Publications by authors named "Henri Tuomilehto"

51 Publications

Self-reported sleep bruxism among Finnish symphony orchestra musicians: Associations with perceived sleep-related problems and psychological stress.

Cranio 2020 Nov 30:1-8. Epub 2020 Nov 30.

Department of Oral and Maxillofacial Diseases, University of Helsinki , Helsinki, Finland.

: This study aimed to evaluate whether self-reported sleep bruxism among musicians is associated with sleep-related problems and/or psychological stress. : Eight hundred-thirty-one Finnish orchestra musicians completed a questionnaire that covered, among others, indicators of sleep-related problems, possible sleep bruxism, and stress. : In total, 488 questionnaires were completed. The single variable ordinal logistic regression models revealed at least moderate associations between frequency of sleep bruxism and female gender, shorter sleep duration, longer sleep latency, problems in sleeping during concert season, feeling more often tired during the daytime, restless legs, a poor self-rated sleep quality, and more stress experience. The variables that remained in the final model were sleep duration, gender, and stress. : Musicians who sleep 7 hours or less per night report more sleep bruxism, as compared to those who sleep 8 hours or more. Female gender and high-stress experience were associated with more sleep bruxism.
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http://dx.doi.org/10.1080/08869634.2020.1853310DOI Listing
November 2020

Mandibular advancement device therapy for obstructive sleep apnea: A longitudinal study among patients treated in community dental care in Finland - Potential for the precision medicine approach.

Cranio 2020 Apr 18:1-6. Epub 2020 Apr 18.

Department of Oral and Maxillofacial Diseases, Faculty of Medicine, University of Helsinki, Helsinki, Finland.

: Obstructive sleep apnea (OSA) is an increasing health problem worldwide. The aim was to evaluate long-term mandibular advancement device (MAD) therapy outcomes in community dental care among OSA patients in Finland.: In all, 142 (77.2%) respondents of a questionnaire, with recently initiated treatment, were included in the study in 2010. Follow-up questionnaires were mailed in 2012 and 2017.: Problems occurred with the device long-term. Orofacial pain was reported more often in 2012 than in 2010 ( < 0.01). Snoring ( < 0.01) and tiredness ( < 0.05) were also significantly increased. In 2017, 50 subjects were still continuing with MAD, 20 of them as a single treatment modality. Treatment modalities in combination with MAD were CPAP, nutrition counseling, and position treatment.: Long-term MAD treatment may lead to a changing treatment-mix and set-backs. This may not only be a treatment adherence issue but also a lack of precision medicine approach regarding OSA.
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http://dx.doi.org/10.1080/08869634.2020.1752431DOI Listing
April 2020

Oro-facial pain experience among symphony orchestra musicians in Finland is associated with reported stress, sleep bruxism and disrupted sleep-Independent of the instrument group.

J Oral Rehabil 2019 Sep 21;46(9):807-812. Epub 2019 May 21.

Department of Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.

Background: To evaluate whether oro-facial pain experience was related to the type of musical instrument and to learn more about the roles of sleep and sleep-related issues in the pain among professional musicians.

Objectives: A standard questionnaire was sent to all Finnish symphony orchestras (n = 19), with altogether 1005 professional musicians and other personnel.

Methods: The questionnaire covered descriptive data, instrument group, items on perceived quality of sleep, possible sleep bruxism, stress experience and oro-facial pain experience during the past 30 days.

Results: In the present study, which included the musicians only, the response rate was 58.7% (n = 488). All orchestras participated in the study, and there was no significant difference in the response rate between the orchestras. The mean age of men (52.3%) was 47.7 (SD 10.3) and of women (47.7%) was 43.4 (SD 9.8) years (P < 0.001). Overall, current pain in the oro-facial area was reported by 28.9%, frequent bruxism by 12.1% and frequent stress by 20.8%. According to Somers' d, there were statistically significant but moderate correlations between overall pain reports in the oro-facial area and disrupted sleep (d = 0.127, P = 0.001), sleep bruxism (d = 0.241, P < 0.001) and stress experiences (d = 0.193, P < 0.001). Logistic regression revealed, independent of the instrument group (string, woodwind, brass wind, percussion), that current oro-facial pain experience was significantly associated with disrupted sleep (P = 0.001), frequent sleep bruxism (P < 0.001) and frequent stress (P = 0.002) experiences.

Conclusions: Among symphony orchestra musicians, oro-facial pain experience seems to be related to perceptions of stress, sleep bruxism and disrupted sleep rather than the instrument group.
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http://dx.doi.org/10.1111/joor.12818DOI Listing
September 2019

Weight gain may affect mandibular advancement device therapy in patients with obstructive sleep apnea: a retrospective study.

Sleep Breath 2019 Jun 27;23(2):531-534. Epub 2018 Sep 27.

Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland.

Purpose: The aim was to analyze whether or not weight gain influences the treatment outcome of patients with obstructive sleep apnea (OSA) treated with mandibular advancement devices (MAD).

Methods: As a part of a follow-up study among OSA patients treated with MAD in primary oral health care, a group of 28 patients reporting worsening of daytime or nighttime symptoms of OSA was given closer examination. Altogether, 21 subjects had a complete set of recordings and were enrolled into the study.

Results: Only three subjects had lost weight during the study period. The mean weight gain of 3.6 kg ± 7.1 kg was significant (p = 0.035). According to linear regression, weight gain was independently significantly associated with lower mean peripheral oxygen saturation 92.4 (SD 1.8 (% per hour) (p = 0.019)) and lowest oxygen saturation 80.1 (SD 7.2 (%) (p = 0.024)) scores.

Conclusions: Weight gain is detrimentally associated with MAD treatment in patients with OSA. These findings suggest that regular follow-up by an experienced dentist is advisable to assess for possible worsening of OSA. Patient support to encourage weight control may be an important adjunct to MAD treatment for OSA.
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http://dx.doi.org/10.1007/s11325-018-1728-1DOI Listing
June 2019

The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2018 09;198(6):e70-e87

Background: Overweight/obesity is a common, reversible risk factor for obstructive sleep apnea severity (OSA). The purpose of this guideline is to provide evidence-based recommendations for the management of overweight/obesity in patients with OSA.

Methods: The Grading of Recommendations, Assessment, Development and Evaluation approach was used to evaluate the literature. Clinical recommendations were formulated by a panel of pulmonary, sleep medicine, weight management, and behavioral science specialists.

Results: Behavioral, pharmacological, and surgical treatments promote weight loss and can reduce OSA severity, reverse common comorbidities, and improve quality of life, although published studies have methodological limitations. After considering the quality of evidence, feasibility, and acceptability of these interventions, the panel made a strong recommendation that patients with OSA who are overweight or obese be treated with comprehensive lifestyle intervention consisting of 1) a reduced-calorie diet, 2) exercise or increased physical activity, and 3) behavioral guidance. Conditional recommendations were made regarding reduced-calorie diet and exercise/increased physical activity as separate management tools. Pharmacological therapy and bariatric surgery are appropriate for selected patients who require further assistance with weight loss.

Conclusions: Weight-loss interventions, especially comprehensive lifestyle interventions, are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. The American Thoracic Society recommends that clinicians regularly assess weight and incorporate weight management strategies that are tailored to individual patient preferences into the routine treatment of adult patients with OSA who are overweight or obese.
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http://dx.doi.org/10.1164/rccm.201807-1326STDOI Listing
September 2018

Health-related correlates of psychological well-being among girls and boys 6-8 years of age: The Physical Activity and Nutrition in Children study.

J Paediatr Child Health 2018 May 3;54(5):506-509. Epub 2018 Apr 3.

Institute of Biomedicine/Physiology, University of Eastern Finland, Finland.

Aim: Due to limited knowledge on the differences in the correlates of psychological well-being (PSWB) between girls and boys, we compared the correlates of PSWB between primary school girls and boys.

Methods: A population sample of 412 children participated in the Physical Activity and Nutrition in Children study. Parents completed a questionnaire that included 19 questions on the components of PSWB, and a PSWB score was computed. We assessed correlates of PSWB, including physical activity, sedentary behaviour, cardiorespiratory fitness, diet quality, body fat content, sleep duration, sleep disordered breathing, prevalent diseases and parental characteristics. We used logistic regression to analyse the risk of being in the lowest third of the PSWB scores.

Results: Low parental education was associated with increased risk (odds ratio (OR) 2.34, P = 0.039) and high cardiorespiratory fitness with decreased risk (OR 0.26, P = 0.006) of poor PSWB in girls. At least 2 h of screen-based sedentary behaviour per day (OR 1.93, P = 0.037), daily parental smoking (OR 2.10, P = 0.034) and sleep disordered breathing (OR 4.24, P = 0.003) were related to increased risk of poor PSWB in boys.

Conclusions: There are large differences in the correlates of PSWB between girls and boys. Most of these correlates are modifiable and related to the health behaviour of children and their parents.
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http://dx.doi.org/10.1111/jpc.13891DOI Listing
May 2018

Predictors of sleep disordered breathing in children: the PANIC study.

Eur J Orthod 2018 05;40(3):268-272

Institute of Dentistry, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.

Objective: We studied longitudinally the associations of craniofacial morphology, mouth breathing, orthodontic treatment, and body fat content with the risk of having and developing sleep disordered breathing (SDB) in childhood. We hypothesized that deviant craniofacial morphology, mouth breathing, and adiposity predict SDB among children.

Materials And Methods: The participants were 412 children 6-8 years of age examined at baseline and 329 children aged 9-11 years re-examined at an average 2.2-year follow-up. An experienced orthodontist evaluated facial proportions, dental occlusion, soft tissue structures, and mode of breathing and registered malocclusions in orthodontic treatment. Body fat percentage was assessed by dual-energy X-ray absorptiometry and SDB symptoms by a questionnaire.

Results: Children with SDB more likely had convex facial profile, increased lower facial height, mandibular retrusion, tonsillar hypertrophy, and mouth breathing at baseline and convex facial profile, mandibular retrusion, and mouth breathing at follow-up than children without SDB at these examinations. Male gender and body adiposity, mouth breathing, and distal molar occlusion at baseline were associated with SDB later in childhood. Adipose tissue under the chin, mandibular retrusion, vertically large or normal throat and malocclusion in orthodontic treatment at baseline predicted developing SDB during follow-up of among children without SDB at baseline.

Limitations: We could not conduct polysomnographic examinations to define sleep disturbances. Instead, we used a questionnaire filled out by the parents to assess symptoms of SDB.

Conclusions: The results indicate that among children, deviant craniofacial morphology, mouth breathing, body adiposity, and male gender seem to have implications in the pathophysiology of SDB.
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http://dx.doi.org/10.1093/ejo/cjx056DOI Listing
May 2018

Sleep of professional athletes: Underexploited potential to improve health and performance.

J Sports Sci 2017 Apr 13;35(7):704-710. Epub 2016 May 13.

b Institute of Public Health and Clinical Nutrition, Department of Clinical Nutrition , University of Eastern Finland , Kuopio , Finland.

Sleep disorders have become increasingly prevalent affecting health and working ability. Restorative sleep may be considered important for athletes' successful recovery and performance. However, some athletes seem to experience major problems in sleeping. Thus far, there is limited scientific information about their sleep. This study aimed to evaluate the quality of sleep and the prevalence of sleep disorders as well as the impact of a structured sleep counselling protocol in professional athletes. A total of 107 professional ice hockey players participated in the study. The exploratory observational 1-year follow-up study consisted of questionnaire-based sleep assessment followed by general sleep counselling and, when needed, polysomnography and an individual treatment plan. One in every four players was found to have a significant problem in sleeping. All athletes considered sleep essential for their health and three in every four players considered that counselling would improve their performance. Counselling and individual treatment were found to improve significantly the quality of sleep with the mean alteration of 0.6 (95% CI 0.2-1.0, P = 0.004) in a scale from 0 to 10. Our results support that sleep problems are common in professional athletes. However, systematic examination, counselling and individual treatment planning can improve the quality of their sleep.
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http://dx.doi.org/10.1080/02640414.2016.1184300DOI Listing
April 2017

Mild obstructive sleep apnea does not modulate baroreflex sensitivity in adult patients.

Nat Sci Sleep 2015 25;7:73-80. Epub 2015 Jun 25.

Department of Clinical Nutrition, School of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland ; Oivauni Sleep Clinic, Kuopio, Finland.

Background: Obstructive sleep apnea (OSA) is a chronic and progressive disease. OSA is associated with increased cardiovascular morbidity and mortality, the risk being more frequently encountered with severe degrees of OSA. Increased sympathetic activation and impaired cardiac autonomic control as reflected by depressed baroreceptor reflex sensitivity (BRS) are possible mechanisms involved in the cardiovascular complications of OSA. However, it is not known at what stage of OSA that changes in BRS appear. The aim of this study was to evaluate BRS in patients with mild OSA.

Methods: The study population consisted of 81 overweight patients with mild OSA and 46 body weight-matched non-OSA subjects. BRS, apnea-hypopnea index, body mass index, and metabolic parameters were assessed. The phenylephrine test was used to measure BRS.

Results: Patients in the OSA group were slightly but significantly older than the non-OSA population (50.3±9.3 years vs 45.7±11.1 years, P=0.02). Body mass index, percentage body fat, blood pressure, fasting glucose, insulin, and lipid levels did not differ between the OSA patients and non-OSA subjects. Absolute BRS values in patients with mild OSA and non-OSA subjects (9.97±6.70 ms/mmHg vs 10.51±7.16 ms/mmHg, P=0.67) and BRS values proportional to age-related and sex-related reference values (91.4%±22.7% vs 92.2%±21.8%, P=0.84) did not differ from each other. BRS <50% of the sex-specific reference value was found in 6% of patients with mild OSA and in 2% of non-OSA subjects (P=0.29).

Conclusion: Patients with mild OSA did not show evidence of disturbed BRS in comparison with weight-matched non-OSA controls.
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http://dx.doi.org/10.2147/NSS.S82443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4487157PMC
July 2015

Effect of oxygen desaturation threshold on determination of OSA severity during weight loss.

Sleep Breath 2016 Mar 21;20(1):33-42. Epub 2015 Apr 21.

Department of Clinical Neurophysiology, Kuopio University Hospital, PO Box 100, 70029, Kuopio, Finland.

Purpose: Weight loss leads to improvement of obstructive sleep apnea (OSA), based on frequency of respiratory events (apnea-hypopnea index, AHI). However, AHI does not incorporate the severity of individual obstruction events. The American Academy of Sleep Medicine suggests two alternative oxygen desaturation thresholds (ODT) for scoring of hypopneas. We hypothesize that lowering the ODT level increases the determined impact of weight loss on OSA severity. We investigate this during weight change with AHI and adjusted AHI. Adjusted AHI is a novel parameter incorporating both severity and number of the events.

Methods: Ambulatory polygraphic data of 54 OSA patients (F 15/M 39, 51.7 ± 8.4 years), divided into weight loss (>5 %, n = 20), control (weight change 0-5 %, n = 26), and weight gain (>5 %, n = 8) groups, were evaluated at baseline and after 5-year follow-up. Effect of ODT (ODT2%-ODT6%) on AHI and adjusted AHI was investigated.

Results: The greatest changes in AHI (decrease in weight loss group and increase in weight gain group) were observed with ODT2%. Changes in AHI diminished with increasing ODT. In weight loss group, adjusted AHI showed a similar but non-significant trend. In contrast, the higher ODT was used in weight gain group, the greater increase in adjusted AHI resulted. Using adjusted AHI instead of AHI, led to a smaller number of patients (20 vs. 55 %, ODT3%) whose OSA severity category improved along weight loss.

Conclusions: Weight loss significantly reduced AHI. This reduction was highly dependent on selected ODT. The change in adjusted AHI did not occur in the same extent. This was expected as the more severe events which tend to remain during the weight loss have greater importance in adjusted AHI, while the event severity is neglected in AHI.
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http://dx.doi.org/10.1007/s11325-015-1180-4DOI Listing
March 2016

Lateral facial profile may reveal the risk for sleep disordered breathing in children--the PANIC-study.

Acta Odontol Scand 2015 20;73(7):550-5. Epub 2015 Apr 20.

Institute of Dentistry, Faculty of Health Sciences, University of Eastern Finland , Kuopio , Finland.

Objective: To evaluate the lateral view photography of the face as a tool for assessing morphological properties (i.e. facial convexity) as a risk factor for sleep disordered breathing (SDB) in children and to test how reliably oral health and non-oral healthcare professionals can visually discern the lateral profile of the face from the photographs.

Materials And Methods: The present study sample consisted of 382 children 6-8 years of age who were participants in the Physical Activity and Nutrition in Children (PANIC) Study. Sleep was assessed by a sleep questionnaire administered by the parents. SDB was defined as apnoeas, frequent or loud snoring or nocturnal mouth breathing observed by the parents. The facial convexity was assessed with three different methods. First, it was clinically evaluated by the reference orthodontist (T.I.). Second, lateral view photographs were taken to visually sub-divide the facial profile into convex, normal or concave. The photos were examined by a reference orthodontist and seven different healthcare professionals who work with children and also by a dental student. The inter- and intra-examiner consistencies were calculated by Kappa statistics. Three soft tissue landmarks of the facial profile, soft tissue Glabella (G`), Subnasale (Sn) and soft tissue Pogonion (Pg`) were digitally identified to analyze convexity of the face and the intra-examiner reproducibility of the reference orthodontist was determined by calculating intra-class correlation coefficients (ICCs). The third way to express the convexity of the face was to calculate the angle of facial convexity (G`-Sn-Pg`) and to group it into quintiles. For analysis the lowest quintile (≤164.2°) was set to represent the most convex facial profile.

Results: The prevalence of the SDB in children with the most convex profiles expressed with the lowest quintile of the angle G`-Sn-Pg` (≤164.2°) was almost 2-fold (14.5%) compared to those with normal profile (8.1%) (p = 0.084). The inter-examiner Kappa values between the reference orthodontist and the other examiners for visually assessing the facial profile with the photographs ranged from poor-to-moderate (0.000-0.579). The best Kappa values were achieved between the two orthodontists (0.579). The intra-examiner Kappa value of the reference orthodontist for assessing the profiles was 0.920, with the agreement of 93.3%. In the ICC and its 95% CI between the two digital measurements, the angles of convexity of the facial profile (G`-Sn-Pg`) of the reference orthodontist were 0.980 and 0.951-0.992.

Conclusion: In addition to orthodontists, it would be advantageous if also other healthcare professionals could play a key role in identifying certain risk features for SDB. However, the present results indicate that, in order to recognize the morphological risk for SDB, one would need to be trained for the purpose and, as well, needs sufficient knowledge of the growth and development of the face.
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http://dx.doi.org/10.3109/00016357.2014.997795DOI Listing
February 2016

Endoscopic dacryocystorhinostomy as treatment for lower lacrimal pathway obstructions in adults: Review article.

Allergy Rhinol (Providence) 2015 Jan;6(1):12-9

Department of Otorhinolaryngology, and University of Eastern Finland, and Kuopio University Hospital, Finland.

Obstruction of the lacrimal pathway is manifested by epiphora, infection, and blurred vision as well as ocular and facial pain. Conservative treatments only achieve temporary relief of symptoms, thus surgery is the treatment of choice. Dacryocystorhinostomy (DCR) is recognized as the most suitable treatment for patients with obstructions of the lacrimal system at the level of the sac or in the nasolacrimal duct. The aim of this operation is to create a bypass between the lacrimal sac and the nasal cavity. During the past 2 decades, advances in rigid endoscopic equipment and other instruments have made it possible to obtain more information about the anatomic landmarks of the nasolacrimal system, which led to the development of less-invasive and safer endoscopic techniques. However, many parts of the treatment process related to endoscopic endonasal dacryocystorhinostomy (EN-DCR) still remain controversial. This article reviews the published literature about the technical issues associated with the success of EN-DCR, and clarifies the pros and cons of different pre- and postoperative procedures in adults with lower lacrimal pathway obstructions.
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http://dx.doi.org/10.2500/ar.2015.6.0116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388871PMC
January 2015

Effect of different oxygen desaturation threshold levels on hypopnea scoring and classification of severity of sleep apnea.

Sleep Breath 2015 Sep 22;19(3):947-54. Epub 2015 Jan 22.

Department of Clinical Neurophysiology, Kuopio University Hospital, PO Box 100, FI-70029, Kuopio, Finland,

Purpose: Recently, there has been a debate about the rules used to score hypopnea events. The purpose of this study was to examine the effect of different oxygen desaturation threshold (ODT) levels on the apnea-hypopnea index (AHI) and on a recently introduced parameter, adjusted AHI. Adjusted AHI incorporates the severity of individual breathing cessation events. We also aimed to clarify the impact of the different ODT levels on the current classification of obstructive sleep apnea (OSA) severity.

Methods: Ambulatory polygraphic recordings of 68 patients (19 F/49 M, median age 53.2 years, AHI ≥5) were analyzed retrospectively. Hypopneas were defined as ≥30% drop in airflow for ≥10 s associated with ≥2% oxygen desaturation (ODT2%), and after that, using stricter ODT criteria (ODT3%-ODT8%).

Results: Compared to ODT4%, the ODT3% resulted in 5.6 events/h higher median conventional AHI, but only 1.5 events/h higher median adjusted AHI. A significant rearrangement of patients between the clinical severity categories took place when using different ODTs. When assessing with ODT3% instead of ODT4%, the portion of the patients with moderate or severe OSA (AHI ≥15) raised from 29.4 to 73.5% using conventional AHI, but only marginally, i.e., from 73.5 to 77.9%, using the adjusted AHI.

Conclusions: The conventional AHI was found to be susceptible even to minor changes in ODT level which may lead to substantial variability in AHI-based classification of disease severity. Since the adjusted AHI comprises information on severity of individual breathing cessations, it reduces the variability related to ODT levels used in hypopnea scoring and can increase the accuracy of estimation of OSA severity.
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http://dx.doi.org/10.1007/s11325-015-1118-xDOI Listing
September 2015

Author response to: endothelial function is not always well preserved in obese patients with mild OSA.

Sleep Breath 2015 Mar 2;19(1):17-8. Epub 2014 Jul 2.

Institute of Clinical Medicine, Department of Otorhinolaryngology, Kuopio University Hospital and the University of Eastern Finland, Kuopio, Finland,

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http://dx.doi.org/10.1007/s11325-014-1017-6DOI Listing
March 2015

Upregulation of inflammatory genes in the nasal mucosa of patients undergoing endonasal dacryocystorhinostomy.

Clin Ophthalmol 2014 25;8:799-805. Epub 2014 Apr 25.

Department of Ophthalmology, Institute of Clinical Medicine, University of Eastern Finland ; Department of Ophthalmology, Kuopio University Hospital, Kuopio, Finland.

Background: Epiphora is a common complaint of nasolacrimal duct obstruction (NLDO) in adults. The precise pathogenesis of NLDO is still unknown, but inflammatory processes are believed to be predisposing factors. Endoscopic dacryocystorhinostomy (EN-DCR) is an effective surgical technique for treating symptomatic NLDO. The purpose of the procedure is to relieve the patient's symptoms by creating an opening, ie, a rhinostoma, between the lacrimal sac and the nasal cavity. Although the success rates after EN-DCR are high, the procedure sometimes fails due to onset of a fibrotic process at the rhinostomy site. The aim of this prospective comparative study was to investigate inflammation-related gene expression in the nasal mucosa at the rhinostomy site.

Methods: Ten participants were consecutively recruited from eligible adult patients who underwent primary powered EN-DCR (five patients) or septoplasty (five controls). Nasal mucosa specimens were taken from the rhinostomy site at the beginning of surgery for analysis of gene expression. Specimens were taken from the same site on the lateral nasal wall for controls. Quantitative reverse transcription polymerase chain reaction (qRT-PCR) was performed for the inflammatory genes interleukin (IL)-6, IL-1β, and CCL2, and because of a clear trend of increased inflammation in the EN-DCR samples, a wider PCR array was performed to compare inflammation-related gene expression in EN-DCR subjects and corresponding controls.

Results: Our qRT-PCR results revealed a clear trend of increased transcription of IL-6, IL-1β, and CCL2 (P=0.03). The same trend was also evident in the PCR array, which additionally revealed notable differences between EN-DCR subjects and controls with regard to expression of several other inflammation-related mediators. At 6-month follow-up, the success rate after primary EN-DCR was 60%, ie, in three of five patients.

Conclusion: The present study demonstrates that there is an intense inflammation gene expression response in the nasal mucosa of patients undergoing EN-DCR.
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http://dx.doi.org/10.2147/OPTH.S50195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4010629PMC
May 2014

Lifestyle changes aiming at weight loss should always be included in the treatment of obese patients with obstructive sleep apnea.

Sleep 2014 May 1;37(5):1021. Epub 2014 May 1.

Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland ; Clinical Research Center, Kuopio University Hospital, Kuopio, Finland.

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http://dx.doi.org/10.5665/sleep.3682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985109PMC
May 2014

The impact of weight reduction in the prevention of the progression of obstructive sleep apnea: an explanatory analysis of a 5-year observational follow-up trial.

Sleep Med 2014 Mar 31;15(3):329-35. Epub 2014 Jan 31.

Clinical Research Center, Kuopio University Hospital, Kuopio, Finland; Department of Medicine, Division of Internal Medicine, University of Helsinki, Helsinki, Finland.

Background: Obstructive sleep apnea (OSA) is a chronic progressive disease, and it is well-documented that severe OSA is associated with an increased cardiovascular morbidity and mortality. Weight reduction has been shown to improve OSA; however, we need further evidence to determine if it may prevent the progression of OSA in the long term. The aim of our study was to assess the impact of weight change during a 5-year observational follow-up of an original 1-year randomized controlled trial.

Methods: The participants were divided into the two groups according to the weight change at 5-year follow-up using the 5% weight loss as a cutoff point, which was later referred to as the successful (n = 20) or unsuccessful groups (n = 27). The change in apnea-hypopnea index (AHI) was the main objective outcome variable.

Results: Fifty-seven patients participated in the 5-year follow-up. At 5 years from the baseline, the change in AHI between the groups was significant in the successful group (-3.5 [95% confidence interval {CI}, -6.1 to -0.9]) compared with the unsuccessful group (5.0 [95% CI, 2.0-8.5]) (P = .002). Successful weight reduction achieved an 80% reduction in the incidence of progression of OSA compared to the unsuccessful group (log-rank test, P = .016).

Conclusions: A moderate but sustained weight reduction can prevent the progression of the disease or even cure mild OSA in obese patients.
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http://dx.doi.org/10.1016/j.sleep.2013.11.786DOI Listing
March 2014

Cholesterol metabolism and weight reduction in subjects with mild obstructive sleep apnoea: a randomised, controlled study.

Cholesterol 2013 16;2013:769457. Epub 2013 May 16.

Institute of Public Health and Clinical Nutrition, Department of Clinical Nutrition, University of Eastern Finland, P.O. BOX 1627, 70211 Kuopio, Finland.

To evaluate whether parameters of obstructive sleep apnoea (OSA) associate with cholesterol metabolism before and after weight reduction, 42 middle-aged overweight subjects with mild OSA were randomised to intensive lifestyle intervention (N = 23) or to control group (N = 18) with routine lifestyle counselling only. Cholesterol metabolism was evaluated with serum noncholesterol sterol ratios to cholesterol, surrogate markers of cholesterol absorption (cholestanol and plant sterols) and synthesis (cholestenol, desmosterol, and lathosterol) at baseline and after 1-year intervention. At baseline, arterial oxygen saturation (SaO2 ) was associated with serum campesterol (P < 0.05) and inversely with desmosterol ratios (P < 0.001) independently of gender, BMI, and homeostasis model assessment index of insulin resistance (HOMA-IR). Apnoea-hypopnoea index (AHI) was not associated with cholesterol metabolism. Weight reduction significantly increased SaO2 and serum cholestanol and decreased AHI and serum cholestenol ratios. In the groups combined, the changes in AHI were inversely associated with changes of cholestanol and positively with cholestenol ratios independent of gender and the changes of BMI and HOMA-IR (P < 0.05). In conclusion, mild OSA seemed to be associated with cholesterol metabolism independent of BMI and HOMA-IR. Weight reduction increased the markers of cholesterol absorption and decreased those of cholesterol synthesis in the overweight subjects with mild OSA.
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http://dx.doi.org/10.1155/2013/769457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671279PMC
June 2013

Endothelial function is well preserved in obese patients with mild obstructive sleep apnea.

Sleep Breath 2014 Mar 4;18(1):177-86. Epub 2013 Jun 4.

Institute of Clinical Medicine, Department of Otorhinolaryngology, Kuopio University Hospital, and University of Eastern Finland, P.O. Box 1777, 70211, Kuopio, Finland,

Purpose: Endothelial dysfunction is one of the early markers of cardiovascular complications in obstructive sleep apnea (OSA). The aim of our study was to evaluate whether overweight patients with mild OSA displayed endothelial dysfunction, and to assess the effect of 1-year lifestyle intervention with an early very low calorie diet in endothelial function.

Methods: At baseline, the study population consisted of 83 overweight patients with mild OSA and 46 weight-matched non-OSA subjects. OSA patients were further randomized into a 1-year supervised lifestyle intervention group or control group which received routine lifestyle counselling. Endothelial function measured by brachial artery flow-mediated dilatation (FMD), apnea-hypopnea index (AHI), body mass index (BMI), and metabolic parameters were assessed at baseline and 12 months.

Results: No correlations between endothelial function and mild OSA were detected. However, patients with impaired endothelial function had lower mean saturation and impaired endothelial function correlated significantly with glucose intolerance and dyslipidemia. After the lifestyle intervention and successful weight reduction, AHI, BMI, serum triglycerides and insulin improved significantly; however, no improvement in FMD was detected.

Conclusions: Mild OSA was not observed to be associated with endothelial dysfunction. Although in mild OSA endothelial function is still preserved, lifestyle intervention with weight reduction did achieve an improvement in other obesity-related risk factors for cardiovascular diseases, thus highlighting the importance of early intervention.
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http://dx.doi.org/10.1007/s11325-013-0867-7DOI Listing
March 2014

The health-related quality-of-life impact of nocturnal awakenings in the middle-aged and older Finnish population.

Qual Life Res 2013 Dec 3;22(10):2737-48. Epub 2013 Apr 3.

Pharmacoeconomics & Outcomes Research Unit (PHORU), School of Pharmacy, Social Pharmacy, University of Eastern Finland, B.O.Box 1627, 70211, Kuopio, Finland,

Purpose: The aim of the study is to examine the health-related quality-of-life (HRQOL) impact of the nocturnal awakenings and the duration of the sleep in the Finnish middle-aged and older population.

Methods: Cross-sectional sample consisted of 823 community-dwelling persons aged 55-75 living in a single municipality in a rural area of Eastern Finland. Frequency of the nocturnal awakenings was dichotomized as reporting "frequent," if the participant reported subjectively awakening "often" or "very often," and "infrequent" if the participant reported awakening "sometimes" or less frequently. HRQOL was measured with a preference-based HRQOL-index instrument, 15D. Analyses were adjusted for gender, BMI, morbidities, depression, employment and marital status, current smoking and drinking, exercise, recommendation to exercise from a health care professional, and subjective opinion about own exercise habits.

Results: Frequent nocturnal awakenings had statistically and clinically significant negative impact on HRQOL, the mean (SE) adjusted marginal HRQOL impact being -0.0416 (0.006). More than 10 and less than 6.5 h of daily sleep were associated with higher probability of having low HRQOL, adjusted odd ratios (95 % CI) being 2.65 (1.11-6.33) and 2.65 (1.55-4.52), respectively. However, the changes in daily sleep duration did not have noticeable influence on the significance or magnitude of the negative HRQOL impact of the frequent nocturnal awakenings.

Conclusions: Nocturnal awakenings displayed a strong independent association with decreased HRQOL. The findings suggest that both clinicians and researchers should pay closer attention to nocturnal awakenings and other sleep problems in order to find ways to improve the quality of life in individuals with such conditions.
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http://dx.doi.org/10.1007/s11136-013-0404-yDOI Listing
December 2013

Obesity and obstructive sleep apnea--clinical significance of weight loss.

Sleep Med Rev 2013 Oct 16;17(5):321-9. Epub 2012 Oct 16.

Oivauni Sleep Clinic, Puijonkatu 12B, 70100 Kuopio, Finland.

Obesity is a major health burden that contributes to increased morbidity and mortality. Obesity is also the most important risk factor for obstructive sleep apnea (OSA); at least 70% of patients are obese. OSA as such, has been linked with increased cardiovascular morbidity and mortality, and OSA patients often display metabolic syndrome. The exact underlying mechanisms behind these associations are complex and not fully understood. In obese individuals, weight reduction and increased physical activity form cornerstones for the prevention and treatment of metabolic syndrome, and recent controlled intervention trials strongly suggest that weight reduction together with a healthy diet and increased physical activity may correct or at least improve the symptoms of OSA. However, regardless of promising results in terms of symptoms of OSA and the undoubted metabolic benefits of changing lifestyles, weight reduction as a treatment of OSA is still underrated by many clinicians. Based on the current knowledge, clinicians should revise their previous attitudes, including suspicions about weight reduction as an effective treatment for OSA patients. Nevertheless, we also need large well-controlled trials on the effects of different weight reduction programs among OSA patients to determine the overall efficacy of different treatment modalities and their long-term success.
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http://dx.doi.org/10.1016/j.smrv.2012.08.002DOI Listing
October 2013

Craniofacial morphology but not excess body fat is associated with risk of having sleep-disordered breathing--the PANIC Study (a questionnaire-based inquiry in 6-8-year-olds).

Eur J Pediatr 2012 Dec 28;171(12):1747-52. Epub 2012 Jul 28.

Oral and Maxillofacial Department, Kuopio University Hospital, P.O. Box 1777, 70211 Kuopio, Finland.

Unlabelled: We investigated the associations of dental occlusion, other craniofacial features and body fat with paediatric sleep-disordered breathing (SDB) in a representative population sample of 491 Finnish children 6-8 years of age. Overweight and obesity were defined using age- and sex-specific body mass index cutoffs by International Obesity Task Force (IOTF) criteria. Body fat percentage was assessed by dual-energy X-ray absorptiometry. Facial proportions, dental occlusion and soft tissue structures were evaluated by an orthodontist. Sleep was assessed by a sleep questionnaire administered by the parents. SDB was defined as apnoeas, frequent or loud snoring or nocturnal mouth breathing observed by the parents. The prevalence of SDB was 9.9 % with no difference between boys and girls. The median (interquartile range) of body fat percentage was 20.6 (17.4-27.1) in girls and 15.0 (11.4-21.6) in boys. Altogether 11.4 % of boys and 15.6 % of girls were classified as having overweight or obesity according to the IOTF criteria. There was no difference in the prevalence of overweight, obesity or body fat percentage between children with SDB and those without it. Children with tonsillar hypertrophy had a 3.7 times higher risk of suffering SDB than those with normal size tonsils after adjustment for age, sex and body fat percentage. Furthermore, children with cross bite had a 3.3 times higher risk of having SDB than those without cross bite, and children with a convex facial profile had a 2.6 times higher risk of having SDB than those with a normal facial profile.

Conclusion: Abnormal craniofacial morphology, but not excess body fat, is associated with an increased risk of having SDB in 6-8-year-old children. A simple model of necessary clinical examinations (i.e. facial profile, dental occlusion and tonsils) is recommended to recognize children with an increased risk of SDB.
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http://dx.doi.org/10.1007/s00431-012-1757-xDOI Listing
December 2012

The association between anxiety and the degree of illness in mild obstructive sleep apnoea.

Clin Respir J 2013 Apr;7(2):197-203

Department of Psychiatry, Institute of Clinical Medicine, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland.

Introduction: Obstructive sleep apnoea (OSA) has been reported to associate with anxiety, but earlier observations are scarce and the role of the persistence of anxiety in this connection is unclear.

Objectives: To examine the associations between OSA and anxiety, and in particular clarify the observations regarding the role of the persistence of anxiety in this connection.

Methods: A total of 61 overweight patients with mild OSA participated in a 12-month lifestyle modification study and reported the presence of anxiety both at baseline and on 12-month follow up. They were divided into three groups (no anxiety, n = 25; past anxiety, n = 13; persistent anxiety, n = 23), and the degree of illness was assessed with the apnoea-hypopnea index (AHI).

Results: The persistence of anxiety was linearly associated with the AHI (P = 0.025), which was highest in individuals with persistent anxiety. The likelihood of belonging to the group with persistent anxiety increased 18% for each one-unit increase in the AHI in a model adjusted for age, gender and bodyfat % (odds ratio 1.18, 95% confidence interval 1.03-1.34, P = 0.014). Further adjustments for daytime sleepiness and the effect of participating in the lifestyle modification intervention did not alter this finding.

Conclusion: Our observations suggest that the persistence of anxiety is independently associated with elevated levels of sleep-disordered breathing and that lifestyle modification interventions with a focus on diet and exercise alone may not be sufficient to treat OSA in individuals with simultaneous persistent anxiety.
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http://dx.doi.org/10.1111/j.1752-699X.2012.00304.xDOI Listing
April 2013

[Surgery for lower nasolacrimal duct obstructions in adults].

Duodecim 2012 ;128(2):205-11

KYS, korva-, nenä- ja kurkkutautien klinikka, Itä-Suomen yliopisto, kliinisen lääketieteen laitos.

Epiphora and purulent discharge are common and irritating clinical manifestations of nasolacrimal duct obstruction (NLDO). If conservative treatment fails, dacryocystorhinostomy (DCR) has proven an efficient surgical method. The aim of DCR is to bypass the obstruction by creating a stoma between the lacrimal sac and the nasal cavity. External DCR has been the gold standard for decades. In recent years with the development of nasal endoscopes, less invasive surgical techniques, such as endonasal endoscopic DCR have become an increasingly popular procedure in the treatment of patients with NLDO. In such patients, the success rates for both external and endonasal DCR are about 90% and a successful procedure has a significant impact on the quality of life.
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April 2012

Mitomycin C in revision endoscopic dacryocystorhinostomy: a prospective randomized study.

Am J Rhinol Allergy 2011 Nov-Dec;25(6):425-8

Department of Otorhinolaryngology, Institute of Clinical Medicine, Kuopio University Hospital, and University of Eastern Finland, Finland.

Background: Endoscopic dacryocystorhinostomy (EN-DCR) is an effective and safe procedure when treating saccal and postsaccal nasolacrimal duct obstruction. However, sometimes scarring of the rhinostomy site caused by fibrosis may occur, particularly in revision operations. The application of intraoperative mitomycin C (MMC), an antiproliferative agent, has been introduced as one possible technique to improve the outcome. We conducted a prospective, randomized study to evaluate if the use of MMC improves the success in endonasal revision DCR procedure.

Methods: Thirty revision EN-DCR procedures were performed during 2004-2010. The patients were randomized into two study groups, according to whether the intraoperative MMC was used or not. The technique of EN-DCR procedure in both groups was the same, but in the MMC group, at the end of the procedure a piece of tampon soaked in MMC (0.4 mg/mL) was placed into the rhinostoma for 5 minutes. No silicone stents were inserted. The surgical outcome at the 6-month follow-up visit was considered successful if the lacrimal sac irrigation succeeded and if the patients' symptoms were relieved.

Results: The success rate after revision EN-DCR with MMC was 93% and without MMC was 60%. The overall success rate was 77%. The difference between the two groups was not statistically significant (p = 0.08). The relief of the symptoms between groups in both the Nasolacrimal Duct Obstruction Symptom Score and ocular symptoms was statistically significant (p = 0.007 and p = 0.02, respectively).

Conclusion: The results of our study indicate that the application of intraoperative mitomycin C may improve the outcome in revision EN-DCR.
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http://dx.doi.org/10.2500/ajra.2011.25.3676DOI Listing
May 2012

Impaired nasal breathing may prevent the beneficial effect of weight loss in the treatment of OSA.

Rhinology 2011 12;49(5):587-92

Department of Otorhinolaryngology, Kuopio University Hospital, Institute of Clinical Medicine, University of Eastern Finland, Finland.

Background: Weight loss is considered an effective treatment for obstructive sleep apnoea (OSA) in overweight patients. Some patients, however, do not benefit from weight loss. It has been postulated that nasal obstruction may act as an independent risk factor for OSA.

Objective: The aim of our study was to evaluate whether impaired nasal airflow might explain the missing effect of weight reduction on OSA.

Methodology: Fifty-two overweight adult patients with mild OSA were recruited. After the 12-month lifestyle intervention, all patients who achieved more than 5% weight loss were divided into two groups based on whether they still had OSA or not. Change in nasal resistance measured by rhinomanometer and AHI were the main outcome variables.

Results: A total of 26/52 patients achieved 5% weight reduction. Of those 26 patients, 16 were objectively cured from OSA and 10 patients did not benefit from weight loss. Nasal resistance reduced significantly more in patients who had been cured from OSA. Smoking had a negative impact on both nasal resistance and improvement of AHI.

Conclusions: Impaired nasal breathing and smoking may prevent the beneficial effects of weight reduction in the treatment of OSA.
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http://dx.doi.org/10.4193/Rhin11.131DOI Listing
December 2011

Initial improvements in apnoea-hypopnoea index after very low calorie diet maintained for 1 year with weight loss maintenance program.

Evid Based Med 2012 Feb 6;17(1):32-3. Epub 2011 Sep 6.

Kuopio University Hospital, Kuopio, Finland.

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http://dx.doi.org/10.1136/ebm.2011.100169DOI Listing
February 2012

Symptom score questionnaire for nasolacrimal duct obstruction in adults--a novel tool to assess the outcome after endoscopic dacryocystorhinostomy.

Rhinology 2010 Dec;48(4):446-51

Department of Otorhinolaryngology, Institute of Clinical Medicine, Kuopio University Hospital, and University of Eastern Finland, Finland.

Background: The incidence of nasolacrimal pathway obstruction increases with age, and dacryocystorhinostomy (DCR) is a commonly applied surgical technique to treat severe cases. However, no disease-specific tools to assess the symptoms and the subjective outcome after DCR have been established. We have developed a specific Nasolacrimal Duct Obstruction Symptom Score (NLDO-SS) questionnaire to evaluate the outcome, and tested it in a prospective clinical trial.

Study Design: Prospective clinical follow-up study.

Methods: Sixty-eight consecutive primary endoscopic dacryocystorhinostomy (EN-DCR) procedures were performed in 64 patients during 2004-2008. Preoperatively and during the three follow-up visits (at 1 week, 2 and 6 months), the patients filled in the NLDO-SS, and at the second and third follow-up visits they also filled in the Glasgow Benefit Inventory (GBI) questionnaire. At one year after the operation, a GBI questionnaire was sent to the patients.

Results: The surgical success rate of EN-DCR was 93 %. EN-DCR resulted in a significant reduction in all of the eight symptoms scores of the NLDO-SS (p= 0.001). The GBI scores indicated a significant benefit at 2 months (+37 (SD; 28) and an even higher benefit at 6 months after surgery (+52 (SD; 29), p= 0.001), but no further improvement was found between 6 and 12 months (+52 vs +52, p= 1.0). The correlation between the total GBI and NLDO-SS was significant (p=0.001).

Conclusions: EN-DCR significantly improves the quality of life as measured by the GBI. The NLDO-SS correlated with the GBI and gave more information about the benefits after EN-DCR than GBI alone. The NLDO-SS proved to be an effective tool to evaluate lacrimal obstructions and EN-DCR benefits. Further studies to validate NLDO-SS are needed.
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http://dx.doi.org/10.4193/Rhino10.069DOI Listing
December 2010

Risk factors for sleep-disordered breathing: the role of craniofacial structure.

Acta Odontol Scand 2011 May 28;69(3):137-43. Epub 2010 Dec 28.

Oral and Maxillofacial Department, Kuopio University Hospital, Kuopio, Finland.

Objective: To evaluate possible differences in craniofacial structure between overweight patients and normal-weight patients with mild sleep-disordered breathing (SDB).

Material And Methods: Subjects were recruited from patients referred to Kuopio University Hospital due to suspicion of SDB. They were divided into two groups based on their body mass index (BMI). The overweight group (BMI > 27 kg/m(2)) consisted of 58 males and 19 females and the normal weight group (BMI ≤ 27 kg/m(2)) of 33 males and 15 females. The mean age of the subjects was 51.4 years. All subjects underwent an overnight cardiorespiratory recording. The mean apnea-hypopnea index (AHI) was 9.3 events/h for the entire study population. Occlusion and craniofacial morphology were examined by an experienced orthodontist.

Results: Significant differences in craniofacial morphology and occlusion were found between the groups: the craniofacial profile in normal-weight patients was more convex (P < 0.000) and the mandible more retrusive (P = 0.004) than in overweight subjects. In addition, distal molar occlusion (P = 0.005) was more prevalent in normal-weight subjects, and their overjet and overbite were increased as compared to overweight patients (P = 0.009 and 0.006, respectively). Similarly, cross bite was detected significantly more often in normal-weight subjects (P = 0.052).

Conclusions: These results reveal that deviations in craniofacial morphology and occlusion are more frequent in normal subjects than in overweight subjects with mild SDB; this may well have implications in the pathophysiology of SDB.
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http://dx.doi.org/10.3109/00016357.2010.545033DOI Listing
May 2011