Post 5.3%; P<0.05) as well as in the supine position (13.6% to 2.9%; P<0.05) were identified. Use of the SPD was associated with 49.7% and 72.9% reductions in percent of time spent with esophageal pH below four in total and supine times respectively. Conclusion: GERD has been well established as a modifiable risk factor for the development of lung allograft failure that manifests as declines in forced expiratory volumes. This analysis has shown significant reductions in esophageal acid exposure following the use of a sleep-positioning device in addition to concurrent anti-secretory therapy. Given the inverse relationship between duration of abnormal esophageal acid exposure and forced expiratory volume, this data suggests the potential role for a SPD in the management of GERD in lung transplant recipients.Figure: Effect of the SPD on total time esophageal pH recorded as less than 4.0.Figure: Effect of the SPD on supine time esophageal pH recorded as less than 4.0.Figure: Birds eye and lateral views of the sleep positioning device provided to lung transplant recipients.

0608 ASSESSMENT OF OBSTRUCTIVE SLEEP APNEA IN PATIENTS WITHCHRONIC PAIN SYNDROME: HOW DOES PORTABLE RESPIRATORY RECORDING COMPARE TOPOLYSOMNOGRAPHY?

Obstructive Sleep Apnea (OSA) is a common condition seen in veterans with Chronic Pain Syndrome (CPS). Portable respiratory recording (PRT) is cheaper and more readily available than polysomnography (PSG). The validity of PRT in the diagnosis of OSA in patients with CPS is not well characterized. Veterans with CPS admitted to a referral pain rehabilitation center underwent PSG along with supervised PRT in the sleep laboratory on presentation. Studies were scored independently by a blinded scorer using AASM scoring criteria, hypopneas were scored based on oxygen desaturation and arousal criteria in PSG while they were scored based on oxygen desaturation on PRT. Generated reports were compared for Apnea Hypopnea Index (AHI), Oxygen Saturation Nadir (OSN), Oxygen Desaturation Index (ODI), Time Supine (TS), and Mean Heart Rate (MHR) using mean, standard deviation and Parson Correlation Coefficient (PCC). Twenty-five veterans with CPS were enrolled (22 male, 3 females with an average BMI of 30.15). Average AHI was 23 +/-15 via PSG and 18.2 +/-16.5 via PRT, with PCC 0.69. Twenty three patients were found to have OSA based on PSG while nineteen patients were found to have OSA based on PRT. Ten patients had severe OSA based on PSG while four patients had severe OSA based on PRT. OSN was 86.1 +/- 22.8% via PSG and 85.8 +/-22.7% via PRT, PCC 0.54. ODI was 13.6 +/- 13.6 via PSG and 14.3 +/- 11.1 via PRT, PCC 0.82. TS was 192.7 +/- 109 min via PSG vs 223 +/- 124.4 min via PRT, PCC 0.81. MHR was 67.6 +/- 19.8 bpm via PSG vs 63.8 +/- 18.6 bpm via PRT, PCC 0.97. The results were not statistically significant. The sensitivity and severity characterization of PRT is suboptimal when compared to the PSG gold standard with chronic pain. Oximetry and positional measurements are similar between PRT and PSG. Further analysis of PRT sensitivity based on patient characteristics may help identify more suitable candidates for PRT testing. None.

Modest Improvement of Untreated Severe Sleep-Disordered Breathing in the Middle-Aged and Elderly.

ObjectiveIt has been reported that untreated sleep-disordered breathing (SDB) deteriorates over time, however this remains contentious. The aim of the present study is to evaluate the clinical course of SDB in middle-aged and older SDB patients, and to identify how relevant factors contribute to the change in SDB severity.MethodsBaseline and follow-up polysomnographic data of 56 untreated SDB patients (mean age, 61.2±5.71) were obtained retrospectively and the mean interval was 62.4±22.0 months. Subgroup analysis was performed based on the baseline severity, and the factors associated with the course of SDB were analyzed.ResultsAt the baseline, 13 subjects were simple snorers, 15 had mild to moderate SDB, and 28 were severe SDB patients. While there was no significant change in apnea-hypopnea index (AHI) as a whole, subgroup analysis showed decrease of AHI in severe SDB patients (43.9±10.6 to 35.6±20.0, p=0.009). The change in supine time percent and baseline AHI were associated with the change in AHI (β=0.387, p=0.003; β=-0.272, p=0.037).ConclusionUntreated SDB did not deteriorate over time with modest improvement in severe SDB. A proportion of severe SDB patients might expect decrease in SDB severity irrespective of changes in sleep position or body weight.

Baseline impedance measured during high-resolution esophageal impedance manometry reliably discriminates GERD patients.

Baseline impedance measured with ambulatory impedance pH monitoring (MII-pH) and a mucosal impedance catheter detects gastroesophageal reflux disease (GERD). However, these tools are limited by cost or patient tolerance. We investigated whether baseline impedance measured during high-resolution impedance manometry (HRIM) distinguishes GERD patients from controls. Consecutive patients with clinical HRIM and MII-pH testing were identified. Gastroesophageal reflux disease was defined by esophageal pH <4 for ≥5% of both the supine and total study time, whereas controls had an esophageal pH <4 for ≤3% of the study performed off PPI. Baseline impedance was measured over 15seconds during the landmark period of HRIM and over three 10minute intervals during the overnight period of MII-pH. Among 29 GERD patients and 26 controls, GERD patients had a mean esophageal acid exposure time of 22.7% compared to 1.2% in controls (P<.0001). Mean baseline impedance during HRIM was lower in GERD (1061Ω) than controls (2814Ω) (P<.0001). Baseline mucosal impedance measured during HRIM and MII-pH correlated (r=0.59, P<.0001). High-resolution esophageal manometry baseline impedance had high diagnostic accuracy for GERD, with an area under the curve (AUC) of 0.931 on receiver operating characteristics (ROC) analysis. A HRIM baseline impedance threshold of 1582Ω had a sensitivity of 86.2% and specificity of 88.5% for GERD, with a positive predictive value of 89.3% and negative predictive value of 85.2%. Baseline impedance measured during HRIM can reliably discriminate GERD patients with at least moderate esophageal acid exposure from controls. This diagnostic tool may represent an accurate, cost-effective, and less invasive test for GERD.

Study on the relationship between obesity and gastroesophageal reflux disease

Objective To investigate the relationship between obesity and esophageal high resolutionmanometry, 24-hour pH monitoring and gastroscopic results of patients with gastroesophageal reflux disease (GERD). Methods A total of 196 patients with GERD(DeMeester score>14.72) were selected and divided into normal weight group (18.5 kg/m2<BMI<24 kg/m2), overweight group (24 kg/m2≤BMI<28 kg/m2) and obese group (BMI≥28 kg/m2) according to body mass index (BMI). Esophageal high resolution manometry, gastroscopy and 24-hour pH monitoring were performed with DeMeester score calculated. The classification of esophagitis was according to Los Angeles standard. Normal distributed measurement data were compared by analysis of variance. Non normal distributed measurement data were repesent as M(P25, P75), and were compared by rank sum test. Chi square test was for count data comparison. Results Compared with normal weight group and overweight group, abdominal length of low esophageal sphincter (LES) of obese group was shorter (1.90 cm, 0.85 cm to 2.45 cm; 2.85 cm, 2.23 cm to 3.20 cm; 2.50 cm, 1.98 cm to 3.0 cm), and the differences were statistically significant (Z=19.913, P 0.05). The percent total time pH≤4 of obesity group was 15.42% (10.31% to 21.49%), percent supine time pH≤4 was 14.21% (5.75% to 34.98%) and percent upright time pH≤4 was 14.25% (8.19% to 18.13%). The reflux episodes (106.50, 67.00 to 145.75) and the longest duration of reflux episodes (28.10 min, 10.90 min to 47.93 min) were more than those of normal group (9.74%, 5.35% to 15.96%; 7.31%, 3.25% to 11.80%; 8.45%, 5.43% to 17.48%; 72.50, 53.00 to 100.50; 15.80 min, 9.90 min to 21.28 min) and overweight group (11.36%, 6.74% to 15.87%; 7.74%, 2.36% to 15.05%; 11.27%, 3.37% to 14.73%; 85.50, 58.75 to 117.75; 21.40 min, 11.50 min to 39.90 min), and the differences were statistically significant (Z=7.054, 11.181, 6.429, 6.452, 8.246, all P 0.05). There was no statistically significant difference in the incidence of Barrett's esophagus among three groups (all P>0.05). Conclusions Compared with that of normal weight group and overweight group of patiento with GERD, abdominal length of LES of obesity group was shorter. With an increase in BMI, acid exposure and the incidences of reflux esophagitis and hiatal hernia also increased. Key words: Gastroesophageal reflux; Esophageal high resolution manometry; BMI; Esophageal pH monitoring; Obesity

Prospective series of two hours supine rest after 4fr sheath-based diagnostic cerebral angiography: Outcomes, productivity and cost.

There is no standard of care for catheter size or post-procedure supine time in cerebral angiography. Catheter sizes range from 4-Fr to 6-Fr with supine times ranging from two to over six hours. The objective of our study was to establish the efficacy, safety, and cost savings of two-hour supine time after 4-Fr elective cerebral angiography. A prospective, single arm study was performed on 107 patients undergoing elective cerebral angiography. All cerebral angiograms were performed with a 4-Fr sheath-based system without closure devices. Ten minutes of manual compression was applied to the femoral access site, with further compression held as clinically indicated. Patients were then monitored in a nursing unit for two hours supine and subsequently mobilized. Nursing discretion was allowed for earlier mobilization. Patients were called the next day to assess delayed hematoma and bleeding. Estimates of cost savings and productivity increases are provided. All patients ambulated in two hours or less. There were no strokes or vessel dissections. Five patients (4.7%) experienced a palpable hematoma, three patients (2.8%) experienced bleeding immediately following the procedure requiring further compression, and one patient (0.9%) experienced minor groin oozing at home. No patient required transfusion, thrombin injection, or endovascular/surgical management of a groin complication. A two-hour post-procedure supine time resulted in cost savings of $952 per angiogram and a total of $101,864. 4-Fr sheath based cerebral angiography with two-hour post-procedure supine time is safe and effective, and allows for a considerable increase in patient satisfaction, cost savings and productivity.

Gastroesophageal Reflux in a Cohort of Morbidly Obese Patients Before and After Sleeve Gastrectomy

Introduction: Laparoscopic sleeve gastrectomy (LSG) offers excellent sustainable weight loss for morbidly obese patients. Previous studies have demonstrated an increase in gastroesophageal reflux (GER) following LSG. The aim of this study was to compare acid reflux parameters in a cohort of obese patients before and after surgery. Methods: We prospectively enrolled adult obese patients greater than 18 years old undergoing preoperative evaluation for LSG. Patients underwent PPIs pre-operative 24 hour combined ambulatory pH and impedance testing off of PPI. Studies were repeated at least 6 months after LSG. Reflux data collected included Johnson-DeMeester (JD) score, to include percent total time pH<4, percent supine time pH<4, percent upright pH <4, number of reflux episodes <5 minutes, longest reflux episode, and impedance testing results. Results: We enrolled 18 consecutive adult patients presenting for preoperative evaluation for LSG with a mean age of 51.5 (SD); 7 were white (78%), and 2 were male (22%). Sixteen patients successfully underwent LSG, of which 9 patients completed their post-operative testing. After LSG, there was a statistical increase in mean acid reflux episodes from 24.36 to 51.57 (p=0.03) and mean distal esophageal impedance episodes from 47.67 to 69.78 (p=0.04), but no change in proximal impedance (p=0.16). Although there was an almost 2-fold increase in mean JD score from 16.68 to 31.23 (p=0.09), this was not statistically significant. Likewise, there was no statistically significant change in total percent time (p=0.23), percent upright reflux (p=0.44), percent supine reflux (p=0.08), number of reflux episodes >5 minutes (p=0.21), or longest reflux episode (p=0.37). Conclusion: In this small ongoing study, LSG significantly increased the number of acid and impedance reflux episodes. A trend towards an increase in JD score was observed.

Capability of a neck worn device to measure sleep/wake, airway position, and differentiate benign snoring from obstructive sleep apnea

To evaluate the accuracy of a neck-worn device in measuring sleep/wake, detecting supine airway position, and using loud snoring to screen for obstructive sleep apnea. Study A included 20 subjects who wore the neck-device during polysomnography (PSG), with 31 records obtained from diagnostic and split-night studies. Study B included 24 community-based snorers studied in-home for up to three-nights with obstructive sleep apnea (OSA) severity measured with a validated Level III recorder. The accuracy of neck actigraphy-based sleep/wake was measured by assessing sleep efficiency (SE). Differences in sleep position measured at the chest and neck during PSG were compared to video-editing. Loud snoring acquired with an acoustic microphone was compared to the apnea-hypopnea index (AHI) by- and acrosspositions. Over-reported SE by neck actigraphy was inversely related to OSA severity. Measurement of neck and chest supine position were highly correlated with video-edits (r = 0.93, 0.78). Chest was bias toward over-estimating supine time while the majority of neck-device supine position errors occurred during CPAP titrations. Snoring was highly correlated with the overall, supine, and non-supine PSG-AHI (r = 0.79, 0.74, 0.83) and was both sensitive and specific in detecting overall, supine, and non-supine PSGAHI >10 (sensitivity = 81, 88, 82 %; specificity = 87, 79, 100 %). At home sleep testing-AHI > 10, the sensitivity and specificity of loud snoring was superior when users were predominantly non-supine as compared to baseline (sensitivity = 100, 92 %; specificity = 88, 77 %). Neck actigraphy appears capable of estimating sleep/wake. The accuracy of supine airway detection with the neck-device warrants further investigation. Measurement of loud snoring appears to provide a screening tool for differentiating positional apneic and benign snorers.

A Comparison of the Three Objective Measures of Gastroesophageal Reflux Disease: Johnson-DeMeester Score, DeMeester Score, and Percent Time pH&lt;4

Purpose: The Johnson-DeMeester (JD) and DeMeester (D) scoring systems, as well as, percent total time pH < 4, have been used to determine the presence of abnormal gastroesophageal reflux (GERD) in clinical and research settings. While all methods are commonly used in practice, no prior study has compared them. The goal of this study was to compare these three objective measures of GERD in a large cohort of adult patients undergoing ambulatory 24-hour pH monitoring. Methods: A retrospective study was performed on 160 patients who underwent 24-hour pH testing off proton-pump inhibitors for at least 1 week for the evaluation of GERD. For each 24-hour pH study, both JD and D composite scores were calculated using the following parameters: percent total time pH<4, percent upright time pH<4, percent supine time pH<4, total number of reflux episodes, number of reflux episodes>5 minutes, and time of longest reflux episode. An abnormal JD score was defined as a score>22.0, and an abnormal D score defined as a score>14.7. The JD and D scores were compared to each other and in their ability to detect the presence of acid reflux expressed as the percent total time pH < 4, using a normal threshold of 4.5%. Results: The study cohort consisted of 52% (83/160) males and 66% (106/160) Caucasians, with a mean (SD) age of 46 (12) years. There was significant correlation between the JD and D composite scores (R2 0.961, p<0.001). The JD and D scores agreed in classifying normal vs. abnormal results in 96% of the studies (153/160), in which 102 study results were normal and 51 studies were abnormal by both scoring systems (kappa 0.903, p=0.000). Disagreement occurred in seven of 160 studies, primarily (4/7) due to differences in upright reflux, where the JD score was normal (range 16.9 to 20.5) and the D score was abnormal (range 14.9 to 18.5). The JD and D scores significantly correlated with percent total reflux (R2=0.793 and R2=0.919, respectively). Furthermore, the JD and D scores significantly correlated to percent upright reflux (R2 = 0.380 and R2= 0.564, respectively) and percent supine reflux (R2=0.789 and R2= 0.628, respectively). When using a value of 4.5% for the normal threshold of total percent time acid reflux, the JD score misclassifi ed 12% (19/16) of patients and the D score misclassified 8% (12/160) of patients, p=0.257. Conclusion: There was a strong agreement (kappa 0.903) between the JD score and D score in classifying a 24-hour pH test as normal or abnormal, with a significant correlation of each scoring system to percent total time pH < 4. Physicians can reliably utilize either the JD score, D score, or total percent time < pH 4 to determine if a patient has a normal or abnormal degree of acid reflux.

Clinical curative effect of electroacupuncture combined with Zhizhukuanzhong Capsules for treating gastroesophageal reflux disease

ObjectiveTo study the clinical curative effect, safety and mechanism of action of electroacupuncture combined with Zhizhukuanzhong capsules (ZZKZC) in treating gastroesophageal reflux disease (GERD). MethodsA total of 480 patients with confirmed GERD were randomly divided into four groups: the electroacupuncture group, the ZZKZC group, the combined therapy group, and the control group, with 120 cases in each group. Each case in the electroacupuncture group was treated with electroacupuncture on Zusanli (ST 36), Zhongwan (CV 12), Neiguan (PC 6), Taichong (LR 3) and Gongsun (SP 4) once daily for 6 weeks. Each case in the ZZKZC group was treated with oral administration of 1.29 g ZZKZC three times daily. The combined therapy group had electroacupuncture and ZZKZC. The control group was given oral administration of 5 mg mosapride three times and 20 mg pantoprazole twice daily. The 24-hour intraesophageal total number of reflux episodes with pH <4 (or bilirubin absorbance ≥ 0.14), the number of long-term (≥5 min) reflux episodes, the percentage of upright time, the percentage of supine time, the percentage of total time of pH <4 (or bilirubin absorbance ≥0.14), endoscopic grading score, symptom score, quality of life score, and adverse reactions were observed before treatment, at the end of treatment and 54 weeks after treatment in the four groups. ResultsThe 24-hour intraesophageal pH and bile reflux, endoscopic grading score and symptom score were all significantly decreased at the end of treatment in every group, while the scores of 8 dimensions of quality of life were all increased compared with those before treatment (P<0.01). All of these indices were better in the combined therapy group than those in the other groups (P<0.05). These indices did not significantly deteriorate in the combined therapy group and electroacupuncture group 54 weeks after treatment compared with the end of treatment (P>0.05); however, these indices all significantly deteriorated in the ZZKZC and control groups (P>0.05). The short and long-term total efficacy rates in the combined therapy group showed significant superiority to those in the other groups (P<0.05 or P<0.01). No serious adverse reactions were found in the four groups. ConclusionElectroacupuncture and ZZKZC play an important role in inhibiting intraesophageal acid and bile reflux, decreasing the endoscopic grading score, and alleviating the symptoms of gastroesophageal reflux to improve the quality of life. However, the effect of combined treatment is more effective, with better security and long-term efficacy, and therefore, this combination treatment is appropriate for clinical use.

Positional sensitivity as a confounder in diagnosis of severity of obstructive sleep apnea

The apnea-hypopnea index (AHI) is used to grade obstructive sleep apnea (OSA) into mild, moderate, and severe forms. Obstructive events are most common in the supine position. The amount of supine sleep thus influences total AHI. Our aim was to determine the prevalence of position-dependent OSA (POSA) and its relation to OSA severity classification as recommended by the American Academy of Sleep Medicine (AASM). Two hundred sixty-five subjects were recruited from primary care hypertension clinics. Whole-night respiratory recordings were performed to determine the AHI in the supine and non-supine positions, respectively. POSA was defined as supine AHI twice the non-supine AHI with supine AHI ≥5. Fifty-three percent had POSA, 22% had non-position-dependent OSA, and 25% had normal respiration. By AASM classification, 81 subjects did not have OSA, but 42% of them had some degree of obstruction when supine, and 5 subjects would have been classified as moderate-severe if they had only slept supine. Conversely, of the 53 classified as mild OSA, 30% would have changed to a more severe classification if they had exclusively slept supine. POSA was common both in subjects that by AASM classification had OSA as well as those without. The severity of OSA, as defined by AASM, could be dependent on supine time in a substantial amount of subjects.

Accurate Position Monitoring and Improved Supine-Dependent Obstructive Sleep Apnea with a New Position Recording and Supine Avoidance Device

Approximately 30% of obstructive sleep apnea (OSA) patients have supine-predominant OSA, and simply avoiding supine sleep should normalise respiratory disturbance event rates. However, traditional supine-avoidance therapies are inherently uncomfortable, and treatment adherence is poor and difficult to monitor objectively. This study evaluated the efficacy of a novel, potentially more acceptable position monitor and supine-avoidance device for managing supine-predominant OSA and snoring. In-laboratory evaluation of position recording accuracy versus video recordings (validation study), and randomized controlled crossover trial of active versus inactive supine-avoidance therapy in the home setting (efficacy study). 17 patients undergoing in-laboratory sleep studies (validation) and 15 patients with supine-predominant OSA (efficacy). EFFICACY STUDY: 1 week of inactive and 1 week of active treatment in randomized order, separated by 1 week. Agreement between 30-sec epoch-based posture classifications from device versus video records was high (median κ 0.95, interquartile range: 0.88-1.00), and there was good supine time agreement (bias 0.3%, 95%CI: -4.0% to 4.6%). In the efficacy study, apnea-hypopnea index (AHI) and snoring frequency were measured in-home using a nasal pressure and microphone based system during inactive and active treatment weeks. The position monitoring and supine alarm device markedly inhibited supine time (mean ± SEM 19.3% ± 4.3% to 0.4% ± 0.3%, p < 0.001) and reduced AHI (25.0 ± 1.7 to 13.7 ± 1.1 events/h, p = 0.030) but not snoring frequency. This new position monitoring and supine alarm device records sleep position accurately and improves OSA but not snoring in patients with supine-predominant OSA.

Normal 24-hour Ambulatory Esophageal pH Values in Koreans

Twenty-four-hour ambulatory esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to quantify normal distal esophageal acid parameters in healthy Koreans. Thirty healthy adults who were not on medication and were free from gastrointestinal symptoms were analyzed. Ambulatory esophageal acid (pH <4) exposure parameters were recorded at 5 cm above the lower esophageal sphincter. The 95th percentiles for reflux parameters assessed in the distal esophagus were as follows: percentage of total time with pH <4, 5.10%; percentage of upright time with pH <4, 7.88%; percentage of supine time with pH <4, 4.00%; number of reflux episodes, 62.7; number of reflux episodes with pH <4 for >5 minutes, 5.3; and the longest single acid-exposure episode, 21.3 minutes. Physiological gastroesophageal reflux occurs frequently in healthy Koreans. These data provide a reference range that could be utilized in studies involving Korean subjects.

Esophageal motility in patients with sliding hiatal hernia with reflux esophagitis

Patients with sliding hiatus hernia (HH) and reflux esophagitis (RE) usually suffer from esophageal dysmotility. The aim of the present study was to investigate the role of acid reflux and duodenal gastroesophageal reflux (DGER), esophageal manometry, and esophageal dysmotility by applying the barium meal examination. RE with HH was initially diagnosed using the reflux disease questionnaire, and was further confirmed by a barium meal examination and an endoscopy. The radiographic technique was used to test for spasms, strictures, and the coarseness of the mucosa, also was to study the types of reflux and clearance. Then, the esophageal manometry, the esophageal 24-hour pH, and the bilirubin monitoring were observed. Fifty-five patients were diagnosed as HH combined with RE and divided into two groups according to the severity of their esophagitis: group HH1 (grades A and B) and group HH2 (grades C and D). The barium meal examination revealed that the mucosa was either granular or nodular in all cases. The dump reflux and delayed clearance were more significant in patients in the HH2 group than those in the HH1 group (P < 0.05). The percentages of total, supine, and upright acid exposure time were greater in patients with HH than those in the control group (P < 0.01), but the differences between the HH1 and the HH2 groups were not significant. Lower esophageal sphincter pressure (LESP) was lower in the HH group than in the control group (P < 0.05). Three DGER parameters: the percentage of time with absorbance greater than 0.14, the number of bile reflux episodes, the number of bile refluxes lasting longer than 5 minutes were (28.43 +/- 23.34), (40.57 +/- 31.30), and (15.15 +/- 8.72), respectively in the HH2 group; these statistics were significantly higher than those for the HH1 (P < 0.05). The frequency and amplitude of peristalsis were all lower in HH patients than in the control (P < 0.05). Of all the patients, 54.3% (30 of 55) with acid reflux and DGER simultaneously in the HH group exhibited refluxes of barium from the stomach to the esophagus in the recumbent position, and 29.4% (5 in 17) with delayed clearance in the HH group were correlated with esophageal body peristalses. The result was that the frequency and amplitude of peristalsis were less and the duration of esophageal peristalsis was longer than those of control group. Esophageal dysmotility may play an important role in the severity of RE combined with HH. Esophageal motility results on a barium examination may coincide with esophageal manometry, 24-hour pH, and bilirubin monitoring in the RE and HH, but the radiologic method was the simplest to apply.

Normal Ambulatory 24-Hour Esophageal pH Values in Koreans -A Multicenter Study-

Ambulatory 24-hr esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease. The aim of this study was to establish normal values for gastroesophageal acid exposure in healthy Koreans. Fifty healthy volunteers (24 males and 26 females; mean age, 45 yr) without reflux symptoms and without reflux esophagitis or hiatal hernia on upper endoscopy underwent ambulatory 24-hr esophageal pH monitoring after esophageal manometry. The 95th percentiles for the reflux parameters were: the percent total time pH <4, 3.7%; the percent upright time pH <4, 5.7%; the percent supine time pH <4, 1.0%; the number of reflux episodes with pH <4, 76.5; the number of reflux episodes with pH <4 for >5 min, 1.5; the duration of the longest episode, 12.5 min; and the composite score, 14.2. Age and gender were not associated with any of the pH parameters. In conclusion, physiological gastroesophageal reflux occurs in healthy Koreans. These normal esophageal pH values will provide reference data for clinical and research studies in Korea.

Assessment of 24‐h oesophageal pH monitoring should be divided to awake and asleep rather than upright and supine time periods*

Oesophageal acid exposure analysis is divided to upright and supine, based on the assumption that the supine-awake period is similar to the supine-asleep period. To determine if the principal acid-reflux characteristics of supine-awake are closer to supine-asleep or upright period. Patients with heartburn underwent an upper endoscopy and pH testing. The patients were instructed to carefully document their upright, supine-awake and supine-asleep periods. A total of 64 patients were enrolled into this study (M/F 35/29; mean age 52.4 +/- 13.3). The mean percentage total time pH <4, frequency of acid-reflux events (per h) and number of sensed reflux events was not different between upright and the supine-awake period (P = ns). In contrast, the mean percentage total time pH <4, frequency of acid-reflux events and number of sensed reflux events was significantly higher in both upright and supine-awake periods vs supine-asleep (4.3 +/- 6.9, 1.86 +/- 2.7 and 0.01 +/- 0.05, P < 0.0001, respectively). The principal characteristics of the acid-reflux events in the supine-awake period are closer to the upright period than to the supine-asleep period.