bluuebunny/crossref_metadata_2025 huggingface dataset:
0664 Temporal Patterns of Suicidal Ideation in the Emergency Department
Authors: Tubbs Andrew , Ghani Sadia , Karp Jordan , Fernandez Fabian-Xosé , Klerman Elizabeth , Perlis Michael , Grandner Michael
Published: May 2022

Introduction

Nocturnal wakefulness may be dangerous for vulnerable populations: the incident risk for suicide is highest at night after adjusting for population wakefulness, and nocturnal wakefulness is associated with suicidal ideation. These observations support the hypothesis that sleep- and circadian-dependent changes in mood, reward processing, and executive function increase the risk for disinhibited behavior at night (during periods of nocturnal wakefulness). The present study evaluated this hypothesis by using the timing of emergency department encounters for suicidal ideation.

Methods

An archival analysis of data from two emergency departments (EDs) in Tucson, Arizona from 2018 and 2019 yielded 51,370 encounters for any reason across 29,359 individuals with usable data, and the time of initial contact was extracted for each case. Of these, 571 individuals (1.94%) sought care for 763 (1.49%) instances of suicidal ideation (determined by ICD-10 code R45.861). Encounters were characterized by date/time, age, sex, race/ethnicity, blood alcohol level (if tested), homelessness, and prior diagnosis of a psychotic disorder, bipolar disorder, or depressive disorder. Suicidal ideation encounters were analyzed as raw counts and as a proportion of all encounters by clock hour and time-of-day categories (night: 12AM-5:59AM; morning: 6AM-11:59AM; afternoon:12PM-5:59PM; evening: 6PM-11:59PM) using robust Poisson models.

Results

Although most ED encounters occurred between 6PM and midnight (mean: 9:42PM), the greatest number of suicidal ideation encounters occurred between 12AM and 3AM (mean: 12:18AM). After adjusting for the per-hour proportion of ED visits, the incident risk for a suicidal ideation encounter increased between 8AM and 11AM, peaked at 10AM (IRR: 1.95 [1.10-3.44]) and was lowest at 4PM (IRR: 0.54 [0.32-0.91]). Compared to the evening, the incident risk of suicidal ideation was 64% greater in the morning (IRR: 1.64 [1.31-2.06]), 25% greater at night (IRR: 1.25 [1.00-1.56]), but not different for afternoon encounters.

Conclusion

After adjusting for overall encounter rates, ED encounters for suicidal ideation are more likely to occur in the morning. Although the morning peak in incident risk is later than the reported nocturnal risk for incident suicide, this may reflect a delay between when an individual develops suicidal ideation and when they seek or receive treatment.

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0668 The Effect of Antidepressant Medications on Sleep Architecture in a Primarily Middle-aged Sample of Women with Multi-morbidities: Chronic Insomnia, Chronic Pain, and Depression
Authors: Sparrow Emilie , Stearns Melanie , Nair Neetu , McCrae Christina
Published: May 2022

Introduction

Depression commonly impacts sleep architecture by increasing REM and decreasing stage 3 sleep. Growing evidence suggests antidepressants may reduce or reverse those effects in depressed individuals but has largely ignored their impact in the context of multi-morbidities. Depression, chronic insomnia, and chronic pain are common in middle-aged women and are thought to share a common neurobiological basis. They often co-occur, and thus, represent a common multi-morbidity triad. Here we examine whether %REM and %stage 3 sleep differ as a function of antidepressant use (yes/no) in a primarily middle-aged sample of women with all three morbidities.

Methods

Female adults (18+ years, n=91, Mage=51, SD=10.16) with comorbid insomnia, chronic pain, and depression (≥17 BDI-II score) completed one night of ambulatory polysomnography and reported antidepressant medication use (yes/no) and type (SSRI/SNRI/SARI/TCA/NDRI) as part of baseline data collection for a RCT (SPIN, NCT02688569). ANCOVA (R v4.1.1) examined group differences (antidepressant use: yes/no) in %REM and %stage3 sleep, controlling for age and sleep medication use.

Results

Only %REM was significantly lower (F=6.213, p=.015) in antidepressant users (n=48, M=14.85, SD=9.38) versus non-users (n=43, M=19.23, SD=6.70). An exploratory follow-up ANCOVA examined whether antidepressant type was important. Two groups were formed based on antidepressant mechanism of action (medications affecting serotonin, i.e., SSRI/SNRI/SARI vs medications affecting other neurotransmitters, i.e., TCA/NDRI), and their means were compared. Only %stage3 sleep was significantly lower (F=7.937, p=.007) in SSRI/SNRI/SARI users (n=37, M=11.18, SD=9.28) versus TCA/NDRI users (n=11, M=19.36, SD=13.04).

Conclusion

Thus, general antidepressant medication use may help decrease REM, but the increase of stage 3 sleep depended on which medications were used (i.e., TCA/NDRI). These findings suggest a neurophysiological functioning difference between types of antidepressants, particularly for this population of women with chronic pain, insomnia, and depression. This difference may be due to SSRI/SNRI/SARIs impacting serotonin, which may have an impact on REM, but not stage 3 sleep. However, the current study only had a small group of people using TCA/NDRIs, limiting generalizability and inferences. Future longitudinal research with a larger sample size is needed to parse out the effects of each antidepressant medication type individually and over time.

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ClinicalTrials-NCT02688569, PI McCrae.
0674 CPAP Adherence and Response to Cognitive Processing Therapy for PTSD in Veterans with Obstructive Sleep Apnea
Authors: Kunes Kristina , Johnson Cyle , Driscoll David , Walters Ryan , Ramaswamy Sriram
Published: May 2022

Introduction

Cognitive processing therapy (CPT) is a recommended first-line psychotherapy treatment for veterans with PTSD. Veterans with PTSD are at higher risk for sleep disorders including obstructive sleep apnea (OSA), and there is evidence that OSA can exacerbate PTSD and vice versa. Several studies have shown that CPAP use is associated with improvement in PTSD symptoms. CPT is an effective, yet time and resource intensive treatment option, making it critical to identify potential health factors impacting its efficacy. This retrospective chart analysis of veterans diagnosed with OSA and PTSD evaluated the effect of CPAP adherence on response to CPT.

Methods

Medical records of patients seen in a VA Health Care System were reviewed to identify veterans diagnosed with OSA and PTSD that received between 1-12 sessions of CPT with documented weekly PTSD Checklist for DSM-5 (PCL-5) scores, Patient Health Questionnaire-9 (PHQ-9) scores, and were issued a CPAP machine for OSA. Data collected included demographics, CPAP adherence (mean CPAP use, % days with greater than 4 hrs./night of CPAP use, mean residual apnea hypopnea index, mask leak), and PTSD symptoms (PCL-5 and PHQ-9 scores). For each outcome, we estimated a linear mixed-effects model; models for PCL-5 allowed heterogeneous residual variances for each veteran.

Results

This study identified 25 veterans receiving CPT for PTSD with access to a CPAP machine for OSA. The median age of patients was 43 years, median BMI was 35.6, and median residual AHI was 2.4. Patients received CPT for a median duration of 11.0 weeks. There was significant improvement in weekly PCL-5 and PHQ-9 scores over the course of CPT (both p < .001). CPAP adherence of at least 4 hrs./night for ≥70% of days did not significantly impact PCL-5 and PHQ-9 scores during CPT. Residual AHI and mask leak were not associated with PTSD symptoms during CPT.

Conclusion

While CPAP nonadherence appears to be a potential contributing factor to the reduced effectiveness of evidence-based treatments for veterans with PTSD, our study revealed significant improvement in PTSD symptoms during CPT regardless of CPAP adherence. Given the retrospective nature and small sample size of this study, further research is needed to expand on these findings.

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0677 Impact of Cognitive Behavioral Therapy for Post-trauma Nightmares on Sleep-efficiency: Examining Data on Sleep Diary Data
Authors: Paquet Caitlin , Villarreal Dayana , Whitney-Snel Kendall , Beims-Ukens Leyli , Davis Joanne
Published: May 2022

Introduction

Prior research has not examined the impact of cognitive behavioral therapy (CBT) for post-trauma nightmares on aspects of sleep quality as measured by sleep diary data. While self-report measures assessing sleep quality have demonstrated that CBT for post-trauma nightmares is associated with significant improvements in sleep quality pre- to post-treatment, it is important to specifically analyze changes using sleep diary data given that research has demonstrated large discrepancies in self-report measures of sleep behavior and prospective sleep diary data.

Methods

All participants in this study were recruited from the local community as part of ongoing clinical trials studying the efficacy of Exposure, Relaxation, Rescription Therapy (ERRT). Each individual reported a history of a criterion A trauma and at least one nightmare weekly. Sleep diary data was collected at each weekly treatment session and included questions regarding time in bed, sleep-onset latency, time out of bed, wake time after sleep onset so that variables of total sleep time, time in bed, and sleep efficiency could be calculated. Participants were instructed to complete the sleep diary each morning while in treatment. Only participants who completed the full ERRT protocol were included.

Results

Results from 93 individuals were analyzed with a dependent samples t-test. The mean sleep efficacy prior to treatment was .85 (SD = .14) and after treatment was .92 (SD = .07), resulting in a t-value of 3.00 (p < .01; Cohen’s d = .57; 95% CI .16 -.96).

Conclusion

Results show that there is a significant and meaningful change in sleep efficiency from pre- to post-treatment of a form of CBT for post-trauma nightmares. Given that ERRT does not directly target time in bed or utilize sleep restriction, this is notable that it is associated with such improvements in sleep directly related to time spent in bed. As some research has suggested that aspects of CBT for insomnia may need to be combined with treatment for nightmares to successfully treat trauma-related sleep disturbances, these results indicate that CBT for nightmares alone may be sufficient. Limitations and future directions will be discussed.

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0681 Association of poor sleep with stress, anxiety, emotional support, social isolation, and depression during the COVID-19 pandemic
Authors: Teague Taylor , Debian Ahmad , Kokonda Manasa , Malhotra Sonal , Arentson-Lantz Emily , Shaib Fidaa , Nowakowski Sara
Published: May 2022

Introduction

The COVID-19 pandemic has impacted multiple facets of daily living: personal finances, physical activity, and mental and physical health. These changes can result in additional stress and negatively affect sleep. It is important for sleep medicine providers to understand how their patients are impacted by these changes to optimize their care. In this study, we evaluated the association of poor sleep with stress, anxiety, emotional support, social isolation, and depression among sleep medicine clinic patients during the COVID-19 pandemic.

Methods

Sleep medicine clinic patients were distributed an online survey at baseline followed by a 6-month follow-up survey (December 2020 - May 2021). Participants answered questions regarding Insomnia Severity Index (ISI), Patient-Reported Outcomes Measurement Information System (PROMIS) measures (sleep disturbance and sleep-related impairments), and COVID-19 testing. Stepwise linear regression was performed using SAS to determine if self-reported poor sleep predicted stress, anxiety, emotional support, social isolation, and depression. This study was approved by Baylor College of Medicine IRB. Informed consent was obtained from all subjects involved in the study.

Results

Eighty-one adults completed baseline survey, and 54 adults (mean age 55.2±18.4 years, 61% female, 70% Caucasian) completed 6-month follow-up survey. At baseline, anxiety had a significant effect on sleep disturbance (0.43±0.11, p=0.0001), sleep-related impairments (0.53±0.12, p=0.0001) and ISI (0.28±0.08, p=0.0004). Upon follow-up, an increase in ISI predicted higher perceived stress (0.18±0.07, p=0.013) and worse anxiety (0.61±0.16, p=0.0003). An increase in sleep disturbance predicted a decrease in emotional support (0.25±0.12, p=0.038). Additionally, an increase in sleep-related impairments predicted an increase in social isolation (0.39±0.11, p=0.0002) and depression (0.57±0.07, p<0.0001). Interestingly, only 3 participants tested positive for COVID-19.

Conclusion

In this study of sleep medicine clinic patients during the COVID-19 pandemic, we observed that poor sleep predicted greater stress, anxiety, social isolation, and depression along with less emotional support. This study illustrates the importance of addressing stress management, mental health (anxiety, depression), and emotional support when treating sleep medicine clinic patients during the COVID-19 pandemic.

Support (If Any)

National Institutes of Health (NIH) Grant #R01NR018342 (PI: Nowakowski); Department of Veteran Affairs, Veterans Health Administration, Office of Research and Development; Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413)
0697 Improving Detection of Obstructive Sleep Apnea in Pregnant Women Using a Six-Point Screening Tool
Authors: Jaziri Miriam , Smith Nicolina , Bazan Luisa , Pitts D'Angela , Kalmbach David
Published: May 2022

Introduction

Pregnant patients with obstructive sleep apnea (OSA) are at higher risk for adverse outcomes. There are currently no established screening tools for pregnant women. OSA in pregnancy continues to be underdiagnosed resulting in missed opportunities to prevent possible adverse outcomes.

Methods

A screening pilot program was implemented at our general obstetrics and maternal fetal medicine (MFM) clinic to improve diagnosis of OSA among pregnant women. Patients were screened by a nurse for snoring/apneas, BMI > 35, essential hypertension, glucose disorders, neck size > 36 cm, and symptoms of excessive daytime sleepiness. If a patient scored 3/6 or greater, a home sleep apnea test (HSAT), and in some cases an in-lab sleep study (PSG), was recommended to test for OSA after discussion of risks and benefits with an obstetrician.

Results

Since the initiation of the screening program, 302 women screened positive for OSA based on our 6-point screening tool. Average gestational age at the time of screening was 14.34 +/- 7.97 weeks. Of the women who scored ≥3 on the 6-point screening tool, 92 (30.46%) were referred directly to a sleep study and 31 (10.3%) received a referral to see a sleep medicine provider. A total of 78 underwent sleep testing and 58 (74.4%) were diagnosed with OSA with an apnea-hypopnea index (AHI) ≥ 5. Most patient were African American (67.9%) with an average age of 31.49 +/-5.74. The diagnosis of OSA correlated moderately well with the total score of the 6-point screening tool (p<.001), BMI (p=.005), essential hypertension (p=.01), glucose disorders (p=.07), and neck size (p=.039). Only a BMI of >35 was independently associated with a 3.7 increase in odds for OSA (95%CI=1.17, 11.76, p=.026).

Conclusion

A significant increase in screening for obstructive sleep apnea was achieved with implementation of the new screening protocol. Ease of use makes the six-point screening protocol a useful tool in clinic. More research is needed to test the accuracy of the six-point screening as a testing tool in this population. Additional barriers to screening and testing for OSA in pregnancy, including social and lifestyle factors should be explored in more depth.

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0720 Accuracy of WatchPat Portable Sleep Monitoring and Sleep Assessment in Patients with Atrial Fibrillation
Authors: Roth Robert , Stafford Patrick , Mehta Nishaki , Bilchick Kenneth , Davis Eric , Bonner Heather , Sobremonte-King Michelle , Cho Yelim , Kwon Younghoon
Published: May 2022

Introduction

Obstructive sleep apnea(OSA) is an established risk factor for atrial fibrillation(AF), necessitating early diagnosis and management. Home-based sleep-monitoring technology has become a mainstream diagnostic modality. Peripheral arterial tonometry (PAT) device is increasingly being used to screen for OSA in patients with AF. Our study aimed to examine the accuracy of Watch-PAT (WP) in OSA evaluation, and night-to-night variability of sleep characteristics as measured by WP when used during consecutive night sleep studies.

Methods

Patients with history of AF undergoing clinically indicated PSG were prospectively enrolled and had concurrent WP while undergoing PSG. Patients then were studied again using WP over two consecutive days at home. We compared agreement of OSA severity(defined as no OSA[AHI (apnea hypopnea index)<5], mild OSA[15>AHI³5], moderate OSA[30>AHI³15], severe OSA[AHI>30]) and total sleep time(TST) using Cohen’s Kappa(K) for categorical and Bland-Altman plots for continuous variables. To further characterize PSG versus WP, the cohort was stratified into paroxysmal versus persistent AF types. 1A/1B hypopnea scoring criteria was defined as per AASM.

Results

Our cohort included 24 patients with AF(80% male, mean age 68y). Most patients had clinically defined OSA(AHI³5). Patients with persistent AF had more severe OSA than those with paroxysmal AF (severe OSA present in 60% vs. 29%). Comparison of PSG to concurrently conducted WP in the lab showed substantial agreement in OSA severity by both 1A(K=0.623) and 1B(0.706) criteria. Percent difference in TST between PSG versus WP in the paroxysmal AF versus persistent groups was not statistically significant(p=0.387). Comparing two consecutive at-home WP tests showed substantial agreement in OSA severity measures(1A=0.872,1B=0.889). Bland-Altman plots for TST and sleep architecture showed ³95% of residuals within 2 standard-deviations, suggesting intertester agreement. Confidence intervals were broad in these plots reflecting our small sample size.

Conclusion

Our findings demonstrate that WP is a reasonable alternative to PSG, particularly if using the 1B criteria to diagnose OSA. Additionally, our results show that persistent versus paroxysmal AF does not seem to affect the results of WP tests. Night to night variability of OSA measures and TST was small. Future studies should verify the results of our study in a larger cohort.

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0726 Visceral adiposity and daytime sleepiness are associated with hypertension in mild-to-moderate sleep apnea: age-related differences
Authors: Karagkouni Efthalia , Vgontzas Alexandros , Fernandez-Mendoza Julio , Lenker Kristina , Basta Maria , Krishnamurthy Venkatesh , Bixler Edward
Published: May 2022

Introduction

Mild-to-moderate obstructive sleep apnea (OSA) affects 15-40% of the adult general population and is associated with incident hypertension, particularly in young and middle-aged adults. We examined whether visceral adiposity, a key predictor of OSA, and excessive daytime sleepiness (EDS), a cardinal symptom of OSA, are associated with hypertension in middle-aged and older adult patients with mild-to-moderate OSA.

Methods

A clinical sample of 148 adults (53.79±12.45y, 36.5% female) with mild-to-moderate OSA (5≤AHI<30) underwent 8-hour polysomnography, a clinical history and physical examination, including measures of blood pressure. EDS was defined as an Epworth Sleepiness Scale (ESS) score ≥11. Hypertension was defined as blood pressure ≥140/90mmHg or the use of anti-hypertensive medication. Visceral Adiposity Index (VAI) was calculated within each sex using Amato et al (2010) standardized formulas based on waist, BMI, triglycerides and HDL cholesterol. Logistic regression models examined the association between VAI, AHI and EDS with hypertension, adjusting for sex and stratifying by age. Under the receiver-operating characteristics (ROC) curves (AUC) with sex, BMI, AHI, VAI and EDS as independent variables examined predictive risk of hypertension.

Results

VAI (OR=1.64, 95%CI=1.23-2.20, p=0.001) and EDS (OR=2.73, 95%CI=1.04-7.17, p=0.042), but not AHI (OR=1.05, 95%CI=0.98-1.13, p=0.165), were associated with significantly increased odds of hypertension in adults aged <60y (46.81±8.83y), while none of these associations were significant in adults aged ≥60y (67.06±5.65y). Adding VAI and EDS to standard clinical factors (age, sex, and BMI) yielded a strong risk model for hypertension in adults aged <60y (AUC= 0.80), and weaker in adults aged ≥60y (AUC=0.62).

Conclusion

These data indicate that the combination of visceral adiposity and subjective sleepiness improves markedly the ability for clinicians to detect cases of mild-to-moderate OSA with increased cardiovascular risk, an association that is strongest in young and middle-aged adults. These findings also further support that OSA in older subjects is a distinctly different phenotype than in young and middle-aged adults.

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0733 Elucidating Sleep-Related Health Disparities across The Socioeconomic Spectrum Leveraging a Large-Scale Sleep Registry
Authors: Mehra Reena , Bruckman David , Schold Jesse , Foldvary-Schaefer Nancy , Kazaglis Louis , Alberts Jay , Orbea Cinthya Pena
Published: May 2022

Introduction

Sleep disparities have been implicated as a contributor to overall health disparities in socially disadvantaged groups. Despite epidemiological studies reporting sleep deprivation and poorer sleep quality among those with low socioeconomic status and group minorities, little is known about the extent to which sleep disorders such as sleep-disordered breathing (SDB), varies across the socioeconomic spectrum.

Methods

A retrospective cohort study was conducted utilizing data from the Cleveland Clinic Sleep Laboratory Registry. All adults who underwent diagnostic or split (baseline diagnostic) polysomnogram (PSG) or home sleep apnea test (HSAT) were included in the study. Area Deprivation Index (ADI), a biomarker of neighborhood socioeconomic disadvantage, was calculated by national rank, i.e. 25th, 50th and 75th percentiles; higher quartiles reflect greater deprivation. Generalized linear models adjusted for age, race, sex, body mass index(kg/m2) and primary payer were used to investigate association of ADI with SDB breathing measures (apnea hypopnea index, (AHI) and sleep-related hypoxemia (percentage of total sleep time <90%SaO2, [TST<90]).

Results

The analytic sample included 81,212 sleep studies; 60,013(74%) were PSG and 21,199(26%) HSAT with age: 52.0[41.0, 62.3], 49% females, 19% black race, with BMI=34.5±8.5 kg/m2, 44% with Medicaid and Medicare. Median ADI National Rank 59.0[39.0, 81.0] with higher 4th quartiles in PSG versus HSAT:29.1% vs 16.3%,p<0.001. In the PSG group, ADI was associated with hypoxia measures: TST<90(coefficient p<0.0001), model R2=0.171; mean SaO2(p<0.0001), R2=0.189; minimum SaO2(p<0.0001), R2=0.169; all measures were higher with higher ADI quartiles. In the HSAT group, ADI was associated with mean SaO2(p<0.0001), R2=0.188 and minimum SaO2(p<0.0001), R2=0.181 with all measures being higher with higher ADI quartiles. AHI was associated with ADI(p=0.0032), R2=0.239; but least squares mean AHI did not differ among ADI quartiles in PSG and HSAT groups. Interactions were observed between ADI and age, BMI and male sex (p<0.05), but not race.

Conclusion

Sleep-related hypoxia was greater among patients living in areas of higher deprivation when considering rankings of neighborhoods by socioeconomic disadvantage. Further understanding of the reason for this sleep disorder-related disparity is needed, i.e. further characterizing theoretical domains and social and geographic determinants of income, education, employment, and housing quality with the overarching goal to improve disparities in health.

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0739 Cerebrovascular Response to Intermittent Hypoxia During Sleep in OSA Patients
Authors: Liu Junjie
Published: May 2022

Introduction

Obstructive sleep apnea (OSA) is associated with increased risks of cerebrovascular accidents, but it remains unclear how OSA impacts the cerebral vasculature. Intermittent hypoxia is a hallmark feature of OSA and recurs throughout sleep. In awake humans, the cerebrovascular response to intermittent hypoxia has been well characterized, as an increase of blood perfusion that begins at least a few seconds after the start of hypoxia. Functional magnetic resonance imaging (fMRI) that measures the blood oxygen level dependent (BOLD) signal has revealed significant differences between the cerebrovascular responses in awake humans with and without OSA. However, intermittent hypoxia occurs primarily during sleep in OSA, yet the cerebrovascular response to intermittent hypoxia has not been studied during sleep.

Methods

Eight adult patients with severe OSA were recruited to this study. Each subject first underwent an acclimatization session in which they tried to sleep in the MRI scanner while listening to sound recordings of the fMRI. Each acclimatized subject then underwent an overnight study in which T2*-weighed BOLD fMRI of the whole brain was conducted for 1.5-3 hours in total (TE: 35 ms, TR: 2.0 s, 35 sagittal slices, 3.5 mm isotropic). Oxygen saturation (SaO2), chest movement, end-tidal carbon dioxide and scalp encephalography (EEG) were simultaneously recorded with the fMRI. After rigid-body motion correction and removal of artifacts, the temporal correlation between BOLD signal and the SaO2 signal was analyzed on a voxel-by-voxel basis.

Results

Four subjects (50%) were acclimatized to sleep in the MRI scanner and completed this study. In all subjects, the BOLD fMRI signal showed an initial decrease corresponding to the decrease of SaO2, followed by a delayed increase corresponding to the hyperperfusion, throughout the gray matter of cerebral cortex. The time course of BOLD fMRI signal was significantly advanced in time, by 2-4 seconds, in the visual cortex compared to the rest of cerebral cortex in all subjects. This phenomenon was also observed in some other brain regions, but not consistently across subjects.

Conclusion

This study is, to our knowledge, the first study of the cerebrovascular response to intermittent hypoxia during sleep in humans. In patients with OSA, we observed spatiotemporal heterogeneity of the cerebrovascular response, such that the response in the visual cortex was significantly advanced in time than other brain regions. This phenomenon has not been reported before, and future studies are needed to understand how this heterogeneity is associated with OSA.

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AASM Foundation
0740 Correlation of Pharyngeal Critical Pressure with Upper Airway Anatomy in Obstructive Sleep Apnea: A Systematic Review
Authors: Hartfield Phillip , Janczy Jaroslaw , Sharma Abhay , Newsome Hillary , Woodson B , Garcia Guilherme
Published: May 2022

Introduction

Obstructive sleep apnea (OSA) is a disease characterized by multiple episodes of upper airway collapse during sleep that causes oxygen desaturation and waking, leading to multiple comorbidities. The gold standard objective measure of upper airway collapsibility is the pharyngeal critical pressure (Pcrit), the nasal pressure at which inspiratory airflow is abolished. The objective of this systematic literature review is to summarize the current understanding of the anatomical factors that determine upper airway collapsibility.

Methods

A search using the PRISMA methodology was performed on PubMed for English language scientific papers that correlated Pcrit to anatomic measurements (such as airway length, airspace cross-sectional area, airway compliance, lung volumes, BMI, neck circumference, and waist circumference). In addition, papers reporting a correlation between Pcrit and the apnea-hypopnea index (AHI) were reviewed.

Results

751 papers were retrieved, and a total of 29 papers that matched eligibility criteria were included in the quantitative synthesis. The literature review confirmed that Pcrit has a significant correlation with the AHI. Pcrit also correlated with multiple anatomic measurements, including airway length, tongue dimensions, lung volume, and measures of obesity including BMI, neck circumference, and waist circumference.

Conclusion

The pharyngeal critical pressure is a measure of disease severity in OSA, as demonstrated by its correlation with AHI. The primary variables determining Pcrit were found to be airway length and measures of obesity. Surprisingly few studies to date have investigated the correlation between Pcrit and pharyngeal compliance and between Pcrit and airway cross-sectional area. In the future, a better understanding of the biomechanical factors that determine upper airway collapsibility is expected to help identify the optimal intervention of each phenotype of airway collapse for personalized medicine.

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Medical College of Wisconsin Department of Otolaryngology
0746 Mediation of Biomarkers of Inflammation in Sleep-Related Hypoxia and COVID-19 Clinical Outcomes
Authors: Orbea Cinthya Pena , Wang Lu , Shah Vaishal , Jehi Lara , Milinovich Alex , Foldvary-Schaefer Nancy , Chung Mina , Aboussouan Loutfi , Mehra Reena
Published: May 2022

Introduction

Central to the pathophysiology of SARS-CoV-2 is immune dysregulation and systemic inflammation, however, it is yet unknown whether sleep-related hypoxemia--which we have recently noted to be associated with worse COVID-19 clinical outcomes--is mediated by these biomarkers and pathways.

Methods

Data from patients who tested positive for SARS-CoV-2 and part of the integrated Cleveland Clinic COVID-19 and sleep laboratory registries from March-November 2020 were included. To assess the mediation effect of biomarkers, the relationship between sleep-related hypoxia measures (% sleep time<90%SaO2,T90) and moderate/severe WHO-7 COVID-19 score (use of supplemental oxygen, non-invasive ventilation, mechanical ventilation/ECMO or death) was first tested. The mediation effect, or natural indirect effect, of biomarkers of inflammation (C-Reactive Protein (CRP), white blood cell (WBC) count (with a focus on lymphocyte count) and lactate) was then estimated by logistic regression models adjusted for demographics, comorbidities, smoking pack year and site location using PROC CAUSALMED statement in SAS software (version 9.4, Cary, NC).

Results

The analytic sample included 446 patients hospitalized due to COVID-19: age:63.3.±13.8 years,51.3% female,39% African American with body mass index(BMI)=36.1±9.3kg/m2. Thirty-six percent used supplemental oxygen, 4% used high-flow or non-invasive ventilation,5% required ECMO or mechanical ventilation and 2% died. Hypoxic measures were associated with moderate/severe WHO-7 COVID-19 outcome: T90 median (>1.8%vs.≤1.8%) (OR=2.04, 95%CI:1.28-3.23,p=0.003), 5% increases in both mean SaO2 (OR=0.43, 95%CI: 0.26-0.70,p=<0.001) and minimum SaO2 (OR=0.84, 95%CI: 0.72-0.99,p=0.03). CRP was associated with mean SaO2 (p=0.040) and minimum SaO2 (p=0.029), likewise mediation analysis showed that there was a significant natural indirect effect of CRP in both hypoxia measures (OR=0.86,95%CI 0.73-0.99,p=0.036;OR=0.95,95%CI 0.90-1.00,p=0.034 respectively). WBC count, but not lymphocyte count subset, was associated with mean SaO2 (p=0.044), but the natural indirect effect was not significant (p=0.23. Lactate was associated with minimum SaO2 (p=0.044), but the natural indirect effect was not significant (p=0.23). T90 median was not associated with CRP(p=0.13), WBC count(p=0.87) or lactate(p=0.28).

Conclusion

CRP appears to represent a relevant mediator of sleep-related hypoxia and WHO-7 clinical outcomes. Further investigation is needed to elucidate if treatment of sleep-related hypoxia downregulates biomarkers of systemic inflammation to modify disease course.

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0755 Comparison of clinical pathways for upper airway stimulation management: in-laboratory titration polysomnography versus home-based efficacy sleep testing
Authors: Kent David , Huyett Phillip , Yu Phoebe , Roy Asim , Mehra Reena , Rundo Jessica , Stahl Stephanie , Manchanda Shalini
Published: May 2022

Introduction

Upper airway stimulation (UAS) therapy is an alternative treatment option for select CPAP-intolerant patients with obstructive sleep apnea. Current standard-of-care management uses in-laboratory polysomnography for titration of UAS stimulation amplitude (tPSG) after 3 months of patient self-titration at home. This home monitoring study was designed to evaluate whether tPSG or efficacy home sleep test (eHST) with tPSG by exception for eHST non-responders would have non-inferior apnea-hypopnea index (AHI) outcomes.

Methods

Enrolled patients underwent UAS implantation as part of regular clinical care and were randomized at the activation visit 1:1 between tPSG or eHST for the 3-month post-activation visit. If eHST results were suboptimal (AHI > 15 events/h or < 50% reduction from baseline AHI) patients underwent tPSG titration at 5 months. Both groups had 2-night eHSTs at 6 months post-activation. The primary endpoint was 6-month AHI equivalence between arms (defined as ± 15 events/h). Secondary endpoints were equivalence of Epworth Sleepiness Score (ESS; ± 2), oxygen desaturation index (ODI; ± 15 events/h), and nightly UAS device usage (± 0.5 h).

Results

The study randomized 60 patients from August 2020 through September 2021, who were primarily middle aged (57 ± 10 years), male (67%), Caucasian (98%), and overweight (BMI 29 ± 3 kg/m2), with severe OSA (AHI 35 ± 16). Eleven patients withdrew from the study early. As of December 2021, 41 and 36 patients have completed 3- and 6-month follow-up visits, respectively. Six-month visit AHI, ESS, ODI, and device usage data between arms is currently blinded and is expected to be complete by Q2 2021 prior to SLEEP 2022.

Conclusion

If the study demonstrates equivalent 6-month AHI, ESS, ODI, and usage outcomes, the use of eHST to ascertain therapy efficacy prior to tPSG could be a non-inferior alternative management option to tPSG.

Support (If Any)

Sponsored by Inspire Medical Systems, Inc.
0757 Cluster Analysis for Identifying Good CPAP Adherence Using the PSG Parameters and Patient Characteristics
Authors: Hamada Eriko , Yamauchi Motoo , Fujita Yukio , Ikegami Azusa , Shirahama Ryutaro , Takaoka Toshio , Nishijima Tsuguo , Yoshikawa Masanori , Muro Shigeo
Published: May 2022

Introduction

CPAP is the standard treatment for obstructive sleep apnea (OSA). One of the important clinical issues to be solved is poor CPAP adherence. A growing body of studies has identified predictive factors for CPAP adherence including AHI, BMI, age, gender, symptoms, etc. When our sleep physicians prescribe CPAP, we would consider these known factors in multiple ways. One may want to know factors' combinations rather than each factor. In this case, cluster analysis might be useful since it is a powerful data-mining tool to sort various factors into meaningful groups. Recently, cluster analysis has been adopted for research of sleep breathing disorders. However, no one has adopted to predict CPAP adherence. In this study, we aimed to explore the usefulness of cluster analysis to predict CPAP adherence using the diagnostic PSG parameters and patients’ characteristics.

Methods

The study design was a retrospective observational multi-center study including 5 certified sleep centers in Japan. For 2 years from 2017, 1133 patients who were diagnosed with OSA with in-lab PSG and newly initiated CPAP therapy were enrolled. We performed cluster analysis using the K-means clustering. Variables for clustering were determined by several sleep physicians among PSG parameters and patients’ characteristics. We assessed CPAP adherence for 90 days and 365 days after CPAP initiation in each created cluster. We adopted CMS criteria for good CPAP adherence, which is, more than four hours of use on 70% of nights.

Results

Cluster analysis classified 5 clusters. A significant difference in CPAP adherence for 90 days and 365 days was seen among 5 clusters with a test of independence (p=0.001, p=0.005, respectively). The cluster presenting moderate obese, very high AHI and ODI, and apnea predominant indicated good adherence, whereas the cluster presenting morbid obese, very high AHI and ODI, sustained severe hypoxia, younger age, and daytime sleepiness indicated poor adherence according to the post-hoc Chi-square test.

Conclusion

Cluster analysis successfully distinguished the different CPAP adherence and identified a combination of OSA patients’ profiles. Thus, cluster analysis would be a useful tool for predicting long-term CPAP adherence.

Support (If Any)
0761 Adaptability of the Treating Obstructive Sleep Apnea Using Targeted Hypoglossal Nerve Stimulation (OSPREY) Trial
Authors: Jacobowitz Ofer , Schwartz Alan , Lovett Eric , Ranuzzi Giovanni , Malhotra Atul
Published: May 2022

Introduction

With few exceptions, clinical trials of hypoglossal nerve stimulation (HGNS) for obstructive sleep apnea (OSA) are single-arm, open-label studies sometimes followed by short-term, unblinded, randomized withdrawal. By contrast, the THN3 study was a parallel-arm, randomized, controlled trial (RCT) of targeted HGNS (THN) in moderate to severe OSA, and provided higher-level evidence of HGNS safety and efficacy.Despite generating strong evidence, conventional RCTs are risky due to their inherent inflexible designs. We therefore launched a confirmatory THN RCT (OSPREY) with an adaptive, Bayesian “Goldilocks” design that optimize its sample size dynamically, yet achieve high-confidence results.

Methods

Four scenarios were simulated within the OSPREY design framework (randomized 2:1 Treatment:Control) for the primary endpoint of apnea-hypopnea index (AHI) response rate (RR): nominal with results equal to those of THN3 (Treatment AHI RR 52%/Control AHI RR 20%), improved Treatment RR (63%/20%), worsened Treatment RR (41%/20%) and null [Treatment RR=Control RR] (20%/20%). Each scenario was simulated 10 times with 10,000 simulations of each interim analysis. Subject outcomes were determined by randomly drawing from a binomial distribution with the relevant AHI RR.Interim analyses in OSPREY begin at 50 randomized subjects and repeat every 20 additional subjects to the maximum sample size of 150, with opportunities for early success and futility at each milestone to generate high-confidence results from an optimal sample size. OSPREY assesses secondary endpoints including quality of life inventories (Epworth Sleepiness Scale; Functional Outcomes of Sleep Questionnaire; EQ-5D, SF-6D and PROMIS sleep questionnaires) and oximetry metrics (Oxygen Desaturation Index, %sleep time below 90% oxygen saturation). Previous results suggest secondary endpoints will be adequately powered at the final sample size determined by AHI RR.

Results

Simulations produced the following outcomes formatted as [scenario: randomized sample size, overall success rate, probability of early success, mean success probability]: null: 150, 0%, 0%, 2.47%; nominal: 130-150, 100%, 80%, 95.3%; improved: 90-130, 100%, 100%, 98.9%; worsened: 150, 100%, 0%, 68.6%.

Conclusion

OSPREY is uniquely able to adapt to various Treatment/Control response scenarios and should provide high-confidence confirmation of the safety and efficacy of THN therapy in moderate to severe OSA.

Support (If Any)

LivaNova
0783 Compliance with Follow-up Polysomnogram in Patients Prescribed Oral Appliance Therapy for Treatment of Obstructive Sleep Apnea
Authors: Kouassiaman Courtland , Foster Shannon , Powell Tyler , Hansen Shana , Brock Matthew
Published: May 2022

Introduction

Literature supports Oral Appliance Therapy (OAT) for mild-to-moderate obstructive sleep apnea (OSA) with evidence showing clinical benefits. The long-term ease of follow makes these devices attractive options for many though requires upfront provider and patient coordination. After prescription of OAT, a dental professional qualified in fabrication must evaluate the patient, the device must be fabricated and a follow-up polysomnogram (PSG) with the device in place should be obtained to determine treatment efficacy. If this guideline is followed in clinical practice is unknown with limited research. Our study evaluates the frequency of follow-up PSG in patients referred for OAT for treatment of OSA in a combined sleep and dental clinic.

Methods

A retrospective chart review was performed to determine if OSA patients who elected to pursue OAT subsequently underwent a follow up PSG after obtaining their device. Patients who did not have their diagnostic study at our institution were excluded. Patients prescribed OAT for primary snoring were also excluded.

Results

We identified 104 patients who were referred for OAT for treatment of OSA; 90 (86.5%) of which followed up with the dental clinic, 84 (80.8%) of which obtained devices, and 14 (13.5%) of which completed a PSG after obtaining their device. Additional review of the original 104 patients demonstrated: 88 (84.6%) were male, mean BMI was 27.6, mean AHI 15.1/hr, and mean age 38.9 years. Review of the 14 patients who obtained follow up PSGs with OAT showed: all were male, mean BMI 27.0, mean AHI 13.8/hr and mean age 38.6 years. Total sleep time (TST) in patients who had a follow up PSG with OAT (mean = 344.2 min) was significantly less than on their diagnostic PSG (mean = 367.2 min, p= 0.043).

Conclusion

Although the AASM CPG for treatment of OSA with OAT recommends follow-up sleep testing to confirm efficacy, the follow-up PSG rate of 13.5% in a single-center closed system indicates poor patient adherence. Increased communication between the dental providers and sleep clinic is encouraged for proper follow up. Further research will need to be done to elucidate the individual and systemic barriers to appropriate follow-up.

Support (If Any)
0785 Cardiovascular Outcomes For Obstructive Sleep Apnea With HGNS Therapy
Authors: Tangutur Akshay , Seay Everett , Boon Maurits , Huntley Colin , Thaler Erica , Dedhia Raj
Published: May 2022

Introduction

Obstructive sleep apnea (OSA) is linked to cardiovascular disease, particularly when left untreated. Hypoglossal nerve stimulation (HGNS) is a novel and promising PAP alternative as it is well-tolerated and reduces OSA severity; however, its effect on mitigating cardiovascular risk secondary to OSA is unknown. The aim of this study is to evaluate the effect of HGNS on sympathetic and vascular function. Our hypothesis is mean 24-hour systolic blood pressures (SBP) will be improved at “active” levels of HGNS.

Methods

This study is a double-blinded, sham-controlled, randomized controlled therapy crossover trial. Subjects are randomized for four weeks in each arm to either “active” HGNS or “sham” HGNS, with “sham” HGNS being defined as the lowest voltage at which HGNS was sensed by the patient and/or visualized by the principal investigator. Included patients had already been implanted with the Inspire® device. Patients were excluded for active PAP therapy use, recent automobile accidents, a minimum difference (<30%) between “active” and “sham” voltages, and pregnancy.

Results

53 patients met all inclusion criteria. Overall, the study cohort was older (mean [SD] age 66.8 [10.2]), overweight (BMI 28.8 [4.36]), 60% male, and predominantly of white race. There was no significant difference in mean 24-hour SBP between “active” and “sham” HGNS (122.4 mmHg [12.2] vs. 122.4 mmHg [11.2], respectively). Further, there was no significant difference in mean SBP during sleep between “active” and “sham” HGNS (115.0 mmHg [15.2] vs. 115.2 mmHg [14.4], respectively).

Conclusion

This is a randomized controlled trial evaluating cardiovascular outcomes in patients with OSA using HGNS therapy. The HGNS system permits a unique investigation of the therapy “on/off” effect on measures of the sympathetic nervous system and vascular health. “Active” HGNS levels, compared to “sham” HGNS levels, do not appear to reduce mean systolic blood pressure during wake or sleep periods.

Support (If Any)

Raj C. Dedhia, MD, MSCR is supported by the American Heart Association and the American Sleep Medicine Foundation.
0794 Understanding Barriers and Communication Behaviors Impacting Referral to Sleep Surgery: Qualitative Patient Perspectives
Authors: Ikeda Allison , McShay Crystina , Marsh Robin , Saini Shireen , Weaver Edward
Published: May 2022

Introduction

Shared decision-making is a process when patients, families, and clinicians work together to make optimal, personalized medical choices in the face of more than one reasonable treatment option. These interactions can influence the joint decision and may have lasting impressions for future healthcare encounters. Considering the American Academy of Sleep Medicine’s recent clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation, we aimed to understand patient experiences, in terms of barriers and communication behaviors in the referral process to sleep surgery consultation.

Methods

We performed a qualitative study consisting of in-depth semi-structured virtual interviews with adult patients (aged ≥18 years) with OSA (apnea-hypopnea index ≥5 events per hour of sleep, scored by AASM-accredited standards) and who were recommended for sleep surgery at a tertiary Sleep Surgery Clinic. Open ended questions focused on patient experiences during healthcare encounters from diagnosis, trials with noninvasive management options and ultimate referral to sleep surgery. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes.

Results

Ten adult patients with OSA who were evaluated in sleep surgery clinic were approached and enrolled from March through April 2021. Barriers to sleep surgery clinic included delays in OSA diagnosis due to limited OSA awareness and perceived inconvenience of sleep study, providers faulting patient for persistent sleep symptoms, patient-reported lack of urgency by providers in troubleshooting noninvasive management options, scheduling delays and waitlists, and cost. Patients were open to trialing noninvasive treatment options, though opportunities for reevaluation and shared decision-making may address unmet needs, as inadequate improvements led to frustration after multiple encounters. Patients appreciated providers who were empathetic and provided information sharing, in terms of transparent and understandable explanations.

Conclusion

This study focused on experiences of patients with OSA and barriers faced to reach sleep surgery consultation. Improved communication structure to discuss unresolved concerns and remaining management options, as well as vetted resources, would set the foundation for effective shared decision-making and timely referral for sleep surgery consultation.

Support (If Any)

Academy of Otolaryngology Head and Neck Surgery Resident Research Centralized Otolaryngology Research Efforts (CORE). NIH T32 DC000018.