bluuebunny/crossref_metadata_2025 huggingface dataset:
1169 Innovative Exposure to Sleep Medicine for Medical Students
Authors: Gupta S , Golden E , Howell M , Irfan M
Published: May 2020

Introduction

Lack of exposure to the field of Sleep Medicine at the medical student level hinders sleep training. Instead of the traditional didactic style, there is a need for innovative collaborative measures to spark interest in the younger generation of learners. The goal of this educational endeavor was to introduce medical students to the field of Sleep Medicine through the platform of Student Interest Group in Neurology (SIGN).

Methods

An interactive session was conducted for SIGN at the University of Minnesota. 24 second-year medical students were divided into 6 groups. The session consisted of introduction, videos of common sleep disorders and interactive briefing afterward. 5-point Likert scale pre and post-session surveys were administered to measure the level of knowledge regarding sleep, familiarity with diagnostic tools, available education, pathways to Sleep Medicine, learner’s interest and impact of the session. Wilcoxon matched-pairs signed-rank test was performed to compare pre- and post-surveys.

Results

There was a significant improvement in measures of students’ knowledge about sleep diagnostic modalities (p =7.8*10-5), education received (p= 3.2*10-5) and pathways to sleep medicine (p=4.1*10-5). Survey also showed improvement in students’ interest in pursuing a Sleep Medicine career (p=0.07). There was no difference in knowledge about the importance of sleep for health (p=0.69). All of the students found the session to be informative.

Conclusion

Early exposure to sleep disorders in interactive format was well received by the medical students with significant improvement in scores regarding sleep education, awareness of diagnostic modalities, career pathway and interest in sleep medicine (p=0.07). Integration of exposure to Sleep Medicine within the medical curriculum in an innovative format should be done to instigate interest in this field. Further larger studies are warranted to evaluate the changes in the students’ interest in the subspecialty with an introduction in the early stages of their career.

Support
1179 Barriers To Sleep Among Children Exposed To Adversity
Authors: Robbins R , Ripple C H , Fleshman C , Bonuck K , Jean-Louis G , Hale L , McGlinchey E , Donskoy I , Wolfson A , Owens J
Published: May 2020

Introduction

Children exposed to adversity (e.g., homelessness, poverty) are at risk of poor sleep. Community settings that serve these children, both residential (e.g., foster care group homes, shelters) and non-residential (e.g., early care and education, schools), hold important understandings to the barriers to sleep they experience. We surveyed a heterogeneous national sample of community-based organizations (CBOs) in our Pajama Program sample to explore these barriers.

Methods

Pajama Program, a national 501(c)(3) nonprofit, administered an online needs assessment in May 2016 to staff at 3,911 CBOs. This poster reports on qualitative responses to the question, What are the primary barriers to sleep and bedtime among children your organization serves? Responses from residential and non-residential CBOs were analyzed separately. Two trained coders independently used the constant comparative method to analyze transcripts.

Results

Survey respondents (1,635) provided services in non-residential (42%), residential (18%) and combined (43%) settings. Organizations provided child welfare/foster care (20.6% of programs); transitional housing/shelter (20.5%); social services (15.6%); and early care and education (12.7%) services. Responses to the target open-ended item were from 127 non-residential and 55 residential programs. Sleep barriers common to both settings included: late/irregular bedtimes; no bedtime routine; lack of sleep education; housing/food insecurity; stress; disrupted/uncomfortable sleep; and adapting to new environments. Trauma was a barrier among residential (vs. non-residential) programs. Non-residential providers noted unstable family situations, bedding insecurity, and poor sleep hygiene.

Conclusion

Our research highlights barriers to sleep among children exposed to adversity, a largely understudied yet high risk group. Barriers reported by residential and non-residential CBOs were more similar than different. was Across program types and settings, CBOs expressed a need for sleep health education interventions for children and caregivers.

Support

Funding for this project was provided by Pajama Program, a national 501(c)(3) non-profit.
1182 Using Home Delivery Of Home Sleep Tests To Improve The Diagnosis Of Obstructive Sleep Apnea
Authors: Sterner T , Yankowy L , Vesnaver D , Senft R
Published: May 2020

Introduction

OSA is a highly prevalent and co-morbid condition across the US and the world. Recent data shows between 14% and 49% of middle-aged men have clinically significant OSA and although the data shows OSA is less prevalent in women, the consequences of this condition is as severe as in men. Further studies suggest 80% of more than 25 million cases of OSA in the US are undiagnosed. At our institution, several factors contributed to the under diagnosis of OSA: knowledge deficit, complicated order process, inconvenience, fear and cost. We developed a plan to increase the diagnosis of OSA by increasing home sleep testing by 50% within 6 months of initiating a home delivery model.

Methods

Our multifaceted, multidisciplinary and comprehensive plan included a contractual agreement with the manufacturer of our preferred device, WatchPAT, to directly ship the HSAT device to the patient, receive the device back after testing and upload the data for physician interpretation. Integration was established between middle-ware and the HSAT software for flow of information. A collaborative effort with our marketing department to develop a health risk assessment tool specific to sleep apnea, targeted by health history, resulted in mailings to thousands of patients. A coordinated effort with our Call Center to explain delivery process and schedule testing was done. Paramount to our success was streamlining the ordering process for providers.

Results

2,122 HSTs were done in the initial 6 months of using home delivery compared to the same 6 month time frame the previous year - an increase of 71%.

Conclusion

Using a broad, collaborative effort among several disciplines within our health care system, we found the access and use of home sleep tests dramatically improved. This was cost effective, saving .5 FTEs, provided a high degree of patient satisfaction and resulted in increased diagnoses.

Support
1183 Board-certified Sleep Medicine Physicians See A Greater Proportion Of Complex Sleep Patients Than Non-specialist Providers
Authors: Jobe S L , Albrecht J S , Scharf S M , Johnson A M , Parthasarathy S , Wickwire E M
Published: May 2020

Introduction

Despite a growing literature regarding the impact of board-certification in sleep medicine, little is known about the complexity of patients seen by board-certified sleep medicine physicians (BCSMPs) relative to non-specialists. To address this gap, the purpose of the current study was to evaluate the differences in sleep complaints among Medicare beneficiaries seen by BCSMPs relative to individuals seen by non-specialists.

Methods

Our data source was a random 5% sample of Medicare administrative claims data from 2006-2013. Sleep disorders were operationalized using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Descriptive analyses were performed to estimate the number of sleep disorder diagnoses patients received by provider status. BCSMPs were identified using a cross-matching procedure based on National Provider Identifier (NPI).

Results

A total of 57,209 Medicare beneficiaries received a sleep disorder diagnosis between 2006-2013. Of these, only 2.2% were seen by BCSMPs. Relative to beneficiaries seen by non-specialists, those seen by BCSMPs were more likely to be diagnosed with more than one sleep disorder (p<0.001). Specifically, 91.0% of individuals seen by non-specialists received only one sleep disorder diagnosis, whereas 75.9% of individuals seen by BCSMPs received only one sleep disorder diagnosis. Among beneficiaries seen by non-specialists, the most common sleep disorders were insomnia (48.2%; n=26,967), obstructive sleep apnea (OSA; 31.4%; n=17,554), and restless legs syndrome (8.7%; n=4,871). Among those seen by BCSMPs, the most common sleep disorders were OSA, (70.4%; n=901), sleep apnea with hypersomnia (16.5%; n=211), and insomnia (11.7%; n=150).

Conclusion

BCSMPs see more complex sleep patients than do non-specialists. These results suggest the possibility that more complex patients are referred for sleep specialty care. Further, these results demonstrate the value of board certification in sleep medicine in caring for complex sleep patients.

Support

This research was supported by an AASM Strategic Research Award from the AASM Foundation to the University of Maryland, Baltimore (PI: EMW).
1190 Engaging Patients And Family Members To Understand What Matters Most Living With Obstructive Sleep Apnea
Authors: Mou J , Silva A , Figetakis K , Ho S S , Williams M , Mebust K A , Xia Y , Xie J , Wang J , Chin N , Vondran R , Vondran R
Published: May 2020

Introduction

As a common but modifiable chronic condition, obstructive sleep apnea (OSA) has been identified as the top secondary cause of many other diseases including cardiovascular diseases and type 2 diabetes. Diagnosing and managing OSA provides neurological, cardiovascular and metabolic benefits, however real-world studies indicate disconnections between evidence and outcomes. Using an engagement approach and qualitative design, this project aims to better understand care and research gaps in OSA in a community healthcare setting.

Methods: Methods

Patient and family representatives were identified and recruited through OSA support meetings hosted by MultiCare Sleep Medicine Centers, to form a board of 12, with three key patient advocates. Six meetings, each facilitated by one or two members of the board, were held to encourage focus group discussion and accommodate interactive conversations on the topic. Discussions were audio recorded and edited to exclude patients’ identifiable information, then transcribed. Manual open coding was completed by two coders for each transcription to develop a codebook, followed by auto-coding and inductive content analysis using Nvivo 11.

Results

All enrolled patients had diagnosed moderate-to-severe OSA and were prescribed with continuous positive airway pressure (CPAP) therapy. Two participants were African American and one was multiethnic. Patients’ age ranged from early 30s to 80s. Seven main themes were identified: OSA diagnostic issues; treatment experiences and options; comorbidities; patient community and support needs; long-term management challenges beyond “compliance”; knowledge of OSA, CPAP and care; and patient-driven research. The first few weeks after CPAP initiation appeared to be a critical time window that impacted patients’ adaptation and use.

Conclusion

Our study revealed barriers and facilitators in OSA diagnosis and treatment. Results showed highly prevalent chronic co-morbidities and the needs to care for patients in the comorbid scenario. It was highlighted that a paradigm of patient-centered care and research is lacking and warranted. Participants also called for better coordination between sleep medicine, primary care, other specialists, durable device suppliers and insurance. Key research efforts are expected to focus on the first 30-day post CPAP dispense to improve compliance.

Support

Patient Centered Outcomes Research Institute (PCORI) (Contract #: 7717241)
1203 Worth The Weight: Weighted Blanket Improves Sleep And Increases Relaxation
Authors: Danoff-Burg S , Rus H M , Cruz Martir L , Raymann R J
Published: May 2020

Introduction

Weighted blankets are designed to create deep touch pressure stimulation, to simulate the feeling of being held or hugged. The deep pressure provided by a weighted blanket, along with consistent sensory input from its weight, is thought to work by lowering stress and reducing physiological arousal, thereby improving sleep. We tested whether a weighted blanket would improve sleep.

Methods

30 participants with objectively measured sleep onset and sleep maintenance issues participated in a 6-week field study, using a non-counterbalanced pre-post intervention design. Intervention consisted of the use of a weighted blanket every night at home. The blanket was filled with microbeads and weighed approximately 10 percent of each participant’s body weight. Sleep was measured objectively using ResMed S+ every night and by daily self-report. Paired t-tests and multilevel regression were used to test for statistical significance.

Results

Objective sleep data from the 28 participants who completed all study requirements showed 7% improvement of Wake After Sleep Onset, 2% decrease in Light Sleep, and slight improvement in Sleep Efficiency (1.5%) and Sleep Maintenance (1.4%) during intervention (all ps < 0.05). Additionally, participants felt they fell asleep faster (13% faster), experienced better sleep quality (14% better), felt more rested in the morning (17% more rested), and felt they slept better through the night without waking up (36% improvement). They also reported feeling 13% less stressed at bedtime and 17% more relaxed while trying to fall asleep.

Conclusion

Using a weighted blanket reduces self-reported feelings of stress, enhances feelings of relaxation, and can improve sleep and reduce time awake at night in people with sleep onset and sleep maintenance issues.

Support

Gravity Blanket
0122 Does Additional Training on an Implicit Motor Sequence Learning Task for Older Adults Improve Sleep-Dependent Memory Consolidation?
Authors: Rodheim K , Spencer R
Published: May 2020

Introduction

Previous studies show sleep dependent consolidation (SDC) for motor sequence learning with regular training in younger adults, whereas, in older adults, this sleep benefit is missing. If hippocampal engagement underlies age-related differences in SDC, then enhanced training should result in significant SDC in older adults. Thus, this study aims to look at younger vs. older adults with regular training and older adults with regular training vs. overtraining to determine if older adults show evidence of SDC. Alternatively, regardless of initial learning, older adults may fail to exhibit SDC because the sleep mechanisms supporting consolidation are impaired.

Methods

Seven younger adults (M=22 years) and seven older adults (M=68.5 years) completed the train condition, while ten older adults (M=67.6 years) completed the overtrain condition. In the encoding phase, participants either completed 5 blocks (train) or 10 blocks (overtrain). Between immediate and delayed recall, participants either slept with Polysomnography (PSG) in the lab or remained awake, and subsequently, completed the alternate condition one week later. Actigraphy was collected for 14 days and PSG (32-electrode EasyCap) was recorded for overnight sleep.

Results

Older adults significantly improved their skill learning from immediate to delayed recall, in both the train (p=0.005) and overtrain (p=0.013) conditions, regardless of sleep or wake. Younger adults did not improve their skill learning in the train condition (p>0.05). However, there was a trending main effect, with younger adults performing the task better compared to older adults in the train condition, at both time points (p=0.061). No other main effects or interactions were significant.

Conclusion

These results suggest the alternative hypothesis that, regardless of initial learning, older adults fail to exhibit SDC. This result is of interest as the age-related differences in sleep, such as sleep spindle characteristics may play a role. Future analysis will include more participants and further exploration into the PSG-recorded sleep architecture and actigraphy-recorded measures of habitual sleep.

Support

This work was funded by NIH R01 AG040133 (PI: Spencer)
1207 Keep It Simple: Wireless Patches For Home Sleep Diagnostics
Authors: Zandieh S O , Reuveny A , Pearson S , Mordechai A , Wang C , Aesmani D , Backeris P , Ancoli-Israel S
Published: May 2020

Introduction

Despite growing use of home sleep testing for the diagnosis of obstructive sleep apnea (OSA), there are significant barriers including limited availability, high cost, and complex wires making it difficult for patients to use on their own. The objective of this study was to evaluate a new flexible, thin, and wireless adhesive patch (proprietor sensors, TatchSleep Pro [TSP]) for the detection of OSA and compare the validity to overnight polysomnography (PSG). The TSP transmits data wirelessly to a smartphone app which in turn uploads the data to a cloud server. Data is presented to a sleep professional via a dedicated interface to score and analyze the results.

Methods

Patients (n=9; mean age=47 (SD=10); mean BMI=33 (SD=6.6); 4 males) undergoing a PSG evaluation for OSA also wore 2 TSP patches applied on the chest and abdomen. The TSP patches detected respiratory effort, derived airflow, derived pressure, body position and movement. Two sets of respiratory data (with common SpO2 and heartrate as a reference from PSG) were created, one from PSG and one from the TSP. The data were then scored by a certified sleep technician, blinded to the conditions. Linear regression analyses were used to compare the two derived apnea-hypopnea indices (AHI). In the morning, all participants were asked about their experience using the TSP. The study was approved by the Western IRB.

Results

There was a significant correlation for AHI between the TSP and PSG (R2= 0.94; p<0.01). All participants found the TSP comfortable to wear and indicated that removing the patches was ‘easy’ or ‘very easy,’

Conclusion

These preliminary results suggest the wireless TSP may be an effective, cost-efficient way to evaluate OSA. Despite small sample, results show promise as a new innovative product for home sleep testing.

Support

Supported by Tatch Inc.
1213 Sleepfect Tracker: A Crossplatform Mobile Researchkit App For Sleep Self-management
Authors: Menon P , Seixas A , Pathan Z , Suhail M , Jean-Louis G , Ayoub S , Naqeeb B , Wani B , Mishra S , Khan S
Published: May 2020

Introduction

We created Sleepfect Tracker, a researchkit-based cross platform app to explore the feasibility and acceptability of a sleep tracking app for sleep self-management.

Methods

We developed Sleepfect Tracker app on Appbakery, a DIY app making platform using ResearchKit for iOS and ResearchDroid for Android users. Sleepfect allows participants to track their sleep behavior (weekly via sleep diary) and environment (monthly), as well as their total sleep time and step counts data via Apple’s HealthKit, Android step count sensors, or Fitbit (wearable). Three hundred and ninety-five (395) individual from around the globe downloaded the app and 163 unique users answered surveys on their sleep behavior, environment, and architecture. In total we collected 6429 sleep and 2882 step data points and provided insights into user sleep behavior and sleep environment. We also analyzed whether sleep duration was associated with steps.

Results

Regarding immediate sleep environment and behavior, 11.1% worked or studied in bed, 27.0% reported having pets in bed, 39.7% red in bed prior to sleep, 40.3% watched TV in bed prior to sleep, 11.3% drank alcohol prior to bed, 9.8% smoked prior to bed or wake during night, 8.1% ate snack at bedtime, and 6.5% ate when they awake at night. 74.3% of the participants used electronic devices in their bedroom. Of the participants who used electronic devices in the bedroom, 52.1% had an average sleep duration of 6-8 hours and 29.8% reported sleeping 4-6 hours. Of the participants who did not use electronic devices in bedroom, 30.1% slept 4-6 hours, 31.8% slept 6-8 hours, and 32.45% slept 8-10 hours, on average. The relationship between steps count and sleep hours was trending, r=.16, p=.07.

Conclusion

Users can evaluate their sleep habits, monitor daily sleep-related behaviors through Sleepfect tracker. The app demonstrated initial usability and feasibility, but long-term usability and effectiveness must be evaluated. Further investigations on which functions will be more useful to help user to improve their sleep and engage users should be considered.

Support

K01HL135452, R01MD007716, R01HL142066, and K07AG052685
1215 Improving Sleep Disorders And Chronic Neck Pain By Adjusting Height Of The Pillow Through Cervical Posture Management
Authors: Yamada S , Yamada K
Published: May 2020

Introduction

Recent studies have suggested that chronic musculoskeletal system pain, including chronic neck pain, accounts for approximately 70% of all sleeping disorders. Simultaneously, sleeping disorders increase pain sensitivity and create a vicious cycle of chronic neck pain. Patients with chronic pain experience a variety of somatic symptoms (e.g., Stomach or bowel problems, Back pain, Pain in your joints, headaches, chest pain, shortness of breath, dizziness, fatigue, and Trouble sleeping) that are difficult to treat. However, treatment of both neck chronic pain and sleeping disorders through cervical posture management by adjusting height of the pillow used while sleeping has yet to be considered.

Methods

Patients who visited our hospital with chief complaints of chronic neck pain were rated according to the Numerical Rating Scale (NRS) and were asked to answer the Somatic Symptom Scale-8 (SSS-8), to ascertain the degree of somatic symptoms. Out of all the patients, only 84 scored at least 8 out of 32 in the SSS-8. Based on the individual results of the 84 respondents, they were given customized pillows to be used for 3 months. The pillows were adjusted using the SSS method developed at our clinic. We adjusted the height of the pillow by 5mm increments to check the cervical inclination angle at approximately 15 degrees in supine position, lateral position with the center line from face to neck at left-right symmetry and finally confirming smooth turning over. The respondents performed NRS and SSS-8 after 2 weeks and 3 months of using the pillow.

Results

The results of this study showed that at 0 weeks / 2 weeks / 3 months. NRS score was 6.8 / 5.1 / 4.1 (p <0.01), and the overall SSS-8 score was 13.2 / 9.9 / 8.2 (p <0.01), showed a marked improvement. By symptom, all symptoms except Stomach or bowel problems showed significant improvement. Trouble sleeping showed the highest improvement at 2.6 / 1.7 / 1.3 (p <0.01).

Conclusion

Chronic neck pain and sleeping disorders improved in the patients. These results suggested that cervical posture management by adjusting height of the pillow is an effective treatment method.

Support

None
1236 A Case of Systemic Amyloidosis and Sleep-Related Hypoventilation
Authors: Castner Lauren M , Garwood Mark D
Published: May 2020

Introduction

Amyloidoses are a group of systemic diseases characterized by misfolded protein fragment deposition within the organs, including the heart, kidney, liver, gastrointestinal tract, nervous system, pulmonary system, and soft tissues1. Obstructive and central sleep apnea are known to occur frequently in those with cardiac amyloidosis. This case discusses a patient with systemic amyloidosis and chronic hypercarbic, hypoxic respiratory failure.

Report of Case

A 66 year old female with a history of systemic amyloidosis, non-ischemic cardiomyopathy, hypertension, and obstructive sleep apnea was admitted for acute on chronic heart failure. Despite intravenous diuresis, she remained hypoxemic, requiring 1 liter per minute of oxygen.

She was found to have bilaterally reduced diaphragmatic excursion and a restrictive ventilatory defect on spirometry. She had a preceding history of chronic carbon dioxide retention with elevated CO2 levels for greater than a year (52-74 mmHg).

Sleep medicine was consulted to assist in evaluation of the patient’s obstructive sleep apnea and hypoxic, hypercarbic respiratory failure. Baseline polysomnogram revealed sleep related hypoventilation with transcutaneous CO2 (TCO2) ranging between 77-86 mmHg without clear obstructive sleep apnea. A bilevel positive airway pressure (BPAP) titration was then performed (TCO2 54-69 mmHg) and while the patient’s obstructive sleep apnea was well treated, sleep-related hypoventilation and central apneas persisted. Average volume assured pressure support (AVAPS) was initiated for management of sleep related hypoventilation. In follow up, the patient is feeling well, off oxygen, with daytime TCO2 38 mmHg.

Conclusion

This case demonstrates a rare complication of systemic amyloidosis in the setting of respiratory failure attributed to amyloid infiltration of the diaphragm. In the few previously reported cases of neuromuscular respiratory failure in systemic amyloidosis there is rapid progression and high mortality3, which highlights the importance of assessing for sleep disordered breathing and additional causes of respiratory failure in a patient with a complex systemic disease.
1243 A Guinness Book Challenge in Upper Airway Stimulation Activation
Authors: Zakhary Nardine , Strohl Kingman
Published: May 2020

Introduction

Upper airway stimulation is a option for CPAP-intolerant patients. Device activation is typically ~4 weeks after the implant procedure.

Report of Case

A 61yo male with severe OSA had an upper airway stimulation device placed by ENT. At that time, stimulation produced bilateral tongue protrusion. In the immediate post-operative period, after closure, a hematoma, at the inferior chest incision, was discovered and drained with cauterization of the bleeding vessel. Seven weeks after implant, patient reported to our sleep clinic for activation of the device; and at that time, there was no sensation or activation up to the maximum amplitude of 5mV. The device reported an acceptable respiratory waveform, and triggering on and off sets but without sensory outcomes. Changing of the electrode configuration with advanced settings had no effect. Impedance values were acceptable. Tongue movements were grossly intact. At 2 months, ENT evaluation found mild hypoglossal nerve neuropraxia. To assess for a device related issue, x-rays of the neck and chest were performed and showed proper placement of the device. At 3.5 months, neuropraxia had resolved but device activation was unsuccessful, with no sensory or motor activation to 5mV stimulation. Plans were made for a procedure during which the lead electrode or implantable pulse generator would be assessed or replaced. At 4 months after implantation, in a multidisciplinary appointment with Sleep, ENT and the device representative, with a 3 electrode negative pole and the generator as the + pole, at 2.3mV, the device was activated. At the present time, the patient is exploring higher and lower mV settings and a PSG titration is scheduled.

Conclusion

This is the longest recorded duration (3.5+ months) of unsuccessful post-operative activation; and it occurred ~2 months after clinical signs of hypoglossal nerve neuropraxia had resolved.
1245 Cheyne-Stokes Respiration and Circulation Time—A Case to Add to the Mystery
Authors: Bhura Sajeer , Rupani Nawaz , Massoud Mona , Chowdhuri Susmita , Shamim-Uzzaman Q Afifa
Published: May 2020

Introduction

Lung-to-finger circulation time (LFCT), the time taken for the circulation to reach the fingertips from the lungs, has been shown to correlate inversely with cardiac function (Hosokawa et al. 2015). LFCT can be measured on PSG as the time from the start of rebreathing after a central respiratory event to the nadir of the oxygen desaturation on the SpO2 signal. Patients with congestive heart failure (CHF) have been found to have increased LFCT, with even longer LFCT in patients with Cheyne-Stokes Respirations (CSR). We are reporting a case where LFCT increased throughout a single night by more than 40%.

Report of Case

A 66-year-old diabetic male with ischemic cardiomyopathy (LVEF 25%), CVA with residual L-sided paresthesias, CKD-IV and hypertension was diagnosed with severe CSA and OSA (AHI 31.5, CAI 13.9, OAI 0.0, MAI 0.2, hypopnea index of 17.4, minimum SpO2 of 80%; supine AHI 56.1). CSR was not mentioned on this diagnostic study. On his titration study, CPAP and BPAP failed to treat CSA, but ASV effectively treated his sleep-disordered breathing; however, he could not be started on ASV due to HFrEF. On a repeat titration after ICD implantation, CSR was prominent in the supine position, on both CPAP and BPAP S/T therapy. Cycle length progressively increased from 40 seconds at the beginning to 57 seconds at the end of the recording, an increase of 42% throughout the night. Circulation time also increased from 31 seconds to over 40 seconds. Scorable central respiratory events resolved but periodicity persisted.

Conclusion

To our knowledge, this is the first case of CSR with such progressive prolongation in cycle length during a single night. It again raises the question of the role of BPAP S/T in CSR with heart failure, and clarification of the potential use of supplemental oxygen in such situations.
0126 Local Slow Wave Sleep and Post-Stroke Brain Repair
Authors: Landsness E C , Brier L M , Hua R X , Chen K , Rosenthal Z P , Culver J P , Lee J
Published: May 2020

Introduction

Recent evidence suggests that slow wave sleep (SWS) is important for synaptic plasticity and brain repair following stroke. Previous studies described a progressive increase in whole cortex and contralesional regional delta power during sleep after stroke, suggesting a global increase in SWS. However, these studies did not distinguish between the effects of global vs. local SWS. We hypothesized that local changes in SWS delta power would parallel changes in the functional remapping and circuit repair.

Methods

To study SWS in living mice we used Thy-1-GCaMP6f mice (n=12), serially imaged (baseline, 24 hours, weeks 1, 4,) during sleep following photothrombotic stroke of the left forepaw somatosensory cortex (S1FP). An optical fluorescence imaging system (OFI) was used to image whole-cortex neuronal activity. The evolution of local delta activity was compared across three ROIs: 1) infarct, 2) perilesional remapped, and 3) perilesional non-remapped left.

Results

The photothrombotic infarct encompassed the left S1FP stimulus map, resulting in significant attenuation of S1FP evoked responses at week 1; however, a small region of activation was retained in posterior left S1FP (peri-lesional remapped). The infarct region demonstrated a decrease in delta power during sleep; however, the perilesional region of future remapping exhibited a rebound in focal delta power at 1 week after an initial decline at 24 hours. In the perilesional non-remapped area delta power decreased, but did not increase until week 4. We also observed an early wide-spread increase in delta power at 24 hours and week 1 that decreased on week 4.

Conclusion

With the high spatial resolution of OFI, we find that SWS is disrupted throughout the brain following focal ischemia. These data suggest that local SWS selectively increases in the region of remapping prior to repair of that circuit and that local SWS may play a role in brain repair following stroke.

Support

AASM Foundation #183-PA-18, #201-BS-18
1247 Rare hypoventilation syndrome identified in obese adolescent
Authors: Dr. Minor Courtney
Published: May 2020

Introduction

With the obesity epidemic persisting in the United States today, it is no surprise that morbidly obese patients with poor sleep are often linked to the diagnoses of obstructive sleep apnea and/or obesity hypoventilation syndrome before testing is even completed. It is important to spread awareness among pediatric sleep providers of the rare hypoventilation syndromes for which most physicians likely have never seen a case. Missed diagnoses may lead to not only increased morbidity and mortality in patients, but under-reporting of cases will further delay crucial research needed to identify the precise pathophysiology that is currently unknown.

Report of Case

Authors encountered a 16 year-old male who had re-presented to pediatric sleep clinic after a two-year period of being lost to follow-up. The patient’s past medical history included Angelman’s syndrome, idiopathic central adrenal insufficiency, autonomic instability, seizure disorder, aggressive conduct disorder, morbid obesity, and hypoventilation without discrete obstructive sleep apnea as diagnosed on sleep study at age 10. Central hypoventilation was designated as idiopathic. The family had now returned to care due to concern for worsening episodes of bradypnea, bradycardia, and cyanosis requiring aggressive tactile stimulation. Review of records over the interim revealed multiple ER visits for stress dose steroids, as well as hospitalizations for hypothermia, bradycardia, and seizures. Consideration was taken that his multiple diagnoses were consistent with the unified diagnosis of Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD), and his hypoventilation thus could be accurately characterized as a syndrome of central hypoventilation rather than idiopathic or related to obesity. In addition, his progressive aggression and severe developmental delay could more accurately be attributed to chronic intermittent hypoxia, thus prompting more urgent need for non-invasive ventilation.

Conclusion

With approximately 100 reported cases, ROHHAD is a rare, clinically distinct entity from other etiologies of hypoventilation. Improved awareness of the diagnosis would hopefully lead to earlier diagnosis and improved anticipatory guidance able to be provided to the family.
1248 Hypersomnia with Pseudo-Cataplexy Associated with Schizoaffective Disorder: A Case Report
Authors: Khogeer Feras , Sachdeva Alok
Published: May 2020

Introduction

Psychiatric illness is an important potential cause of excessive daytime sleepiness (EDS), hypersomnia, and narcolepsy-like symptoms. We report a case of hypersomnia and pseudo-cataplexy associated with schizoaffective disorder.

Report of Case

A 28-year-old man with obstructive sleep apnea (OSA) and schizoaffective disorder presented to our sleep medicine clinic complaining of EDS, cataplexy-like attacks, sleep paralysis, depressed mood, and dream intrusion. Questions about cataplexy often provoked brief episodes of speech arrest, eye closure, and neck flexion lasting a few seconds.

An MSLT with CPAP showed a mean sleep latency of 3 minutes and 3 sleep onset REM periods (SOREMPs); however, actigraphy showed that the SOREMPs occurred during the patient’s habitual sleep period and the patient discontinued a REM-suppressing medication within a few days of the study. The HLA-DQB1*0602 allele was absent.

Following circadian adjustment, a repeat MSLT with CPAP showed zero sleep and no SOREMPs. The preceding polysomnogram showed a total sleep time (TST) of 7.8 hours, no epileptiform activity, adequately-treated OSA, and a REM latency of 53 minutes. Prior to these studies, two weeks of sleep diary and actigraphy showed a TST greater than 10 hours. Ultimately, treatment of the patient’s psychiatric disorder resulted in a reduction of his EDS and TST.

Conclusion

Patients with psychiatric illness can present with hypersomnia, EDS, and narcolepsy-like symptoms such as pseudo-cataplexy. Misdiagnosing such a patient with narcolepsy can lead to treatments capable of worsening the primary underlying psychiatric disturbance. MSLT results must be interpreted in the context of a patient’s clinical history and sleep schedule; if there is concern for a false positive result, repeat testing should be considered.
1250 Agrypnia Excitata in a Patient with Paraneoplastic Autoimmune Encephalitis
Authors: Sanchez J L , Saeed S , Battistini H
Published: May 2020

Introduction

Agrypnia Excitata (AE) is a syndrome characterized by loss of sleep with permanent motor and autonomic hyper activation. This case describes this peculiar syndrome in a patient with paraneoplastic autoimmune encephalitis.

Report of Case

DG is a 35 yr old male with a history of anti-Ma2 limbic encephalitis secondary to cystic teratoma of the left testis diagnosed 6 months prior to presenting in Sleep Clinic. His parents described significant sleep disturbances including short sleep and wake periods throughout the day and night with no apparent pattern, acting out dreams, motor activity during sleep including pulling at his clothes or using his hands to manipulate invisible objects. Additionally they described low-grade fevers, and severe hyperphagia. Polysomnogram showed absence of slow-wave sleep and what appeared to be an admixture of stage 1 non-rapid eye movement (NREM) with rapid-eye movement (REM) sleep. Multiple sleep-latency testing (MSLT) demonstrated a mean sleep latency of 5.2 minutes and four sleep-onset REM periods (SOREMPs). Magnetic resonance imaging of the brain revealed persistent inflammation of the mesial temporal lobes and hippocampal region. Cerebral spinal fluid testing showed persistent anti-Ma2 antibodies. Based on this clinical presentation we made a diagnosis of Agrypnia Excitata.

Conclusion

Agrypnia Excitata is a syndrome characterized by loss of the normal sleep-wake rhythm. Sleep consists of the disappearance of spindle-delta activities, and persistent stage 1 NREM sleep mixed with recurrent episodes of REM sleep. The second hallmark of AE is persistent motor and autonomic hyperactivity observed during wake and sleep. AE has been described in three distinct clinical syndromes: Morvan Syndrome (autoimmune encephalitis), Fatal Familial Insomnia, and Delirium tremens. The pathogenesis of AE consists of intra-limbic disconnection releasing the hypothalamus and brainstem reticular formation from cortico-limbic inhibitory control. In autoimmune encephalitis, antibodies that act on voltage-gated potassium channels within the limbic system have been implicated in the pathophysiology.
1252 Rapid-onset Obesity with Hypothalamic Dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD) Syndrome in a Patient on Stimulants and Normal BMI at the Time of Diagnosis: A Case Report and Literature Review
Authors: McGhee Vera , Viteri Ernesto , Schoumacher Robert , Relia Sachin , Harris Atia
Published: May 2020

Introduction

ROHHAD is a rare and complex pediatric disorder presenting in early childhood with rapid onset obesity, followed by central hypoventilation, hypothalamic dysfunction, endocrine disorders, and neurobehavioral disorders.

Report of Case

We present a unique case of a 6-year-old girl diagnosed with ROHHAD in the setting of normal Body Mass Index (BMI). Patient had a history of food-seeking behavior, hyperphagia, and rapid onset obesity at the age of 4 years old with subsequent development of autonomic dysregulation, hypoventilation, and neurobehavioral disorders. At the time of evaluation in Sleep Medicine Clinic for snoring and disrupted sleep the patient had been treated for hyperactivity with several appetite-suppressing stimulant medications leading to weight loss and causing her to have a normal BMI. The original polysomnogram demonstrated severe Obstructive Sleep Apnea (OSA) with obstructive Apnea-Hypopnea Index (AHI) of 11.2/hour and was concerning for hypoventilation based on the end-tidal CO2 values and morning blood gas. Despite improvement in OSA with CPAP therapy, the patient’s hypercapnia persisted. The overall clinical presentation resulted in extensive multispecialty workup, which ultimately led to the diagnosis of ROHHAD syndrome despite the patient’s normal BMI.

Conclusion

ROHHAD syndrome is a rare and complex pediatric disorder requiring multi-disciplinary approach, with early diagnosis and intervention being essential for management of the condition. Hypothalamic obesity is one of the diagnostic hallmarks of ROHHAD. However, about half of patients with ROHHAD develop neurobehavioral disorders, which might require treatment with stimulant medications. Literature review revealed several case reports addressing the effect of stimulant medications on hypothalamic obesity, however none focusing on patients with ROHHAD syndrome. This case raises questions about the role of appetite-suppressing medications in the management of obesity in patients with ROHHAD. It also suggests possible need for further specific workup in patients on stimulants with hypoventilation in the absence of obesity.
1265 Severe Central and Obstructive Sleep Apnea in Teenager with Severe Obesity, Tonsillar Hyper-trophy, and Maxillary Constriction
Authors: Jaeger Mary-Alice
Published: May 2020

Introduction

Obesity in children escalated in the past 50 years. For American children 2-19 years old, Obesi-ty(BMI >= 95th%) increased from 5% in 1971-4 to 19%(13.7 million children)2015-16. Severe Obesity(BMI >=120th% or >35) is less common with prevalences of 1% 1971-4 to 6% in 2015-16(1). Obesity increases risk for physical and mental illness.

Sleep apnea risk factors include obesity, maxillary restriction(3), and adenotonsillar hypertro-phy(4).

Report of Case

16 yo boy with snoring, gasping during sleep, witnessed apneas, mouth breathing, morning head-aches, EDS, and learning disability requiring an IEP. Past medical history of neonatal snoring, apneas, and reflux.

Physical exam revealed severe obesity(BMI 45.3), high arched/narrow palate, Class II bite, large tongue, Mallampati IV, Grade 3-4 tonsils, CricoMental Space +1cm. Inattentive with mildly de-pressed affect. No cardiovascular, pulmonary or neurologic findings.

PSG: CAI 31.2, OAHI 23.8. Average O2 sat 97% with 11 minutes<88%. End-tidal CO2 average 50 during sleep and wake. 51% of total sleep time with ETCO2>50 mmHg.

CPAP titration: CAI 1.8, OAHI 10.4. Average O2 sat 96% with <1 minute<88%. Events improved with CPAP 14 cm H20 to OAHI 3.5 with >30 minutes of supine REM.

Conclusion

Severe Central Sleep Apnea with significant obstructive component associated with hypoxia and hypoventilation. With the diurnal hypoventilation, the likely etiology for central apneas is Obesity Hypoventilation Syndrome(5). The central apnea improved with CPAP. His management included CPAP therapy, ENT referral for adenotonsillectomy(5), bariatric referral, and further evaluation for learning/behavior concerns.

In retrospect, earlier diagnosis/intervention on behalf of this teenage boy with a history of neonatal snoring presenting now with Severe Obesity, tonsillar hypertrophy and maxillary constriction may have made a significant difference for his cognitive/mental/physical health outcomes.
1271 High-Density EEG Correlates During Confusional Arousals in a Child With a Long-Lasting History Of Sleepwalking
Authors: Castelnovo A , Amato N , Riccardi S , Pereno M , Miano S , Manconi M
Published: May 2020

Introduction

Sleepwalking belongs to a family of disorders (Disorders of Arousal - DOA) that are thought to derive from incomplete arousals out of Non Rapid Eye Movement (NREM) sleep. At yet, our knowledge about the specific neural dynamics occurring during clinical episodes is limited and relies on one SPECT case study, four stereo-EEG case reports/series and one single high-density electro-encephalography (hdEEG) case report. We herein describe a single case captured by hdEEG.

Report of Case

We collected two consecutive sleep recordings (using a 256-channel hdEEG coupled with standard video-polysomnography) of a non-medicated, otherwise healthy, 13-year-old male, with a history of recurrent daily sleepwalking episodes. We visually identified 17 behavioral events during sleep stage 3 and divided them into two groups: clear clinical episodes (n = 7) and simple movements associated with burst of delta waves (n = 10). Source power topography in the delta range (1-4 Hz) was computed using LORETA. Source images during selected episodes were compared to 30 second-windows of baseline stage 3 sleep. Comparisons were performed using statistical non-parametric mapping with supra-threshold cluster tests. Events were associated with an increase of delta power over the right frontopolar prefrontal cortex (rPFC) / Broadman area 10 (BA10) at their onset. This finding was clearly observable even when considering only clear-cut events, followed by the involvement of the right dorsolateral and medial prefrontal cortex / BA9 and of the left superior temporal gyrus/ BA 22.

Conclusion

We were able to replicate a recently published case report by our group, where we highlighted the putative role of rPFC and PFC and prefronto-temporal circuit in DOA episodes. Intriguingly, we observed a lateralization of this effect, with a prominent right frontal involvement. Novel research has shown a physiological asymmetry in the generation of large slow waves between the two hemispheres. An increased right-left unbalance might prime behavioral episodes in DOA patients.
0139 Associations of Actigraphic Sleep Parameters with Maximal Oxygen Consumption and Resting Metabolism in Well-Functioning Older Adults
Authors: Alfini A J , Wanigatunga A A , Schrack J A , Wanigatunga S , Li J , Rojo-Wissar D M , Mehta R , Okoye S , Zipunnikov V , Simonsick E M , Spira A P
Published: May 2020

Introduction

Both poor sleep and poor cardiorespiratory fitness are common in older age and associated with negative health outcomes. Additionally, among older adults, higher resting metabolic rate (RMR) has been associated with increased morbidity and mortality risk. To evaluate whether, and in what ways, sleep may affect these relationships, we investigated the association of actigraphic sleep indices with cardiorespiratory fitness and RMR in older adults.

Methods

We studied 393 community-dwelling participants in the Baltimore Longitudinal Study of Aging (mean age 73.5±10.3 years, 52% women) who completed 6.7±0.9 nights of wrist actigraphy, RMR testing, and a maximal graded exercise test. Primary predictors included mean actigraphic total sleep time (TST, minutes), sleep efficiency (SE, %), wake after sleep onset (WASO, minutes), and average wake bout length (WBL, minutes). Cardiorespiratory fitness, as measured by maximal oxygen consumption (V O2MAX; ml/kg/min), and RMR (kcal/day) were the primary outcomes.

Results

After adjustment for age, sex, race, body mass index, comorbidity index, and depressive symptoms, longer WBL was associated with lower V O2MAX (β=-0.12, 95% confidence interval (CI)=-0.20, -0.04), greater WASO was associated with lower V O2MAX (β=-0.09, 95% CI=-0.17, -0.01), and greater SE was associated with higher V O2MAX (β=0.12, 95% CI=0.03, 0.20). In addition, longer TST was associated with lower RMR (β=-0.10, 95% CI=-0.19, -0.01) and longer WBL was linked to higher RMR (β=0.12, 95% CI=0.04, 0.21).

Conclusion

In well-functioning older adults, indices of greater wakefulness after sleep onset are linked with poorer cardiorespiratory fitness and higher resting metabolism, while longer and more efficient sleep are associated with better fitness and lower resting metabolic rate. Our findings suggest that sleep disturbance may be linked to disrupted energy homeostasis, evidenced by excessive energy expenditure at rest and inefficient energy utilization in response to maximal demands. Prospective analyses are necessary to determine the nature of these associations.

Support

This study was supported in part by National Institute on Aging (NIA) grants R01AG050507 and T32-AG027668, the NIA Intramural Research Program (IRP), and Research and Development Contract HHSN-260-2004-00012C.