title: History of Arda

text: Tolkien once considered writing a sequel to "The Lord of the Rings", called "The New Shadow", which would have taken place in Eldarion's reign, and in which Eldarion deals with his people turning to evil practices – in effect, a repetition of the history of Númenor. In a 1972 letter concerning this draft, Tolkien mentioned that Eldarion's reign would have lasted for about 100 years after the death of Aragorn. His realm was to be "great and long-enduring", but the lifespan of the royal house was not to be restored; it would continue to wane until it was like that of ordinary Men.


title: History of Arda

text: In a letter, Tolkien wrote that "This legendarium ["The Silmarillion"] ends with a vision of the end of the world [after all the ages have elapsed], its breaking and remaking, and the recovery of the Silmarilli and the 'light before the Sun' – after a final battle [Dagor Dagorath] which owes, I suppose, more to the Norse vision of Ragnarök than to anything else, though it is not much like it." The concept of Dagor Dagorath appears in Tolkien's manuscripts that were published by his son Christopher in "The Shaping of Middle-earth" but not in the published "Silmarillion", where the eventual fate of Arda is left open-ended in the closing lines of the "Quenta Silmarillion".


title: History of Arda

text: Scholars, noting that Tolkien was a devout Catholic, have stated that the "Ainulindalë" creation myth echoes the Christian account of creation. Brian Rosebury calls its prose "appropriately 'scriptural'". Verlyn Flieger cites Tolkien's poem "Mythopoeia" ("Creation of Myth"), where he speaks of "man, sub-creator, the refracted light / through whom is splintered from a single White / to many hues, and endlessly combined / in living shapes". She analyses in detail the successive splintering of the original created light, via the Two Lamps, the Two Trees, and the Silmarils, as the wills of different beings conflict. She states that for Tolkien, this creative light was equated with the Christian "Logos", the Divine Word. Jane Chance remarks on the biblical theme of the conflict between the creator Eru Ilúvatar and the fallen Vala Melkor/Morgoth, mirroring that between God and Satan. Similarly, she notes, the struggles of Elves and Men corrupted by Morgoth and his spiritual descendant Sauron echo those of Adam and Eve tempted by Satan in the Garden of Eden, and the fall of man.


title: History of Arda

text: Flieger has observed that the splintering of the created light is a process of decline and fall from a once-perfect state. She identifies a theory of decline that influenced Tolkien, namely Owen Barfield's theory of language in his 1928 book "Poetic Diction". The central idea was that there was once a unified set of meanings in an ancient language, and that modern languages are derived from this by fragmentation of meaning. Tolkien took this to imply the separation of peoples, in particular the complicated and repeated sundering of the Elves.


title: History of Arda

text: Scholars including Flieger have noted that if Tolkien intended to create a mythology for England, in the history of Arda as told in "The Silmarillion" he had made it very dark. John Garth has identified his experiences in the First World War as formative; he began his Middle-earth writings at that time. Flieger suggests that Middle-earth arose not only from Tolkien's own wartime experience, but out of that of his dead schoolfriends Geoffrey Bache Smith and Rob Gilson. Janet Brennan Croft writes that Tolkien's first prose work after returning from the war was "The Fall of Gondolin", and that it is "full of extended and terrifying scenes of battle"; she notes that the streetfighting is described over 16 pages.


title: History of Arda

text: Among the many influences that scholars have proposed as possibly important on the history of Arda is Greek mythology. The disappearance of the island of Númenor recalls Atlantis. The Valar borrow many attributes from the Olympian gods. Like the Olympians, the Valar live in the world, but on a high mountain, separated from mortals; Ulmo, Lord of the Waters, owes much to Poseidon, and Manwë, the Lord of the Air and King of the Valar, to Zeus. Tolkien compared Beren and Lúthien with Orpheus and Eurydice, but with the gender roles reversed. He mentioned Oedipus, too, in connection with Túrin in the "Children of Húrin". Flieger has compared Fëanor with Prometheus: they are associated with fire, and are punished for rebelling against the gods' decrees.


title: History of Arda

text: Arda is summed up by the Tolkien scholar Paul H. Kocher as "our own green and solid Earth at some quite remote epoch in the past."


title: History of Arda

text: In a letter written in 1958, Tolkien places the beginning of the Fourth Age some 6,000 years in the past:


title: History of Arda

text: The Tolkien scholar Richard C. West writes that one of the "very final passages" of the internal chronology of "Lord of the Rings", "The Tale of Aragorn and Arwen", ends not just with Arwen's death, but the statement that her grave will remain on the hill of Cerin Amroth in what was Lothlorien "until the world is changed, and all the days of her life are utterly forgotten by men that come after ... and with the passing of [Arwen] Evenstar no more is said in this book of the days of old." West observes that this points up a "highly unusual" aspect of Tolkien's legendarium among modern fantasy: it is set "in the real world but in an imagined prehistory." As a result, West explains, Tolkien can build what he likes in that distant past, elves and wizards and hobbits and all the rest, provided that he tears it all down again, so that the modern world can emerge from the wreckage, with nothing but "a word or two, a few vague legends and confused traditions..." to show for it.


title: History of Arda

text: West praises and quotes Kocher on Tolkien's imagined prehistory and the implied process of fading to lead from fantasy to the modern world:


title: History of Arda

text: The Tolkien scholar Stuart D. Lee and the medievalist Elizabeth Solopova make "an attempt at a summary", which runs as follows. The "Silmarillion" describes events "presented as factual" but taking place before Earth's actual recorded history. What happened is processed through the generations as folk-myths and legends, especially among the (Old) English. Before the Fall of Numenor, the world was flat. In the Fall, it became round; further geological events reshaped the continents into the Earth as it now is. All the same, the old tales survive here and there, resulting in mentions of Dwarves and Elves in real Medieval literature. Thus, Tolkien's imagined mythology "is an attempt to reconstruct our pre-history." Lee and Solopova comment that "Only by understanding this can we fully realize the true scale of his project and comprehend how enormous his achievement was."


title: History of Arda

text: The poet W. H. Auden wrote in "The New York Times" that "no previous writer has, to my knowledge, created an imaginary world and a feigned history in such detail. By the time the reader has finished the trilogy, including the appendices to this last volume, he knows as much about Tolkien's Middle Earth, its landscape, its fauna and flora, its peoples, their languages, their history, their cultural habits, as, outside his special field, he knows about the actual world." The scholar Margaret Hiley comments that Auden's "feigned history" echoes Tolkien's own statement in the foreword to the second edition of "Lord of the Rings" that he much preferred history, true or feigned, to allegory; and that Middle-earth's history is told in "The Silmarillion".


title: Sparta, Laconia

text: Sparta ( ) is a city and municipality in Laconia, Greece. It lies at the site of ancient Sparta. The municipality was merged with six nearby municipalities in 2011, for a total population (as of 2011) of 35,259, of whom 17,408 lived in the city.


title: Sparta, Laconia

text: Beginning in the 13th century, the political and cultural center of Laconia shifted to Mystras, some 4 km to the west.


title: Sparta, Laconia

text: The settlement at ancient Sparta, named Lacedaemonia, continued to exist, although greatly depopulated, until modern times as a town of a few thousand people who lived among the ruins, in the shadow of Mystras. The Palaiologos family (the last Byzantine Greek imperial dynasty) also lived in Mystras. The Despotate of the Morea was captured by the Ottomans under Mehmed II in 1460.


title: Sparta, Laconia

text: In 1834, after the Greek War of Independence, King Otto of Greece decreed the town should be expanded into a city. Modern day Sparta, the capital of the prefecture of Lakonia, lies on the eastern foothills of Mount Taygetos in the Evrotas River valley. The city has been built upon the site of ancient Sparta, whose Acropolis lies north of the modern city. To the southwest stands Mt. Taygetos. To the east of the city stands the Parnonas mountain range, which is forested predominantly with Greek fir trees and other conifers.


title: Sparta, Laconia

text: Modern Sparta's origins date back to October 20, 1834, when King Otto issued a decree on the construction of the new city. Bavarian city planners, headed by Fr. Stauffert, designed a city of 100,000 inhabitants based on the neo-classical architectural model.


title: Sparta, Laconia

text: Today Sparta maintains its good design, boasting large squares and wide streets lined with trees, while many of the older buildings remain in excellent condition. The city of Sparta is the economic, administrative and cultural center of Lakonia. A key factor in the advancement of the city's development is the operation of two departments of the University of Peloponnese and a department of the Technological Educational Institute.


title: Sparta, Laconia

text: The centrally located main square is dominated by the most imposing neo-classical building in Sparta, the City Hall. Built in 1909, City Hall bears the signature of the Greek architect G. Katsaros. During the monarchy (which was abolished by referendum in 1973), the title of Duke of Sparta was used for the Greek crown prince, the διάδοχος ("diádokhos").


title: Sparta, Laconia

text: The municipality of Sparta was formed at the 2011 local government reform by the merger of the following seven former municipalities, that became municipal units:


title: Sparta, Laconia

text: The municipality has an area of 1,181.780 km, the municipal unit 84.453 km. The municipal unit consists of the local communities Sparta, Afisi, Amykles, Kalyvia Sochas and Kladas.


title: Sparta, Laconia

text: Sparta is regarded as one of the most conservative cities in Greece; it has never had a left-wing mayor and it was one of the few cities that voted in 1974 to retain the monarchy. Laconia was the region with the highest proportion of "yes" votes (which was supported by the conservative party) in the 2015 bailout referendum.


title: Sparta, Laconia

text: The city of Sparta enjoys a sunny and warm Mediterranean climate (Köppen "Csa"). Winters are mild and cool, while summers tend to be particularly hot. January mean maximum temperatures are around while July and August mean maximum temperatures are around in the city proper. Sparta registers the highest summer average maximum temperatures in Greece and is notorious for its scorching summer heat. In July 2012 the city registered an average maximum temperature of , making it Greece's highest monthly average maximum temperature to date.


title: Sparta, Laconia

text: in 1874–76 to house the collection of local archaeological finds by Panagiotis Stamatakis, it was the first Greek museum in a provincial city.


title: Sparta, Laconia

text: The ruins of ancient Sparta lie north of the city. Entering by the South Gate of the Acropolis, known as Lakedaemonia, there is the Rotunda, the Theatre and the Temple of Athena Chalkioikos to the West. Exiting the Acropolis by the North Gate there are the remains of the earliest ancient walls, the Heroon and the Altar of Lycourgos, whereas to the East there is the Sanctuary of Artemis Orthia. To the North is the Monastic Church of Osios Nikonas (10th century).


title: Sparta, Laconia

text: The "Tomb of Leonidas", or "Leonidaion" (), is a limestone structure of the late 5th century BC, likely a temple, but named for Leonidas I in the 19th century, being the only ancient monument indicated within the limits of the newly-planned town in 1834.


title: Sparta, Laconia

text: The Spartathlon has taken place every September since 1983. It is an ultramarathon starting in Athens and finishing in Sparta at the statue of Leonidas, with many international participants.


title: Obstructive sleep apnea

text: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both may result. A high frequency of apneas or hypopneas during sleep may interfere with restorative sleep, whichin combination with disturbances in blood oxygenationis thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime (e.g. excessive daytime sleepiness, decreased cognitive function).


title: Obstructive sleep apnea

text: Most individuals with OSA are unaware of disturbances in breathing while sleeping, even after awakening. A bed partner or family member may observe an individual snoring or appear to stop breathing, gasp, or choke while sleeping. Individuals who live or sleep alone are often unaware of the condition. Symptoms may be present for years or even decades without identification, during which time the individual may become conditioned to the daytime sleepiness, headaches and fatigue associated with significant levels of sleep disturbance. Obstructive sleep apnea has been associated with neurocognitive morbidity, as well as a link between snoring and neurocognitive disorders.


title: Obstructive sleep apnea

text: In the third edition of the International Classification of Sleep Disorders (ICSD-3), obstructive sleep apnea is classified amongst the sleep-related breathing disorders and is divided in two categories, namely adult OSA and pediatric OSA. Obstructive sleep apnea is differentiated from central sleep apnea (CSA), which is characterized by episodes of reduction or cessation in breathing attributable to decreased effort, rather than upper airway obstruction. The respiratory effort must then be assessed in order to correctly classify the apnea as obstructive given the specificity of the diaphragmatic activity in this condition: the inspiratory effort is continued or increased through the entire episode of absent airflow. When hypopneas are present alongside apneas, the term obstructive sleep apnea-hypopnea is used and when it is associated with daytime sleepiness and other daytime symptoms, it is called obstructive sleep apnea-hypopnea syndrome. To be categorized as obstructive, the hypopnea must meet one or more of the following symptoms: (1) snoring during the event, (2) increased oronasal flow flattening, or (3) thoraco-abdominal paradoxical respiration during the event. If none of them are present during the event, then it is categorized as central hypopnea.


title: Obstructive sleep apnea

text: Common symptoms of OSA syndrome include unexplained daytime sleepiness, restless sleep, and loud snoring (with periods of silence followed by gasps). Less common symptoms are morning headaches; insomnia; trouble concentrating; mood changes such as irritability, anxiety, and depression; forgetfulness; increased heart rate or blood pressure; decreased sex drive; unexplained weight gain; increased urinary frequency or nocturia; frequent heartburn or gastroesophageal reflux; and heavy night sweats.


title: Obstructive sleep apnea

text: Many people experience episodes of OSA for only a short period. This can be the result of an upper respiratory infection that causes nasal congestion, along with swelling of the throat, or tonsillitis that temporarily produces very enlarged tonsils. The Epstein-Barr virus, for example, is known to be able to dramatically increase the size of lymphoid tissue during acute infection, and OSA is fairly common in acute cases of severe infectious mononucleosis. Temporary spells of OSA syndrome may also occur in individuals who are under the influence of a drug (such as alcohol) that may relax their body tone excessively and interfere with normal arousal from sleep mechanisms.


title: Obstructive sleep apnea

text: The hallmark symptom of OSA syndrome in adults is excessive daytime sleepiness. Typically, an adult or adolescent with severe long-standing OSA will fall asleep for very brief periods in the course of usual daytime activities if given an opportunity to sit or rest. This behavior may be quite dramatic, sometimes occurring during conversations with others at social gatherings.


title: Obstructive sleep apnea

text: The hypoxia (absence of oxygen supply) related to OSA may cause changes in the neurons of the hippocampus and the right frontal cortex. Research using neuro-imaging revealed evidence of hippocampal atrophy in people with OSA. They found that OSA can cause problems in mentally manipulating non-verbal information, in executive functions and working memory. This repeated brain hypoxia is also considered to be a cause of Alzheimer's disease.


title: Obstructive sleep apnea

text: Diagnosis of obstructive sleep apnea is significantly more common among people in relationships, who are alerted to their condition by being informed by their sleeping partner since individuals with obstructive sleep apnea are often unaware of the condition. There is a stigma associated with loud snoring, and it is not considered a feminine trait. Consequently, females are less likely to be told by their partners that they snore, or to admit it to themselves or doctors. Furthermore, CPAP (Continuous Positive Airway Pressure) machines are also perceived negatively by females, and less likely to be utilized to their full extent in this group.


title: Obstructive sleep apnea

text: Although this so-called "hypersomnolence" (excessive sleepiness) may also occur in children, it is not at all typical of young children with sleep apnea. Toddlers and young children with severe OSA instead ordinarily behave as if "over-tired" or "hyperactive"; and usually appear to have behavioral problems like irritability, and a deficit in attention. Adults and children with very severe OSA also differ in typical body "habitus". Adults are generally heavy, with particularly short and heavy necks. Young children, on the other hand, are generally not only thin but may have "failure to thrive", where growth is reduced. Poor growth occurs for two reasons: the work of breathing is intense enough that calories are burned at high rates even at rest, and the nose and throat are so obstructed that eating is both tasteless and physically uncomfortable. OSA in children, unlike adults, is often caused by obstructive tonsils and adenoids and may sometimes be cured with tonsillectomy and adenoidectomy.


title: Obstructive sleep apnea

text: This problem can also be caused by excessive weight in children. In this case, the symptoms are more like the symptoms adults feel such as restlessness, exhaustion, etc. If adenotonsillar hypertrophy remains the most common cause of OSA in children, obesity can also play a role in the pathophysiology of upper airway obstruction during sleep which can lead to OSA, making obese children more likely to develop the condition. The recent epidemic increase of obesity prevalence has thus contributed to changes in the prevalence and in the characteristics of pediatric OSA, the severity of OSA being proportional to the degree of obesity. Obesity leads to the narrowing of upper airway structure due to fatty infiltration and fat deposits in the anterior neck region and cervical structures. Alongside with the additional weight loading on the respiratory system, it increases the risk of pharyngeal collapsibility while reducing the intrathoracic volume and diaphragm excursion. Moreover, excessive daytime sleepiness resulting from sleep fragmentation can decrease physical activity and thus lead to weight gain (by sedentary habits or increased food intake to overcome somnolence). The obesity-related obstruction of upper airway structure has led some authors to distinguish between two types of OSA in children: type I is associated with marked lymphadenoid hypertrophy without obesity and type II is first associated with obesity and with milder upper airway lymphadenoid hyperplasia. The two types of OSA in children can results in different morbidities and consequences. Studies have shown that weight loss in obese adolescents can reduce sleep apnea and thus the symptoms of OSA.


title: Obstructive sleep apnea

text: The transition from wakefulness to sleep (either REM sleep or NREM sleep) is associated with a reduction in upper-airway muscle tone. During REM sleep, muscle tone of the throat and neck, as well as that of the vast majority of skeletal muscles, are almost completely relaxed. This allows the tongue and soft palate/oropharynx to relax, reducing airway patency and potentially impeding or completely obstructing the flow of air into the lungs during inspiration, resulting in reduced respiratory ventilation. If reductions in ventilation are associated with sufficiently low blood-oxygen levels or with sufficiently high breathing efforts against an obstructed airway, neurological mechanisms may trigger a sudden interruption of sleep, called a neurological arousal. This arousal can cause an individual to gasp for air and awaken. These arousals rarely result in complete awakening but can have a significant negative effect on the restorative quality of sleep. In significant cases of OSA, one consequence is sleep deprivation resulting from the repetitive disruption and recovery of sleep activity. This sleep interruption in Stage 3 (also called slow-wave sleep), and in REM sleep, can interfere with normal growth patterns, healing and immune response, especially in children and young adults.


title: Obstructive sleep apnea

text: The fundamental cause of OSA is a blocked upper airway, usually behind the tongue and epiglottis, whereby the otherwise patent airway, in an erect and awake patient, collapses when the patient is lying on his or her back and loses muscle tone upon entering deep sleep.


title: Obstructive sleep apnea

text: At the beginning of sleep, a patient is in light sleep and there is no tone loss of throat muscles. Airflow is laminar and soundless. As the upper airway collapse progresses, the obstruction becomes increasingly apparent by the initiation of noisy breathing as air turbulence increases, followed by gradually louder snoring as a Venturi effect forms through the ever-narrowing air passage.


title: Obstructive sleep apnea

text: The patient's blood-oxygen saturation gradually falls until cessation of sleep noises, signifying total airway obstruction of airflow, which may last for several minutes.


title: Obstructive sleep apnea

text: Eventually, the patient must at least partially awaken from deep sleep into light sleep, automatically regaining general muscle tone. This switch from deep to light to deep sleep can be recorded using ECT monitors.


title: Obstructive sleep apnea

text: In light sleep, muscle tone is near normal, the airway spontaneously opens, normal noiseless breathing resumes and blood-oxygen saturation rises. Eventually, the patient reenters deep sleep, upper airway tone is again lost, the patient enters the various levels of noisy breathing and the airway blockage returns.


title: Obstructive sleep apnea

text: The cycle of muscle-tone loss and restoration coinciding with periods of deep and light sleep repeats throughout the patient's period of sleep.


title: Obstructive sleep apnea

text: The number of apnoea and hypopnoea episodes during any given hour is counted and given a score. If a patient has an average of five or more episodes per hour, mild OSA may be confirmed. An average of 30 or more episodes per hour indicates severe OSA.


title: Obstructive sleep apnea

text: The causes of spontaneous upper-airway blockage are strongly debated by clinical professionals. The areas of thought are divided mostly into three medical groups.


title: Obstructive sleep apnea

text: Some otorhinolaryngologists believe the risk factors to be structural features that give rise to a narrowed airway, such as enlarged tonsils, an enlarged posterior tongue or fat deposits in the neck. Further factors leading to OSA can be impaired nasal breathing, floppy soft palate or a collapsible epiglottis.


title: Obstructive sleep apnea

text: Some oral and maxillofacial surgeons believe the risk factors to be a number of primary forms of mandibular hypoplasia, which offers a primary anatomical basis to the development of OSA through glossoptosis. Some maxillofacial surgeons who offer orthognathic surgery for treatment of OSA believe that their treatments offer superior guarantees of cure of OSA.


title: Obstructive sleep apnea

text: It is well known that children, adolescents or adults with OSA are often obese. Obese people show an increase in neck fat tissue which potentiate respiratory obstruction during sleep.


title: Obstructive sleep apnea

text: However, people of all ages and sex with normal body mass indices (BMIs) can also demonstrate OSA – and these people do not have significant measures of subdermal or intra neck fat as shown on DEXA scans. It is speculated that they may have increased muscle mass, or alternatively have a tendency to decreased muscle tone potentiating airway collapse during sleep.


title: Obstructive sleep apnea

text: However, loss of muscle tone is a key feature of deep sleep anyway, and whilst obesity seems a common association, it is not an invariable state of OSA.


title: Obstructive sleep apnea

text: Sleeping supine (on one's back) is also represented as a risk factor for OSA. Clearly, gravity and loss of tongue and throat tone as a person enters deep sleep are clear and obvious factors contributing to OSA developing. But this explanation is also confounded by the presence of neck obesity.


title: Obstructive sleep apnea

text: Use of CPAP definitively primarily expands a collapsed upper airway, allowing for nasal breathing – and positive use of CPAP would prove that airway collapse is the cause of OSA.


title: Obstructive sleep apnea

text: Throat lesions, particularly enlarged tonsils, are well recognized as aggravators of OSA, and removal may provide full or partial or semi-permanent relief from OSA, which also indicates that enlarged tonsils may play a role in the pathogenesis of OSA.


title: Obstructive sleep apnea

text: Old age is often accompanied by muscular and neurological loss of muscle tone of the upper airway. Decreased muscle tone is also temporarily caused by chemical depressants; alcoholic drinks and sedative medications being the most common. Permanent premature muscular tonal loss in the upper airway may be precipitated by traumatic brain injury, neuromuscular disorders, or poor adherence to chemical and or speech therapy treatments.


title: Obstructive sleep apnea

text: Individuals with decreased muscle tone and increased soft tissue around the airway, and structural features that give rise to a narrowed airway are at high risk for OSA. Men, in which the anatomy is typified by increased mass in the torso and neck, are at increased risk of developing sleep apnea, especially through middle age and later. Typically, women experience this condition less frequently and to a lesser degree than do men, owing partially to physiology, but possibly also to differential levels of progesterone. Prevalence in post-menopausal women approaches that of men in the same age range. Women are at greater risk for developing OSA during pregnancy.


title: Obstructive sleep apnea

text: Lifestyle factors such as smoking may also increase the chances of developing OSA as the chemical irritants in smoke tend to inflame the soft tissue of the upper airway and promote fluid retention, both of which can result in narrowing of the upper airway. Cigarettes may also have an impact due to a decline of blood nicotine levels, which alters sleep stability. Smokers thus show a higher risk to develop OSA, but the effect of cigarettes on increased OSA is reversible with the cessation of smoking. Children exposed to cigarette smoke may also develop OSA as the lymphadenoid tissue will proliferate excessively in contact with the irritants. An individual may also experience or exacerbate OSA with the consumption of alcohol, sedatives, or any other medication that increases sleepiness as most of these drugs are also muscle relaxants. Allergic rhinitis and asthma have also been shown to be implicated in the increased prevalence of adenotonsillar hypertrophy and OSA.


title: Obstructive sleep apnea

text: OSA also appears to have a genetic component; those with a family history of it are more likely to develop it themselves.


title: Obstructive sleep apnea

text: Of substantial recent interest is the idea that there is a general human tendency towards developing short lower jaws (neoteny) is a major cause of OSA through a combined condition called glossoptosis. The posterior “normal” tongue is displaced backwards by a smaller “abnormal” anterior tongue and lower jaw. In much the same way, a narrow upper jaw will also contribute to OSA due to its relation to airway volume. A more narrow upper jaw results in more narrow nasal passages and a more narrow throat, this also appears to be why so many OSA patients experience nasal congestion especially while lying down.


title: Obstructive sleep apnea

text: Maxillofacial surgeons see many effects of small lower jaws, including crowded teeth, malocclusions, as well as OSA – all of which are treatable by surgical operations that increase and normalise jaw size. Operations such as custom BIMAX, GenioPaully, and IMDO (in adolescence) offer a valid medical option that replaces all traditional forms of OSA treatment – including CPAP, Mandibular Advancement Splints, tonsillectomy and UPPP. There are patterns of unusual facial features that occur in recognizable syndromes. Some of these craniofacial syndromes are genetic, others are from unknown causes. In many craniofacial syndromes, the features that are unusual involve the nose, mouth, and jaw, or resting muscle tone, and put the individual at risk for OSA syndrome.


title: Obstructive sleep apnea

text: Down syndrome is one such syndrome. In this chromosomal abnormality, several features combine to make the presence of obstructive sleep apnea more likely. The specific features of Down syndrome that predispose to obstructive sleep apnea include relatively low muscle tone, narrow nasopharynx, and large tongue. Obesity and enlarged tonsils and adenoids, conditions that occur commonly in the western population, are much more likely to be obstructive in a person with these features than without them. Obstructive sleep apnea does occur even more frequently in people with Down syndrome than in the general population. A little over 50% of all people with Down syndrome experience obstructive sleep apnea, and some physicians advocate routine testing of this group.


title: Obstructive sleep apnea

text: In other craniofacial syndromes, the abnormal feature may actually improve the airway, but its correction may put the person at risk for obstructive sleep apnea "after" surgery when it is modified. Cleft palate syndromes are such an example. During the newborn period, all humans are obligate nasal breathers. The palate is both the roof of the mouth and the floor of the nose. Having an open palate may make feeding difficult, but generally, does not interfere with breathing, in fact, if the nose is very obstructed, then an open palate may relieve breathing. There are a number of clefting syndromes in which the open palate is not the only abnormal feature; additionally, there is a narrow nasal passage – which may not be obvious. In such individuals, closure of the cleft palate – whether by surgery or by a temporary oral appliance – can cause the onset of obstruction.


title: Obstructive sleep apnea

text: Skeletal advancement in an effort to physically increase the pharyngeal airspace is often an option for craniofacial patients with upper airway obstruction and small lower jaws (mandibles). These syndromes include Treacher Collins syndrome and Pierre Robin sequence. Mandibular advancement surgery is one of the modifications needed to improve the airway, others may include reduction of the tongue, tonsillectomy or modified uvulopalatoplasty.


title: Obstructive sleep apnea

text: OSA can also occur as a serious post-operative complication that seems to be most frequently associated with pharyngeal flap surgery as compared to other procedures for the treatment of velopharyngeal inadequacy (VPI). In OSA, recurrent interruptions of respiration during sleep are associated with temporary airway obstruction. Following pharyngeal flap surgery, depending on size and position, the flap itself may have an "obturator" or obstructive effect within the pharynx during sleep, blocking ports of airflow and hindering effective respiration. There have been documented instances of severe airway obstruction, and reports of post-operative OSA continues to increase as healthcare professionals (i.e. physicians, speech language pathologists) become more educated about this possible dangerous condition. Subsequently, in clinical practice, concerns of OSA have matched or exceeded interest in speech outcomes following pharyngeal flap surgery.


title: Obstructive sleep apnea

text: The surgical treatment for velopalatal insufficiency may cause obstructive sleep apnea syndrome. When velopalatal insufficiency is present, air leaks into the nasopharynx even when the soft palate should close off the nose. A simple test for this condition can be made by placing a tiny mirror on the nose, and asking the subject to say "P". This p sound, a plosive, is normally produced with the nasal airway closes off – all air comes out of the pursed lips, none from the nose. If it is impossible to say the sound without fogging a nasal mirror, there is an air leak – reasonable evidence of poor palatal closure. Speech is often unclear due to inability to pronounce certain sounds. One of the surgical treatments for velopalatal insufficiency involves tailoring the tissue from the back of the throat and using it to purposefully cause partial obstruction of the opening of the nasopharynx. This may actually "cause" OSA syndrome in susceptible individuals, particularly in the days following surgery, when swelling occurs (see below: Special Situation: Anesthesia and Surgery).


title: Obstructive sleep apnea

text: Finally, patients with OSA are at an increased risk of many perioperative complications when they are present for surgery, even if the planned procedure is not on the head and neck. Guidelines intended to reduce the risk of perioperative complications have been published.


title: Obstructive sleep apnea

text: There are 3 levels of consequences: physiologic, intermediate and clinical. The physiologic consequences contain hypoxia, sleep fragmentation, autonomic nervous system dysregulation or hyperoxia. The intermediate results regroup inflammation, pulmonary vasoconstriction, general metabolic dysfunction, oxidation of proteins and lipids or increased adiposity. The clinical repercussions are composed by pulmonary hypertension, accidents, obesity, diabetes, different heart diseases or hypertension.


title: Obstructive sleep apnea

text: Obstructive sleep apnea is the most common Sleep-Disordered Breathing (SDB) and affects up to 11% of children born at term – it is even more common (3 to 6 times more) in children born pre-term. As a SDB, OSA in children can lead to several adverse consequences, also in the long-term with consequences lasting into adulthood. The implications of OSA in children are complex and cover a large scope of consequences: when it is left untreated, OSA can lead to morbidity affecting many different domains of life (organs, body systems, behavioral disturbance, depression, decreased quality of life, etc.). Therefore, nocturnal symptoms indicating the presence of OSA (e.g. snoring, gasping, restless sleep and excessive energy used to breathe during sleep) are associated with daytime symptoms such as concentration and learning difficulties and irritability, neurocognitive development impairment, decreased school performance and behavioral difficulties. For example, SDB such as OSA contributes to hyperactive behavior that can lead to the diagnosis and treatment of attention deficit hyperactivity disorder (ADHD). However, once the SDB is treated, the hyperactive behavior can improve, and the treatment can be stopped. Obesity also has an impact on the consequences of OSA and lead to different manifestations or severity. Studies have shown that, contrary to adults, children with obstructive sleep-disordered breathing are able to maintain cerebral oxygenation. However, the condition still has effects on the brain and can lead to adverse neurocognitive and behavioral sequelae. It is particularly concerning as those consequences happen while the brain is still developing. The degree to which the sleep is disturbed and fragmented has been significantly linked to the severity of the consequences, the latter having the possibility to decrease once the sleep is improved. It is more the disruption of sleep processes than the total amount of sleep the child experience that generates the adverse consequences on the child's daytime functioning; it contributes to the hyperactivity for example.


title: Obstructive sleep apnea

text: Children with OSA may experience learning and memory deficits and OSA has also been linked to lowered childhood IQ scores.


title: Obstructive sleep apnea

text: Nocturnal sleep fragmentation has been linked to neurocognitive impairments, therefore, the identification of SDB such as OSA is crucial in children, those impairments having the possibility to be reversible with the appropriate treatment for the sleep disorder. The neurocognitive and behavioral dysfunctions commonly present in children with OSA include the following: hyperactivity, impulsivity, aggressive behaviors, low social and communication abilities and reduced adaptive skills.


title: Obstructive sleep apnea

text: Children with OSA commonly show cognitive deficits, resulting in attention and concentration difficulties, as well as lower academic performance and IQ. Poor academic performances have been linked to OSA and suggested to result from cortical and sympathetic arousals and hypoxemia which affects memory consolidation. A study with Indian children affected by OSA has shown poor school grades, including mathematics, science, language and physical education. This study allowed to see the overall impact of OSA on learning abilities associated with language or numeracy skills, and physical development. It has been suggested that the deficits in academic performance related to OSA could be mediated through reduced executive functions or language skills, those domains contributing highly to learning abilities and behavior. The deficits in school performance can nevertheless be improved if adenotonsillectomy is performed on children to treat the OSA. It is thus crucial to identify the OSA for children with school difficulties; many cases remaining unnoticed.


title: Obstructive sleep apnea

text: As studies have shown that learning skills and behaviors can be improved if the OSA is treated, the neurocognitive and behavioral deficits are thus at least partly reversible. This reversible dimension has been postulated to be negatively correlated to the duration of the symptoms, which would mean that the longer the OSA is left untreated, the less reversible are the consequences.


title: Obstructive sleep apnea

text: Similarly to adults, OSA in children is linked to a higher risk for cardiovascular morbidities, due to increased sympathetic activity and impaired cardiac autonomic control. Amongst the cardiovascular dysfunctions resulting from OSA, we can find systemic hypertension and blood pressure dysregulation (elevated blood pressure, or variability of the blood pressure for example). The variability of the blood pressure has been shown to be correlated with the severity of the symptoms such as the frequency of the apnea and hypopnea. Pulmonary hypertension is also common amongst the cardiovascular problems resulting from OSA. Children with obstructive sleep-disordered breathing also show a faster heart rate during wakefulness and during sleep.


title: Obstructive sleep apnea

text: In adult patients, OSA has been shown to be associated with insulin resistance. In children, metabolic consequences of OSA are complicated to assess as they can also be associated to puberty and obesity (if present). However, when OSA is associated with obesity, the interaction of the two conditions can lead to metabolic disturbances such as insulin resistance and altered lipidemia, liver disease, abdominal adiposity and metabolic syndrome. Obesity interact with those effects.


title: Obstructive sleep apnea

text: Children with OSA also show a higher risk for nocturnal enuresis and it is hypothesized to be caused by an excessive production of urine, impaired performance of the bladder and urethra or an inability to suppress the nocturnal bladder contraction, due to a failure to arouse. The risk for nocturnal enuresis increases with the severity of the sleep-disordered breathing: the more respiratory events per hour of sleep, the higher is the risk for nocturnal enuresis. Obesity may also play a role as it is associated with OSA and with nocturnal diuresis (due to unhealthy diet). The interaction between OSA and obesity might thus result in nocturnal enuresis. Considering the high prevalence of nocturnal enuresis amongst children with sleep-disordered breathing, it is important to consider the latter in the differential diagnosis of nocturnal enuresis as the treatment of the sleep disorder might have a favourable therapeutic effect on the enuresis. For example, an adenotonsillectomy performed to reduce OSA has a positive impact on nocturnal enuresis. A study has shown that this surgery has 60–75% chance to resolve the nocturnal enuresis completely, and 80–85% chance to reduce its symptoms alongside others symptoms of OSA.


title: Obstructive sleep apnea

text: Contrary to adults, excessive daytime sleepiness (EDS) is not the most commonly reported symptoms in children with OSA. However, using objective questionnaires, it is possible to notice that the frequency of EDS in children is higher than what is reported by the parents or caretakers (40–50%). And the risk for EDS is even increased when OSA is associated with obesity.


title: Obstructive sleep apnea

text: Due to all the consequences and symptoms it generates, OSA in children lead to a significant decrease in the quality of life, the decrease being even higher when obesity is present. The quality of life can however be improved with the treatment of OSA. SBD have also been linked to a higher rate of internalizing disorders such as anxiety and depression. Indeed, depressive symptoms have shown to be higher in children with OSA, especially in males. Once again, the severity of depressive symptoms is positively correlated with the severity of the SBD. It also interacts with obesity as obese children have higher risk to show depressive symptoms and obesity can cause OSA. The link can also go the other way around with the depression inducing obesity (due to overeating) which worsens the OSA. Adenotonsillectomy can decrease the intensity of the depressive symptoms.


title: Obstructive sleep apnea

text: Other consequences of a disturbed sleep in children with OSA comprise anhedonia increased fatigue and decreased interest in daily activities, which in turn can affect the child's social relationships.


title: Obstructive sleep apnea

text: While there are some similarities between adults and children, OSA does not have the same consequences in both populations. Examples of similarities are the snoring – which is the most common complaint in both pediatric OSA and OSA in adults – variability of blood pressure and cardiovascular morbidities. A major difference is the excessive daytime sleepiness (EDS) which is commonly reported in adult OSA, while it is not very common in pediatric OSA. Nevertheless, OSA in adults also implies a large scope of adverse and serious consequences, the latter leading to higher mortality amongst OSA patients. Those consequences are even worsened by common morbidities such as obesity.


title: Obstructive sleep apnea

text: Similarly to children, OSA affects cognitive functions in adults. Meta-analysis have shown that the most common cognitive impairments happen in the domains of attention, verbal and visual delayed long-term memory, visuospatial/constructional abilities and executive functions, such as mental flexibility. The executive functioning – mainly dominated by the prefrontal cortex – being significantly impaired in patients with OSA, it is believed that the prefrontal region and its connectivity are affected by sleep disorders.


title: Obstructive sleep apnea

text: Regarding memory deficits, verbal memory is significantly impaired as patients show difficulties in recalling verbal information immediately as well as with a delay. While meta-analysis have shown no deficits in retention of information for patients with OSA, those impairment in verbal memory may be linked to problems in encoding information. This deficit in encoding of information is also noticed in visuo-spatial memory; however, the visual memory seems to be intact in OSA patients.


title: Obstructive sleep apnea

text: The cognitive impairments have been suggested to be resulting from sleep fragmentation and sleep deprivation, as well as the excessive daytime sleepiness associated with them. More precisely, attention and memory deficits seem to result from sleep fragmentation, while deficits in global cognitive function (executive function, psychomotor function, language abilities) are more related to hypoxia or hypercarbia which accompanies the obstructive events during sleep. However, no consistent correlation has been found between the degree of cognitive impairment and the severity of the sleep disturbance or hypoxia.


title: Obstructive sleep apnea

text: These impairments may improve with an effective treatment for OSA, such as continuous positive airway pressure (CPAP) therapy. Driving a motor vehicle is an example of a complex task that relies on driver's cognitive abilities, such as attention, reaction time and vigilance. Very brief moments of inattention called microsleep events could be an indicator for daytime vigilance impairment, although these may not be present in all drivers with obstructive sleep apnea.


title: Obstructive sleep apnea

text: The hyperactivity and difficulties in emotional regulation found in pediatric patients (children) are not reported in adults. OSA in adults is nevertheless associated with personality changes and automatic behavior. The biggest impact of OSA is the excessive daytime sleepiness (EDS), reported in approximately 30% of OSA patients. EDS can be caused by the disturbance of sleep quality, the insufficient sleep duration or the sleep fragmentation and it is responsible for further complications as it may lead to depressive symptoms, impairments of social life and decreased effectiveness at work. Studies have shown that those consequences of EDS can be improved following a CPAP treatment.


title: Obstructive sleep apnea

text: OSA in adults is associated with a higher risk for cardiovascular morbidities, diabetes, hypertension, coronary artery disease and stroke – OSA might have a role in the etiology of these conditions. Those conditions may lead to increased mortality that an appropriate treatment for OSA may reduce. OSA is often linked with hypertension as it induces an increase in sympathetic activity that can lead to the elevation of blood pressure. The OSA-related hypercapnia has been suggested to be related to this development of hypertension. Treating the OSA may prevent the development of hypertension.


title: Obstructive sleep apnea

text: The relationship between OSA and excess body weight is complex as obesity is more prevalent amongst OSA patients but can also be a risk factor for the development of OSA – it accounts for 58% of adult cases. Thus, both OSA and obesity (when present) may work synergistically and lead to hyperlipidemia, diabetes, insulin resistance and other symptoms of the metabolic syndrome. The metabolic syndrome itself is often associated with OSA: 74–85% of OSA patients are diagnosed with it. CPAP therapy can lead to an improvement of some of the cardiovascular component of the metabolic syndrome while weight loss is also recommended for its positive effects on OSA consequences and metabolic dysfunctions. An intervention comprising exercise and diet is thus effective for the treatment of OSA as it positively impacts the severity of both obesity symptoms and OSA symptoms.


title: Obstructive sleep apnea

text: Individuals with Type 2 diabetes are often co-diagnosed with OSA, where Type 2 diabetes prevalence rates range between 15% to 30% within the OSA population. The relationship between OSA and Type 2 diabetes could possibly be explained by the fact that OSA-characteristic fragmented sleep and irregular hypoxemia leads to the dysregulated metabolism of glucose in the blood. In particular, many polysomnography studies showed that OSA left untreated worsens glycemic control in individuals with Type 2 diabetes. However, it is possible that the relationship between OSA and Type 2 diabetes is bidirectional since diabetes-related nerve dysfunction may affect the respiratory system and induce breathing disturbances during sleep.


title: Obstructive sleep apnea

text: Sleep is of major importance for psychological and emotional health. As it is greatly impaired in OSA, this condition is associated with mood disorders and several psychological outcomes, especially depression and anxiety. Therefore, psychological disorders are commonly observed in OSA patients who show a higher prevalence of psychological distress, mostly due to the impaired sleep quality and structure and the repeated episodes of hypoxia. The presence of psychological disorders may also worsen the sleep disorders which implies that the psychopathology may either be a factor or a consequence of the OSA. The adverse consequences of OSA such as cardiovascular comorbidities and metabolic disturbances also play a role on the development of mental disorders, and patients with chronic condition have also been reported to have higher risk to experience depression. In OSA patients with psychiatric disorders, it is crucial to treat the OSA as it may reduce the psychiatric symptoms.


title: Obstructive sleep apnea

text: Some cases of OSA are caused by nasal obstruction which has also been related to psychological problems due to an altered ratio of calcium and magnesium in brain cells. Nasal obstruction can thus aggravate the psychological health of OSA patients. Nasal surgery for those patients might decrease the OSA severity and improve the psychological symptoms.


title: Obstructive sleep apnea

text: Untreated OSA also leads to a decreased quality of life, difficulties in social functioning, occupational problems and accidents and a greatly increased rate of vehicle accidents. Those serious outcomes of OSA are mostly related to the excessive daytime sleepiness resulting from the sleep fragmentation and highlight the need to provide the patients with appropriate treatment. Effective treatment majorly improves those adverse consequences, including quality of life.


title: Obstructive sleep apnea

text: OSA patients also frequently report pain disorders such as headache or fibromyalgia, OSA patients showing an increased pain intensity alongside a decreased pain tolerance.


title: Obstructive sleep apnea

text: In a systematic review of published evidence, the United States Preventive Services Task Force in 2017 concluded that there was uncertainty about the accuracy or clinical utility of all potential screening tools for OSA, and recommended that current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults.


title: Obstructive sleep apnea

text: The diagnosis of OSA syndrome is made when the patient shows recurrent episodes of partial or complete collapse of the upper airway during sleep resulting in apneas or hypopneas, respectively. Criteria defining an apnea or a hypopnea vary. The American Academy of Sleep Medicine (AASM) defines an apnea as a reduction in airflow of ≥ 90% lasting at least 10 seconds. A hypopnea is defined as a reduction in airflow of ≥ 30% lasting at least 10 seconds and associated with a ≥ 4% decrease in pulse oxygenation, or as a ≥ 30% reduction in airflow lasting at least 10 seconds and associated either with a ≥ 3% decrease in pulse oxygenation or with an arousal.


title: Obstructive sleep apnea

text: To define the severity of the condition, the Apnea-Hypopnea Index (AHI) or the Respiratory Disturbance Index (RDI) are used. While the AHI measures the mean number of apneas and hypopneas per hour of sleep, the RDI adds to this measure the respiratory effort-related arousals (RERAs). The OSA syndrome is thus diagnosed if the AHI is > 5 episodes per hour and results in daytime sleepiness and fatigue or when the RDI is ≥ 15 independently of the symptoms. According to the American Association of Sleep Medicine, daytime sleepiness is determined as mild, moderate and severe depending on its impact on social life. Daytime sleepiness can be assessed with the Epworth Sleepiness Scale (ESS), a self-reported questionnaire on the propensity to fall asleep or doze off during daytime. Screening tools for OSA itself comprise the STOP questionnaire, the Berlin questionnaire and the STOP-BANG questionnaire which has been reported as being a very powerful tool to detect OSA.


title: Obstructive sleep apnea

text: According to the International Classification of Sleep Disorders, there are 4 types of criteria. The first one concerns sleep – excessive sleepiness, nonrestorative sleep, fatigue or insomnia symptoms. The second and third criteria are about respiration – waking with breath holding, gasping, or choking; snoring, breathing interruptions or both during sleep. The last criterion revolved around medical issues as hypertension, coronary artery disease, stroke, heart failure, atrial fibrillation, type 2 diabetes mellitus, mood disorder or cognitive impairment. Two levels of severity are distinguished, the first one is determined by a polysomnography or home sleep apnea test demonstrating 5 or more predominantly obstructive respiratory events per hour of sleep and the higher levels are determined by 15 or more events. If the events are present less than 5 times per hour, no obstructive sleep apnea is diagnosed.


title: Obstructive sleep apnea

text: A considerable night-to-night variability further complicates diagnosis of OSA. In unclear cases, multiple testing might be required to achieve an accurate diagnosis.


title: Obstructive sleep apnea

text: Nighttime in-laboratory Level 1 polysomnography (PSG) is the gold standard test for diagnosis. Patients are monitored with EEG leads, pulse oximetry, temperature and pressure sensors to detect nasal and oral airflow, respiratory impedance plethysmography or similar resistance belts around the chest and abdomen to detect motion, an ECG lead, and EMG sensors to detect muscle contraction in the chin, chest, and legs. A hypopnea can be based on one of two criteria. It can either be a reduction in airflow of at least 30% for more than 10 seconds associated with at least 4% oxygen desaturation or a reduction in airflow of at least 30% for more than 10 seconds associated with at least 3% oxygen desaturation or an arousal from sleep on EEG.


title: Obstructive sleep apnea

text: An "event" can be either an apnea, characterized by complete cessation of airflow for at least 10 seconds, or a hypopnea in which airflow decreases by 50 percent for 10 seconds or decreases by 30 percent if there is an associated decrease in the oxygen saturation or an arousal from sleep. To grade the severity of sleep apnea, the number of events per hour is reported as the apnea-hypopnea index (AHI). An AHI of less than 5 is considered normal. An AHI of 5–15 is mild; 15–30 is moderate, and more than 30 events per hour characterizes severe sleep apnea.


title: Obstructive sleep apnea

text: In patients who are at high likelihood of having OSA, a randomized controlled trial found that home oximetry (a non-invasive method of monitoring blood oxygenation) may be adequate and easier to obtain than formal polysomnography. High probability patients were identified by an Epworth Sleepiness Scale (ESS) score of 10 or greater and a Sleep Apnea Clinical Score (SACS) of 15 or greater. Home oximetry, however, does not measure apneic events or respiratory event-related arousals and thus does not produce an AHI value.


title: Obstructive sleep apnea

text: The treatment of OSAS depends upon the level of obstruction, if the obstruction is at nose or epiglottis a surgery could be required depending on the condition. Numerous treatment options are used in obstructive sleep apnea. Avoiding alcohol and smoking is recommended, as is avoiding medications that relax the central nervous system (for example, sedatives and muscle relaxants). Weight loss is recommended in those who are overweight. Continuous positive airway pressure (CPAP) and mandibular advancement devices are often used and found to be equally effective. Physical training, even without weight loss, improves sleep apnea. There is insufficient evidence to support widespread use of medications. In selected patients, e.g. with tonsillar hyperplasia tonsillectomy is recommended. In patients failing CPAP and oral appliances, surgical treatment with conservative uvulopalatopharyngoplasty (UPPP) as salvage surgery is recommended. Randomized controlled studies of the efficacy of UPPP are published, showing effect on nocturnal respiration and excessive daytime sleepiness, and a systematic Meta-analysis.


title: Obstructive sleep apnea

text: The most widely used current therapeutic intervention is "positive airway pressure" whereby a breathing machine pumps a controlled stream of air through a mask worn over the nose, mouth, or both. The additional pressure holds open the relaxed muscles. There are several variants:


title: Obstructive sleep apnea

text: Encouraging people with moderate to severe OSA to use CPAP devices can be challenging as their use often requires a behavioural change in sleeping habits. 8% of people who use CPAP devices stop using them after the first night, and 50% of people with moderate to severe OSA stop using their devices in the first year. Educational initiatives and supportive interventions to help improve compliance with CPAP therapy have been shown to improve the length of time people who need CPAP therapy use their devices.


title: Obstructive sleep apnea

text: "Oral appliances" or splints are often preferred but may not be as effective as CPAP. This device is a mouthguard similar to those used in sports to protect the teeth. It is designed to hold the lower jaw slightly down and forward relative to the natural, relaxed position. This position holds the tongue farther away from the back of the airway and may be enough to relieve apnea or improve breathing.


title: Obstructive sleep apnea

text: Many people benefit from sleeping at a "30-degree elevation" of the upper body or higher, as if in a recliner. Doing so helps prevent the gravitational collapse of the airway. Sleeping on a side as opposed to sleeping on the back is also recommended.


title: Obstructive sleep apnea

text: Some studies have suggested that "playing a wind instrument" may reduce snoring and apnea incidents. This may be especially true of double reed instruments.


title: Obstructive sleep apnea

text: In children, orthodontic treatment to expand the volume of the nasal airway, such as nonsurgical Rapid Palatal expansion is common.


title: Obstructive sleep apnea

text: Since the palatal suture is fused in adults, regular RPE using tooth-borne expanders cannot be performed. Mini-implant assisted rapid palatal expansion (MARPE) has been recently developed as a non-surgical option for the transverse expansion of the maxilla in adults. This method increases the volume of the nasal cavity and nasopharynx, leading to increased airflow and reduced respiratory arousals during sleep. Changes are permanent with minimal complications.


title: Obstructive sleep apnea

text: Surgical treatments to modify airway anatomy, known as sleep surgery, are varied and must be tailored to the specific airway obstruction needs of a patient. Surgery is not considered a first line treatment for obstructive sleep apnea in adults. There are prospective, randomized, comparative clinical trials, and also a systematic Meta-analysis, showing evidence that conservative uvulopalatopharyngoplasty (UPPP) with or without tonsillectomy is effective in selected patients failing conservative treatment. For those with obstructive sleep apnea unable or unwilling to comply with first line treatment, the surgical intervention has to be adapted to an individual's specific anatomy and physiology, personal preference and disease severity. Uvulopalatopharyngoplasty with or without is the most common surgery for patients with obstructive sleep apnea. Studies have shown that treatment effect of tonsillectomy increases with tonsil size. However, there is little randomized clinical trial evidence for other types of sleep surgery.


title: Obstructive sleep apnea

text: In the morbidly obese, a major loss of weight (such as what occurs after bariatric surgery) can sometimes cure the condition.


title: Obstructive sleep apnea

text: OSA in children is often due to enlarged tonsils and adenoids because the lymphoid tissue grows fast during young age. Surgical removal of enlarged tonsils (tonsillectomy) and the adenoid (adenoidectomy) are currently first line treatment among children with OSA. The operation is a common procedure but in the most extreme cases, children with severe OSA requires special precautions before, surgery (see "Surgery and obstructive sleep apnea syndrome" below). In some countries, a milder surgical procedure called tonsillotomy is used to remove the protruding tonsillar tissue, a method associated with less pain and lower risk of postoperative hemorrhage.


title: Obstructive sleep apnea

text: For patients who cannot use a continuous positive airway pressure device, the U.S. Food and Drug Administration in 2014 granted pre-market approval for an upper airway stimulation system that senses respiration and delivers mild electrical stimulation to the hypoglossal nerve in order to increase muscle tone at the back of the tongue so it will not collapse over the airway. The device includes a handheld patient controller to allow it to be switched on before sleep and is powered by an implantable pulse generator, similar to one used for cardiac rhythm management. Approval for this active implantable neuromodulation device was preceded by a clinical trial whose results were published in the "New England Journal of Medicine".


title: Obstructive sleep apnea

text: Radiofrequency ablation (RFA), which is conceptually analogous in some ways to surgery, uses low frequency (300 kHz to 1 MHz) radio wave energy to target tissue, causing coagulative necrosis. RFA achieves its effects at 40 °C to 70 °C unlike other electrosurgical devices which require 400 °C to 600 °C for efficacy.


title: Obstructive sleep apnea

text: Subsequent evaluations of safety and efficacy have led to the recognition of RFA by the American Academy of Otolaryngology as a somnoplasty treatment option in selected situations for mild to moderate OSA, but the evidence was judged insufficient for routine adoption by the American College of Physicians.


title: Obstructive sleep apnea

text: RFA has some potential advantages in carefully selected medical settings, such as intolerance to the CPAP device. For example, when adherence is defined as greater than four hours of nightly use, 46% to 83% of patients with obstructive sleep apnea are non-adherent with CPAP for a variety of reasons, including discomfort while sleeping.


title: Obstructive sleep apnea

text: RFA is usually performed in an outpatient setting, using either local anesthetics or conscious sedation anesthesia, the procedure itself typically lasting under 3 minutes. The targeted tissue, such as tongue or palate, is usually approached through the mouth without the need for incisions, although occasionally the target is approached through the neck using assisted imaging. If the tongue is being targeted, this can be done from either dorsal or ventral side. Complications include ulceration, infection, nerve weakness or numbness and swelling. These complications occur in less than 1% of procedures.


title: Obstructive sleep apnea

text: Evidence is insufficient to support the use of medications to treat obstructive sleep apnea. This includes the use of fluoxetine, paroxetine, acetazolamide, and tryptophan among others.


title: Obstructive sleep apnea

text: Recent studies are trying to investigate cannabinoids as a treatment for OSA, especially dronabinol which is a synthetic form of THC (delta-9-tetrahydrocannabinol). Cannabis is known to influence sleep, for example it can reduce sleep onset latency, however, results are not consistent. Studies about dronabinol have shown positive impact on the OSA, as they observed a reduced AHI (Apnea-Hypopnea Index) and an increased self-reported sleepiness (the objective sleepiness being unaffected). However, more evidence are needed as many effects of those substances remain unknown, especially the effects of a long-term intake. The effect on sleepiness and weight gain are particularly of concern. Because of uncertainty about its effects and a lack of consistent evidence, the American Academy of Sleep Medicine does not approve the use of medical cannabis for the treatment of OSA.


title: Obstructive sleep apnea

text: Evidence to support oral appliances/functional orthopedic appliances in children is insufficient with very low evidence of effect. However, the oral appliances/functional orthopedic appliances may be considered in specified cases as an auxiliary in the treatment of children who have craniofacial anomalies which are risk factors of apnea.


title: Obstructive sleep apnea

text: Stroke and other cardiovascular diseases are related to OSA, and those under the age of 70 have an increased risk of early death. Persons with sleep apnea have a 30% higher risk of heart attack or death than those unaffected. In severe and prolonged cases, increased in pulmonary pressures are transmitted to the right side of the heart. This can result in a severe form of congestive heart failure known as "cor pulmonale". Diastolic function of the heart also becomes affected. Elevated arterial pressure (i.e., hypertension) can be a consequence of OSA syndrome. When hypertension is caused by OSA, it is distinctive in that, unlike most cases (so-called essential hypertension), the readings do "not" drop significantly when the individual is sleeping (non-dipper) or even increase (inverted dipper).


title: Obstructive sleep apnea

text: Without treatment, the sleep deprivation and lack of oxygen caused by sleep apnea increases health risks such as cardiovascular disease, aortic disease (e.g. aortic aneurysm), high blood pressure, stroke, diabetes, clinical depression, weight gain, obesity, and even death.


title: Obstructive sleep apnea

text: OSA is associated with cognitive impairment, including deficits in inductive and deductive reasoning, attention, vigilance, learning, executive functions, and episodic and working memory. OSA is associated with increased risk for developing mild cognitive impairment and dementia, and has been associated with neuroanatomical changes (reductions in volumes of the hippocampus, and gray matter volume of the frontal and parietal lobes) which can however be at least in part reversed with CPAP treatment.


title: Obstructive sleep apnea

text: Until the 1990s, little was known regarding the frequency of OSA. A recent meta-analysis of 24 epidemiological studies on the prevalence of OSA in the general population aged 18 and older revealed that for ≥ 5 apnea events per hour, OSA prevalence ranged from 9% to 38%, specifically ranging from 13% to 33% in men and 6% to 19% in women, while in the population aged 65 and older, OSA prevalence was as high as 84%, including 90% in men and 78% in women. Nevertheless, for ≥ 15 apnea events per hour, OSA prevalence ranged from 6% to 17%, and almost 49% prevalence in the older population aged 65 and older. Moreover, a higher BMI is also linked to a higher prevalence of OSA, where a 10% increase in body weight led to a 6-fold risk of OSA in obese men and women.


title: Obstructive sleep apnea

text: However, OSA is underdiagnosed as it is not always accompanied by daytime sleepiness which can leave the sleep-disordered breathing unnoticed. The prevalence of OSA with daytime sleepiness is thus estimated to affect 3% to 7% of men and 2% to 5% of women, and the disease is common in both developed and developing countries. OSA prevalence increases with age and is most commonly diagnosed in individuals over 65 years old, with estimations ranging from 22.1% to 83.6%. The prevalence has drastically increased the past decades mainly explained by the obesity epidemic currently observed.


title: Obstructive sleep apnea

text: Men are more affected by OSA than women, but the phenomenology differs between both genders. Snoring and witnessed apnea are more frequent among men but insomnia for example is more frequent among women. The OSA frequency increase with age for the women. The mortality is higher for women.


title: Obstructive sleep apnea

text: Some studies report that it is more frequent among the Hispanic and African American population than among the white population.


title: Obstructive sleep apnea

text: If studied carefully in a sleep lab by polysomnography (formal "sleep study"), it is believed that approximately 1 in 5 American adults would have at least mild OSA.


title: Obstructive sleep apnea

text: Neurostimulation is currently being studied as a method of treatment; an implanted hypoglossal nerve stimulation system received European CE Mark (Conformité Européenne) approval in March 2012. Also being studied are exercises of the muscles around the mouth and throat through activities such as playing the didgeridoo.


title: Conductivity (electrolytic)

text: Conductivity (or specific conductance) of an electrolyte solution is a measure of its ability to conduct electricity. The SI unit of conductivity is Siemens per meter (S/m).


title: Conductivity (electrolytic)

text: Conductivity measurements are used routinely in many industrial and environmental applications as a fast, inexpensive and reliable way of measuring the ionic content in a solution. For example, the measurement of product conductivity is a typical way to monitor and continuously trend the performance of water purification systems.


title: Conductivity (electrolytic)

text: In many cases, conductivity is linked directly to the total dissolved solids (TDS). High quality deionized water has a conductivity of about 0.05 μS/cm at 25 °C, typical drinking water is in the range of 200–800 μS/cm, while sea water is about 50 mS/cm [incorrect according to source] (or 50,000 μS/cm).


title: Conductivity (electrolytic)

text: Conductivity is traditionally determined by connecting the electrolyte in a Wheatstone bridge. Dilute solutions follow Kohlrausch's Laws of concentration dependence and additivity of ionic contributions. Lars Onsager gave a theoretical explanation of Kohlrausch's law by extending Debye–Hückel theory.


title: Conductivity (electrolytic)

text: The SI unit of conductivity is S/m and, unless otherwise qualified, it refers to 25 °C. More generally encountered is the traditional unit of μS/cm.


title: Conductivity (electrolytic)

text: The commonly used standard cell has a width of 1 cm, and thus for very pure water in equilibrium with air would have a resistance of about 10 ohms, known as a megohm. Ultra-pure water could achieve 18 megohms or more. Thus in the past, megohm-cm was used, sometimes abbreviated to "megohm". Sometimes, conductivity is given in "microsiemens" (omitting the distance term in the unit). While this is an error, it can often be assumed to be equal to the traditional μS/cm.


title: Conductivity (electrolytic)

text: The conversion of conductivity to the total dissolved solids depends on the chemical composition of the sample and can vary between 0.54 and 0.96. Typically, the conversion is done assuming that the solid is sodium chloride; 1 μS/cm is then equivalent to about 0.64 mg of NaCl per kg of water.


title: Conductivity (electrolytic)

text: The electrical conductivity of a solution of an electrolyte is measured by determining the resistance of the solution between two flat or cylindrical electrodes separated by a fixed distance. An alternating voltage is generally used in order to minimize water electrolysis. The resistance is measured by a conductivity meter. Typical frequencies used are in the range 1–3 kHz. The dependence on the frequency is usually small, but may become appreciable at very high frequencies, an effect known as the Debye–Falkenhagen effect.


title: Conductivity (electrolytic)

text: A wide variety of instrumentation is commercially available. Most commonly, two types of electrode sensors are used, electrode-based sensors and inductive sensors. Electrode sensors with a static design are suitable for low and moderate conductivities, and exist in various types, having either two or four electrodes, where electrodes can be arrange oppositely, flat or in a cylinder. Electrode cells with a flexible design, where the distance between two oppositely arranged electrodes can be varied, offer high accuracy and can also be used for the measurement of highly conductive media. Inductive sensors are suitable for harsh chemical conditions but require larger sample volumes than electrode sensors. Conductivity sensors are typically calibrated with KCl solutions of known conductivity. Electrolytic conductivity is highly temperature dependent but many commercial systems offer automatic temperature correction.


title: Conductivity (electrolytic)

text: Resistance, , is proportional to the distance, , between the electrodes and is inversely proportional to the cross-sectional area of the sample, (noted on the Figure above). Writing (rho) for the specific resistance, or resistivity.


title: Conductivity (electrolytic)

text: In practice the conductivity cell is calibrated by using solutions of known specific resistance, , so the individual quantities and need not be known precisely, but only their ratio. If the resistance of the calibration solution is , a cell-constant, defined as the ratio of and ( = ), is derived.


title: Conductivity (electrolytic)

text: Sometimes the conductance (reciprocical of the resistance) is denoted as = . Then the specific conductance (kappa) is:


title: Conductivity (electrolytic)

text: The specific conductance of a solution containing one electrolyte depends on the concentration of the electrolyte. Therefore, it is convenient to divide the specific conductance by concentration. This quotient, termed molar conductivity, is denoted by


title: Conductivity (electrolytic)

text: Strong electrolytes are hypothesized to dissociate completely in solution. The conductivity of a solution of a strong electrolyte at low concentration follows Kohlrausch's Law


title: Conductivity (electrolytic)

text: where is known as the limiting molar conductivity, is an empirical constant and is the electrolyte concentration. (Limiting here means "at the limit of the infinite dilution".) In effect, the observed conductivity of a strong electrolyte becomes directly proportional to concentration, at sufficiently low concentrations i.e. when


title: Conductivity (electrolytic)

text: An interpretation of these results was based on the theory of Debye and Hückel, yielding the Debye–Hückel–Onsager theory:


title: Conductivity (electrolytic)

text: where and are constants that depend only on known quantities such as temperature, the charges on the ions and the dielectric constant and viscosity of the solvent. As the name suggests, this is an extension of the Debye–Hückel theory, due to Onsager. It is very successful for solutions at low concentration.


title: Conductivity (electrolytic)

text: A weak electrolyte is one that is never fully dissociated (there are a mixture of ions and complete molecules in equilibrium). In this case there is no limit of dilution below which the relationship between conductivity and concentration becomes linear. Instead, the solution becomes ever more fully dissociated at weaker concentrations, and for low concentrations of "well behaved" weak electrolytes, the degree of dissociation of the weak electrolyte becomes proportional to the inverse square root of the concentration.


title: Conductivity (electrolytic)

text: Typical weak electrolytes are weak acids and weak bases. The concentration of ions in a solution of a weak electrolyte is less than the concentration of the electrolyte itself. For acids and bases the concentrations can be calculated when the value or values of the acid dissociation constant are known.


title: Conductivity (electrolytic)

text: For a monoprotic acid, HA, obeying the inverse square root law, with a dissociation constant , an explicit expression for the conductivity as a function of concentration, , known as Ostwald's dilution law, can be obtained.


title: Conductivity (electrolytic)

text: Various solvents exhibit the same dissociation if the ratio of relative permittivities equals the ratio cubic roots of concentrations of the electrolytes (Walden's rule).


title: Conductivity (electrolytic)

text: Both Kohlrausch's law and the Debye–Hückel–Onsager equation break down as the concentration of the electrolyte increases above a certain value. The reason for this is that as concentration increases the average distance between cation and anion decreases, so that there is more interactions between close ions. Whether this constitutes ion association is a moot point. However, it has often been assumed that cation and anion interact to form an ion pair. So, an "ion-association" constant , can be derived for the association equilibrium between ions A and B:


title: Conductivity (electrolytic)

text: Davies describes the results of such calculations in great detail, but states that should not necessarily be thought of as a true equilibrium constant, rather, the inclusion of an "ion-association" term is useful in extending the range of good agreement between theory and experimental conductivity data. Various attempts have been made to extend Onsager's treatment to more concentrated solutions.


title: Conductivity (electrolytic)

text: The existence of a so-called "conductance minimum" in solvents having the relative permittivity under 60 has proved to be a controversial subject as regards interpretation. Fuoss and Kraus suggested that it is caused by the formation of ion triplets, and this suggestion has received some support recently.


title: Conductivity (electrolytic)

text: Other developments on this topic have been done by Theodore Shedlovsky, E. Pitts, R. M. Fuoss, Fuoss and Shedlovsky, Fuoss and Onsager.


title: Conductivity (electrolytic)

text: The limiting equivalent conductivity of solutions based on mixed solvents like water alcohol has minima depending on the nature of alcohol. For methanol the minimum is at 15 molar % water, and for the ethanol at 6 molar % water.


title: Conductivity (electrolytic)

text: Generally the conductivity of a solution increases with temperature, as the mobility of the ions increases. For comparison purposes reference values are reported at an agreed temperature, usually 298 K (≈ 25 °C or 77 °F), although occasionally 20 °C (68 °F) is used. So called 'compensated' measurements are made at a convenient temperature but the value reported is a calculated value of the expected value of conductivity of the solution, as if it had been measured at the reference temperature. Basic compensation is normally done by assuming a linear increase of conductivity versus temperature of typically 2% per kelvin. This value is broadly applicable for most salts at room temperature. Determination of the precise temperature coefficient for a specific solution is simple and instruments are typically capable of applying the derived coefficient (i.e. other than 2%).


title: Conductivity (electrolytic)

text: Measurements of conductivity formula_10 versus temperature can be used to determine the activation energy formula_11, using the Arrhenius equation:


title: Conductivity (electrolytic)

text: where formula_13 is the exponential prefactor, the gas constant, and the absolute temperature in Kelvin.


title: Conductivity (electrolytic)

text: Despite the difficulty of theoretical interpretation, measured conductivity is a good indicator of the presence or absence of conductive ions in solution, and measurements are used extensively in many industries. For example, conductivity measurements are used to monitor quality in public water supplies, in hospitals, in boiler water and industries which depend on water quality such as brewing. This type of measurement is not ion-specific; it can sometimes be used to determine the amount of total dissolved solids (TDS) if the composition of the solution and its conductivity behavior are known. Conductivity measurements made to determine water purity will not respond to non conductive contaminants (many organic compounds fall into this category), therefore additional purity tests may be required depending on application.


title: Conductivity (electrolytic)

text: Applications of TDS measurements are not limited to industrial use; many people use TDS as an indicator of the purity of their drinking water. Additionally, aquarium enthusiasts are concerned with TDS, both for freshwater and salt water aquariums. Many fish and invertebrates require quite narrow parameters for dissolved solids. Especially for successful breeding of some invertebrates normally kept in freshwater aquariums—snails and shrimp primarily—brackish water with higher TDS, specifically higher salinity, water is required. While the adults of a given species may thrive in freshwater, this is not always true for the young and some species will not breed at all in non-brackish water.


title: Conductivity (electrolytic)

text: Sometimes, conductivity measurements are linked with other methods to increase the sensitivity of detection of specific types of ions. For example, in the boiler water technology, the boiler blowdown is continuously monitored for "cation conductivity", which is the conductivity of the water after it has been passed through a cation exchange resin. This is a sensitive method of monitoring anion impurities in the boiler water in the presence of excess cations (those of the alkalizing agent usually used for water treatment). The sensitivity of this method relies on the high mobility of H in comparison with the mobility of other cations or anions. Beyond cation conductivity, there are analytical instruments designed to measure Degas conductivity, where conductivity is measured after dissolved carbon dioxide has been removed from the sample, either through reboiling or dynamic degassing.


title: Sint Eustatius

text: Sint Eustatius (, ), also known locally as Statia (), is an island in the Caribbean. It is a special municipality (officially "public body") of the Netherlands.


title: Sint Eustatius

text: The island lies in the northern Leeward Islands portion of the West Indies, southeast of the Virgin Islands. Sint Eustatius is immediately to the northwest of Saint Kitts, and to the southeast of Saba. The regional capital is Oranjestad. The island has an area of . Travellers to the island by air arrive through F. D. Roosevelt Airport. Formerly part of the Netherlands Antilles, Sint Eustatius became a special municipality of the Netherlands on 10 October 2010. Together with Bonaire and Saba it forms the BES islands.


title: Sint Eustatius

text: The name of the island, "Sint Eustatius", is the Dutch name for Saint Eustace (also spelled Eustachius or Eustathius), a legendary Christian martyr, known in Spanish as "San Eustaquio" and in Portuguese as "Santo Eustáquio" or "Santo Eustácio".


title: Sint Eustatius

text: The earliest inhabitants were Caribs believed to have come from the Amazon basin (South America) and migrated north from Venezuela via the Lesser Antilles. In the early 20th century, settlement traces were discovered at Golden Rock and Orange Bay.


title: Sint Eustatius

text: Multiple pre-Columbian sites have been found on the island, most notably the site referred to as the "Golden Rock Site". It is thought that the island was likely seen by Christopher Columbus in 1493. From the first European settlement, in the 17th century up until the early 19th century, St. Eustatius changed hands twenty-one times between the Netherlands, Britain, and France.


title: Sint Eustatius

text: In 1636, the chamber of Zeeland of the Dutch West India Company took possession of the island, reported to be uninhabited at the time. In 1678 the islands of St. Eustatius, Sint Maarten and Saba were under the direct command of the Dutch West India Company, with a commander stationed on St. Eustatius to govern all three. At the time, the island was of some importance for the cultivation of tobacco and sugar.


title: Sint Eustatius

text: In the 18th century, St. Eustatius's geographical placement in the middle of Danish (Virgin Islands), British (Jamaica, St. Kitts, Barbados, Antigua), French (St. Domingue, Ste. Lucie, Martinique, Guadeloupe) and Spanish (Cuba, Santo Domingo, Puerto Rico) territories—its large harborage, neutrality and status from 1756 as a free port with no customs duties were all factors in it becoming a major point of transhipment of goods, and a locus for trade in contraband. St. Eustatius's economy flourished under the Dutch by ignoring the monopolistic trade restrictions of the British, French and Spanish islands; it became known as "The Golden Rock".


title: Sint Eustatius

text: "It has no produce, no fortifications for its defence, nor martial spirit nor military regulations ... Its utility was its defence. The universality of its use, the neutrality of its nature was its security and its safeguard. Its proprietors had, in the spirit of commerce, made it an emporium for all the world. ... Its wealth was prodigious, arising from its industry and the nature of its commerce."


title: Sint Eustatius

text: The island sold arms and ammunition to anyone willing to pay, and it was therefore one of the few places from which the young United States could obtain military stores. The good relationship between St. Eustatius and the United States resulted in the noted "First Salute".


title: Sint Eustatius

text: On 16 November 1776, the 14-gun American brig "Andrew Doria" commanded by Captain Isaiah Robinson sailed, flying the Continental Colors of the fledgling United States, into the anchorage below St. Eustatius' Fort Oranje. Robinson announced his arrival by firing a thirteen gun salute, one gun for each of the thirteen American colonies in rebellion against Britain. Governor Johannes de Graaff replied with an eleven-gun salute from the cannons of Fort Oranje (international protocol required two guns fewer to acknowledge a sovereign flag). It was the first international acknowledgment of American independence. The "Andrew Doria" had arrived to purchase munitions for the American Revolutionary forces. She was carrying a copy of the Declaration of Independence which was presented to Governor De Graaff. An earlier copy had been captured by the British on its way to Holland. It was wrapped in documents that the British believed to be a strange cipher, but were actually written in Yiddish, addressed to Jewish merchants in Holland.


title: Sint Eustatius

text: President Franklin D. Roosevelt visited St. Eustatius for two hours on 27 February 1939 on USS "Houston" to recognise the importance of the 1776 "First Salute". He presented a large brass plaque to St. Eustatius, displayed today under a flagpole atop the walls of Fort Oranje, reading:


title: Sint Eustatius

text: ""In commemoration to the salute to the flag of the United States, Fired in this fort November 16. 1776, By order of Johannes de Graaff, Governor of Saint Eustatius, In reply to a National Gun-Salute, Fired by the United States Brig of War Andrew Doria, Under Captain Isaiah Robinson of the Continental Navy, Here the sovereignty of the United States of America was first formally acknowledged to a national vessel by a foreign official. Presented by Franklin Delano Roosevelt, President of the United States of America""


title: Sint Eustatius

text: The recognition provided the title for Barbara W. Tuchman's 1988 book "The First Salute: A View of the American Revolution".


title: Sint Eustatius

text: The British took the Andrew Doria incident seriously, and protested bitterly against the continuous trade between the United Colonies and St. Eustatius. In 1778, Lord Stormont claimed in Parliament that, "if Sint Eustatius had sunk into the sea three years before, the United Kingdom would already have dealt with George Washington". Nearly half of all American Revolutionary military supplies were obtained through St. Eustatius. Nearly all American communications to Europe first passed through the island. The trade between St. Eustatius and the United States was the main reason for the Fourth Anglo-Dutch War of 1780–1784. Notably, the British Admiral George Brydges Rodney, having occupied the island for Great Britain in 1781, urged the commander of the landing troops, Major-General Sir John Vaughan, to seize "Mr. Smith at the house of Jones – they (the Jews of St. Eustatius, Caribbean Antilles) cannot be too soon taken care of – they are notorious in the cause of America and France." The war was disastrous for the Dutch economy.


title: Sint Eustatius

text: Britain declared war on the Republic of the Seven United Netherlands on 20 December 1780. Even before officially declaring war, Britain had outfitted a massive battle fleet to take and destroy the weapons depot and vital commercial centre that St. Eustatius had become. British Admiral George Brydges Rodney was appointed the commander of the battle fleet. 3 February 1781, the massive fleet of 15 ships of the line and numerous smaller ships transporting over 3,000 soldiers appeared before St. Eustatius prepared to invade. Governor De Graaff did not know about the declaration of war. Rodney offered De Graaff a bloodless surrender to his superior force. Rodney had over 1,000 cannon to De Graaff's one dozen cannon and a garrison of sixty men. De Graaff surrendered the island, but first fired two rounds as a show of resistance in honour of Dutch Admiral Lodewijk van Bylandt, who commanded a ship of the Dutch Navy which was in the harbor. Ten months later, the island was conquered by the French, allies of the Dutch Republic in the war. The Dutch regained control over the looted and plundered island in 1784.


title: Sint Eustatius

text: At its peak, St. Eustatius may have had a largely transient population of about 10,000 people. Most were engaged in commercial and maritime interests. A census list of 1790 gives a total population (free and enslaved people combined) of 8,124. Commerce revived after the British left. Many of the merchants (including the Jews) returned to the island. However, French and British occupations from 1795 disrupted trade and also the North-Americans, now globally recognised as an independent nation, had meanwhile developed their own trading network and did not need St. Eustatius anymore. The island was eclipsed by other Dutch ports, such as those on the islands of Curaçao and Sint Maarten. During the last years of the 18th century Statia developed trade in bay rum. The economy declined in the early 19th century. From about 1795 the population declined, dropping to 921 in 1948.


title: Sint Eustatius

text: The first record of Jews on St. Eustatius dates to 1660. The Jews were mainly merchants with significant international trading and maritime commercial ties. Jews were captains, owners or co-owners with Christian partners, of significant numbers of ships originating out of St. Eustatius. A few were island plantation owners. Jews were estimated to have comprised at least 10% of the permanent population of St. Eustatius.


title: Sint Eustatius

text: Ten days after the island surrendered to the British on 3 February 1781, Rodney ordered that the entire Jewish male adult population assemble for him. They were rounded up and thirty one heads of families were summarily deported to St. Kitts without word or mercy to their dependents. The choice of exiling the Jews to St. Kitts was significant. The nearby British Island of Nevis had a large Jewish population and an established community capable of aiding the refugees. St. Kitts did not have any Jewish community or population. The other seventy-one were locked up in the weighing house in Lower Town where they were held for three days.


title: Sint Eustatius

text: Expulsion of Americans followed on 23 February, of merchants from Amsterdam on 24 February and of other Dutch citizens and Frenchmen on 5 March. The crews of the Dutch ships Rodney took were sent to St. Kitts for imprisonment – after first stripping them of all their belongings. Because of their maltreatment, many perished. The Jews were well received on St. Kitts – where many knew them as their respected business partners. They were supported in their protest against their deportation and it proved successful. They were allowed to return to St. Eustatius after a few weeks to observe all their property being sold at small fractions of the original value after having been confiscated by Rodney.


title: Sint Eustatius

text: The resentment the British felt for the population of this island that helped the Americans to defeat them translated in a harsh treatment of the inhabitants. There were numerous complaints about "individuals of both sexes being halted in the streets and being body searched in a most scandalous way." Pieter Runnels, an eighty-year-old member of the island council and captain of the civic guard, did not survive the rough treatment he received aboard Rodney's ship. He, a member of one of the island's oldest-established families, became the only civilian casualty of the British occupation. British soldiers prevented the family and others paying their last respects at his funeral from using the water from the family's own cistern.


title: Sint Eustatius

text: The tomb of former governor Jan de Windt was broken open by British soldiers, all the silver decorations stolen off the caskets, and the bodies of the governor and his wife exposed, without any of Rodney's officers interfering.


title: Sint Eustatius

text: Rodney singled out the Jews: the harshness was reserved for them alone. He did not do the same to French, Dutch, Spanish or even the American merchants on the island. He permitted the French to leave with all their possessions. Rodney was concerned that his unprecedented behavior would be repeated upon British islands by French forces when events were different. However, Governor De Graaff was also deported.


title: Sint Eustatius

text: As he did with all other warehouses, Rodney confiscated the Jewish warehouses, looted Jewish personal possessions, even cutting the lining of their clothes to find money hidden in there. When Rodney realized that the Jews might be hiding additional treasure, he dug up the Jewish cemetery.


title: Sint Eustatius

text: Later, in February 1782, Edmund Burke, the leading opposition member of the Whig Party, upon learning of Rodney's actions in St. Eustatius, rose to condemn Rodney's anti-Semitic, avaricious vindictiveness in Parliament:


title: Sint Eustatius

text: ""...and a sentence of general beggary pronounced in one moment upon a whole people. A cruelty unheard of in Europe for many years… The persecution was begun with the people whom of all others it ought to be the care and the wish of human nations to protect, the Jews… the links of communication, the mercantile chain… the conductors by which credit was transmitted through the world…a resolution taken (by the British conquerors) to banish this unhappy people from the island. They suffered in common with the rest of the inhabitants, the loss of their merchandise, their bills, their houses, and their provisions; and after this they were ordered to quit the island, and only one day was given them for preparation; they petitioned, they remonstrated against so hard a sentence, but in vain; it was irrevocable.""


title: Sint Eustatius

text: From about 1815, when there was no longer a viable Jewish community using and maintaining the synagogue on St. Eustatius, it gradually fell into ruin.


title: Sint Eustatius

text: The synagogue building, known as Honen Dalim, (He who is charitable to the Poor) was constructed in 1737. Permission for building the synagogue came from the Dutch West India Company, additional funding came from the Jewish community on Curaçao. Permission was conditional on the fact that the Jewish house of worship would be sited where "the exercise of their (Jewish) religious duties would not molest those of the Gentiles". The building is located off a small lane called Synagogue Path, away from the main street. The synagogue attested to the wealth of the Jews of St. Eustatius and their influence on the island.