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According to the cognitive neuropsychological hypothesis of antidepressant action, the onset of subjectively experienced therapeutic effects to treatment is preceded by favourable changes in psychological functioning that can be measured by implicit methods. The aim of this study was to examine additional data to explore this hypothesis in an intention-to-treat repetitive transcranial magnetic stimulation (rTMS) study targeting the right parietal cortex. Changes in depression scores from baseline and the sensitivity for recognizing emotional facial expressions were studied in 28 patients with depressive disorder receiving ten sessions of real (n=14) or sham (n=14) rTMS treatments in a double-blind, sham-controlled design. In the patient group results showed significantly higher sensitivity for recognizing angry facial expressions in response to receiving real compared to receiving sham rTMS treatment. Overall mood improvement was similar across real and sham rTMS treatments. However, the sensitivity for recognizing angry facial expressions was correlated to the percentage decrease in depression scores. These results provide the first preliminary support for the cognitive neuropsychological hypothesis of antidepressant action in rTMS treatment.

Introduction: The intensive care unit is short of a suitable tool for instant detection of cerebral ischemia. Synchronization likelihood (SL) electroencephalography (EEG) analysis has proven to be a promising approach for instant online seizure detection. The aim of this study was to investigate the value of SL analysis in the detection of cerebral ischemia., Patients and Methods: SL analysis was studied using conventional EEG recordings during 143 carotid endarterectomy procedures. We compared EEG data before and after clamping of the carotid artery for 2 different anesthesia protocols (isoflurane or propofol) in patients with and without development of cerebral ischemia, making use of SL analysis. Cerebral ischemia was defined by using EEG variables., Results: Fifty-eight patients received isoflurane and 85 propofol anesthesia of whom overall 27% developed ischemia. In patients from the isoflurane group who developed ischemia, the mean overall SL decreased [from 0.220 (SD 0.052) before clamping to 0.208 (SD 0.044) after clamping; P=0.06] In patients with ischemia in the propofol group, the mean overall SL remained stable (0.185; P=0.87) Patients from both groups without development of ischemia had increased mean overall SL values after clamping [isoflurane: from 0.210 (SD 0.041) before clamping to 0.219 (SD 0.051) after clamping; P=0.08. Propofol: from 0.188 (SD 0.019) to 0.189 (SD 0.021); P=0.57]., Conclusions: No significant changes in the mean SL were observed after development of ischemia during either isoflurane or propofol anesthesia. SL analysis does not seem suitable for detection of cerebral ischemia in anesthetized patients.

In a retrospective cohort study, we evaluated whether improvements in nasal continuous positive airway pressure (nCPAP) technology, particularly the introduction of automatic adjustment of the nCPAP pressure (auto-CPAP), have led to better acceptance and (long-term) compliance in patients with obstructive sleep apnea syndrome (OSAS) as compared to earlier reported data. Questionnaires were sent to 256 patients, who were referred to our clinic for an overnight polysomnography from January 1997 to July 2005 and received nCPAP therapy for OSAS. Of the 256 patients, 24 patients were unavailable for follow-up. Of the remaining 232 patients, 58 patients (25%) had discontinued therapy, while 174 patients (75%) were still using nCPAP after 2 months to 8 years of follow-up. One Hundred and thirty eight (79%) of these 174 patients used nCPAP for at least 4 h/night during >or= 5 nights/week, 82,1% of the conventional nCPAP (fixed pressure CPAP) group (n = 78) and 77,1% of the auto-CPAP group (n = 96). Therefore, including the 58 failures, only 59.5% of patients can be seen as compliant. There were no statistical differences between the fixed pressure CPAP and auto-CPAP users, and between the compliant and non-compliant users according to age, BMI, AHI and Epworth sleepiness scale (ESS). Auto-CPAP patients used significantly more cm H2O. The long-term compliance of nCPAP therapy has have increased only slightly since the introduction of the fixed pressure CPAP 25 years ago, in spite of many efforts to improve it. It seems that a plateau has been reached and that it is unrealistic to aim at a substantially higher compliance rate.

We analyzed the role of sleep position in obstructive sleep apnea syndrome (OSAS). The polysomnograms of 120 patients with sleep apnea syndrome were analyzed. We associated the apnea hypopnea index (AHI) of the supine position with the AHI of the other positions. Patients were stratified in a group of positional patients (PP) (AHI supine >or= 2 x AHI other positions) and a group of non-positional patients (NPP). In 55.8% of our patients, OSAS was position dependent. PP patients were significantly (6.7 years) younger. BMI and AHI were higher in the NPP group, but the difference was not significant. Level of obstruction in the upper airway (retropalatinal vs retrolingual vs both levels) as assessed by sleep endoscopy was not significantly different between the two groups. Total sleep time (TST) was equal in both groups, but the average time in supine position was 37 min longer in the PP group. This study confirms the finding that in more than 50% of patients, OSAS is position dependent. Apart from age, no patient characteristics were found indicating the position dependency. Overall AHI does not identify positional OSAS.

One hundred and twenty-three patients with snoring problems and/or obstructive Sleep Apnea Syndrome (OSAS) were offered Rhinosleep Flextube-reflectometry during sleep registration to assess the upper airway. The main point of interest was patient acceptance of the procedure. 36 patients with OSAS received Rhino Flextube reflectometry. Of these, 19 (53%) completed a whole night registration with the Rhinosleep tube and 17 (47%) did not. This low success rate is multifactorial and will be discussed in detail in the text. The development of Rhinosleep is a challenge, as it improves the topical diagnostic work-up of OSAS patients. At present however various practical problems have to be solved to make it a viable alternative to sleep endoscopy.

Should all patients with socially unacceptable snoring (SUS) undergo polysomnography, or is history-taking sufficient to identify the presence of obstructive sleep apnoea syndrome (OSAS)? Three hundred and eighty consecutive patients with SUS who underwent sleep registration were evaluated retrospectively to determine the predictive value of a history of apnoea or excessive daytime somnolence (hypersomnia). Of the patients analysed, 54% had OSAS, defined as an apnoea/hypopnoea index (AHI) of >15. This is higher than previously reported in the literature (46.7%). (Incidental) apnoea was reported by 337 (89%) of the patients, with a sensitivity of 0.92 and a specificity of 0.13. The predictive value--as related to the gold standard, i.e. sleep registration, of a negative test and of a positive test for OSAS is low (0.56 and 0.59, respectively). Hypersomnia was reported by 280 (74%) of the patients, with a sensitivity of 0.29 and a specificity of 0.72. The predictive value of a negative test and a positive test for OSAS is also low, 0.45 and 0.56, respectively. These data confirm that apnoea and hypersomnia in the history do not have a reliable predictive value of an obstructive sleep apnoea syndrome. We conclude that sleep registration is indicated in all patients with SUS, to rule out or confirm the presence of OSAS.