bluuebunny/crossref_metadata_2025 huggingface dataset:
1188 Test Characteristics of a Machine Learned Electronic Medical Record Extractable Tool for OSA Case Identification in a Community-Based Population
Authors: Patel S I , Kukafka D , Antonescu C , Combs D , Lee-Iannotti J , Quan S F , Parthasarathy S
Published: May 2020

Introduction

Obstructive sleep apnea (OSA) is a significantly underdiagnosed medical condition. A machine learning method known as SLIM (Supersparse Linear Integer Models) that can be extracted from the Electronic Health Record (EHR) has found to be superior to patient-reported sleep-related symptoms to diagnose OSA. Such an evaluation, however, was previously validated in a laboratory-based population. Our aim was to determine the test characteristics for the EHR-extractable SLIM tool in a community-based population.

Methods

Subjects who participated in the Sleep Heart Health Study (SHHS) were included in this analysis. Variable definitions of OSA were determined using an Apnea Hypopnea Index (AHI) threshold of 5 per hour, 15 per hour, or the presence of any comorbidity (hypertension, ischemic heart disease, stroke, mood disorders, impairment of cognition, or sleepiness) when the AHI was between 5 to 15 per hour. Variable hypopnea definitions based upon degree of oxygen desaturation and associated arousals were considered.

Results

In the SHHS dataset, the Receiver Operating Characteristics (ROC) for a SLIM score threshold of 9 for men and 5 for women was good when OSA was defined by AHI > 5 per hour (hypopneas with either > 3% oxygen desaturation or arousals). Specifically, the ROC was 0.72 (95% Confidence Intervals [CI] 0.70; 0.74) with a Positive Predictive Value [PPV] of 0.98 and Likelihood Ratio of a positive test (LR+) of 11.3. The LR+ (6.0) and PPV (0.92) were also good when an AHI of 5 per hour threshold was adopted with hypopneas scored using the minimum 3% oxygen desaturation alone. Similarly, the ROC was good 0.74 (95%CI 0.73; 0.76) with a Positive Predictive Value [PPV] of 0.98 and Likelihood Ratio of a positive test (LR+) of 11.3. The LR+ (8.9) and PPV (0.81) were also good in the presence of comorbidities when AHI was 5 to 15 per hour using > 4% oxygen desaturation alone.

Conclusion

The EHR-extractable tool can be an actionable tool for case-identification of patients needing a referral for sleep study in a community-based population. Such an approach could facilitate an automated, rather than manual, OSA screening approach aimed at managing population health.

Support

HL138377
1191 Development of a Clinically-Validated Questionnaire and Scoring Algorithm Designed to Identify Common Sleep Problems Among Adults
Authors: Galaska B , Bakker J M , Sert Kuniyoshi F , Bush M , Salazar J , Jasko J G , Friedman A L , White D P
Published: May 2020

Introduction

Although sleep is critical to maintaining health and quality of life, inadequate sleep duration and/or quality is common. It can be difficult to distinguish sleep problems that may be addressed through adjustments to lifestyle versus issues that may represent a more serious condition requiring medical intervention. SmartSleep Analyzer is a cloud-based questionnaire and scoring algorithm designed to categorize respondents according to likely sleep problems as follows: obstructive sleep apnea (OSA), snoring, trouble falling asleep or staying asleep, delayed sleep phase disorder (DSPD), shift work disorder (SWD), chronic sleep restriction (CSR), or no sleep problem. Primary, secondary, and tertiary categorizations are provided, where applicable. The objective of this study was to validate the questionnaire scoring algorithm categorization/s against a sleep physician assessment.

Methods

From 2,316 available records, 90 complete questionnaires were randomly selected for this analysis. The questionnaire scoring algorithm categorization was compared against the consensus assessment of three independent sleep physicians who each reviewed the answers to all questions before arriving at a diagnosis.

Results

The questionnaire respondents (70% female) were aged 42.2±14.5 years, had a mean BMI of 32.0±7.7 kg/m2, and self-reported sleep duration of 6.5±1.4 hours/night. The primary, secondary, or tertiary categorization of the questionnaire scoring algorithm matched the primary consensus categorization of the physicians 90.6% of the time (95% confidence interval (CI): 82.6 to 95.7). When OSA and snoring were grouped, agreement increased to 98.9% (95% CI: 94.0 to 100). In all analyses undertaken, the accuracy of questionnaire scoring algorithm against the physicians exceeded the accuracy of the physicians when compared to each other.

Conclusion

These results demonstrate that our questionnaire and scoring algorithm performs well in identifying sleep problems that may impact adult respondents, using physician-review as the comparison standard.

Support

Philips
1206 Automated Sleep Apnea Assessment Based On Machine Learning And Wearable Technology
Authors: Chiu H , Lee P , Ku B , Liu Y
Published: May 2020

Introduction

Obstructive sleep apnea (OSA) is a condition characterized by repeated episodes of partial or complete obstruction of the respiratory passages during the sleep. Traditional polysomnography (PSG) for OSA estimation is bulky and time-consuming for daily use. Therefore, this study aims to develop a novel photoplethysmography (PPG) and accelerometer based smart watch for OSA detection, in which a high-performance and low-complexity automated OSA detection was embedded for long-term in-home measurement.

Methods

The developed watch measured PPG signals from wrist radial artery and body motion from accelerometer as well. 121 patients (92 males, 29 females) were recruited from the normal community and Center of Sleep, National Taiwan University Hospital, Taiwan in this study. All OSA scoring were analyzed by three registered PSG technologists. The AHI of the cohort was 10.1±18.3 (0 to 82.7). An automated OSA detection algorithm was designed based on machine-learning (ML) technique, in which was iteratively updated according to each 30-second epoch of the collected data. Subsequently, obstructive and hypopnea events were detected according to the OSA detection algorithm.

Results

To better valid the effectiveness, this study focused on the estimation performance of the subjects with AHI>15. Based on hold-out validation, the average sensitivity and precision in the AHI>15 cohort were 77.2% and 58.6%, respectively, with a Cohen’s kappa of 0.46. The interclass correlation between the watch and technologists was 0.81 (95%CI: 0.61-0.91). The result showed that the proposed automated OSA detection could achieve consistent result with technologist during standard sleep testing.

Conclusion

This study developed a wrist-based watch based on ML technique to assess OSA severity. We compared the performance with clinical technologists for the OSA detection. Further, the sensitivity and precision were generally acceptable while subjects were with AHI>15. The proposed wrist-based watch could provide reliable performance for OSA estimation, and may be of a light for future in-home sleep studies.

Support

This study was supported by Mediatek Inc.
1210 Development Of An Auditory Neurofeedback During Sleep Onset Process
Authors: Douch M , Soubrier M , Pinaud C , Harris M , Thorey V
Published: May 2020

Introduction

Biofeedback is proposed as an alternative method to help patients with insomnia reducing their anxiety. Some studies have shown that auditory neurofeedback can be effective at reducing sleep-onset latency. However, the AASM sleep stage classification only describes the sleep-onset as a binary state (i.e. wake or N1) which makes it not adapted for neurofeedback. We introduced a simple 4-stages classification for sleep-onset, on 10 seconds EEG epoch. The aim of this study was to develop an automatic method to detect these stages, and an online algorithm embedded in the Dreem headband (DH) that adapted the auditory feedback based on the current stage.

Methods

Fourteen subjects underwent an overnight PSG monitoring, from which the first sleep-onset period was extracted. We defined the simple 4-stages classification for sleep-onset on 10 seconds EEG epoch as following: SO1) > 75% of the epoch covered by alpha frequencies SO2) between 25% and 50% of the window covered with alpha frequencies, SO3) Alpha frequencies covered less than 25% and theta frequencies covered less than 30% of the epoch, and SO4) Theta frequency covered more than 30% of the epoch. For the manual scoring, 4 sleep scorers have been given the instructions and a Q&A session after scoring the first two records. For the algorithm, a sound triggering algorithm was linked to a neural network trained on the scored data, to dynamically adapt the sound to the sleep-onset stage.

Results

The scorers reached an average agreement of 68 + 15% over all the records. The neural network reached an accuracy of 68%. Per state the accuracy was: 71 ± 32% (S1), 52 ± 22% (S2), 54 ± 23% (S3), 79 ± 21% (S4). The automatic neurofeedback was able to adapt sound stimulations in real-time based on stages and was well perceived among first testers.

Conclusion

The results of this preliminary work show that we can reach a higher agreement by reducing the epoch duration and use this classification to produce automatic biofeedback during the sleep onset period. Further studies using a data-driven method should be conducted.

Support

This study supported by Dreem sas.
1224 Treatment of Severe OSA Using Low Flow Oxygen in a Neonate with Robin Sequence
Authors: Saeed Sidra , Amos Louella
Published: May 2020

Introduction

Robin Sequence (RS) involves the clinical triad of micrognathia, glossoptosis and cleft palate. There is a spectrum of severity, but most neonates with RS have upper airway obstruction, resulting in severe obstructive sleep apnea, sometimes requiring surgical interventions such as tongue-lip adhesion, mandibular distraction, or tracheostomy. We present an infant with RS and severe obstructive sleep apnea which was managed with supplemental oxygen.

Report of Case

Our patient was born at 39 weeks gestation with RS. He had a normal DNA microarray. He was discharged after a 3 week NICU hospitalization for poor feeding. Over the next 2 months, he had poor weight gain and worsening obstructive breathing and was evaluated by craniofacial surgery at that time. Room air polysomnography (PSG) was recommended and revealed an AHI of 21, REM AHI of 48, supine AHI of 25, prone AHI of 19, mean SPO2 of 98%, minimum SPO2 of 61%, and normal capnography with 0% of the time spent > 50 mmHg. A repeat sleep study on 1/4LPM oxygen in the supine position revealed an AHI of 1.7, mean SPO2 of 99%, minimum SPO2 of 92%, and normal capnography. He was discharged on supplemental oxygen. At 4 months of age, he had good weight gain. At 10 months of age, room air PSG revealed persistent OSA with an AHI of 7.2, REM AHI of 21, mean SPO2 of 97%, minimum SPO2 of 81%, and normal capnography. At age 3 yrs, his PSG on room air showed resolution of his OSA with an AHI of 0.6, mean SPO2 of 97%, minimum SPO2 of 87% and normal capnography.

Conclusion

This case illustrates the spectrum of severity of RS and the utility of low flow oxygen to treat OSA in this patient population.
1225 Sexsomnia: A Case of Sleep Masturbation And Sleeping In An Open Work Environment
Authors: Kim David S , Foster Brian E , Rizzo Meagan M , Collen Jacob F , Soca Rodolfo
Published: May 2020

Introduction

Sleep sex or sexsomnia is classified in the International Classification of Sleep Disorders as a non-rapid eye movement (NREM) parasomnia. The overall prevalence is unknown but several conditions such as obstructive sleep apnea (OSA), shift work, and/or insufficient sleep have been reported as factors affecting the frequency of NREM parasomnias. Parasomnias, with sexsomnias in particular, can cause significant emotional distress to patients and their families. We present a case of co-morbid sexsomnia and OSA in a patient serving in the military that had the complicating factor of sleeping in open quarters.

Report of Case

A 40-year-old male in active duty military without significant past medical history or medication use presented to clinic with a two year history of disruptive sleep masturbation reported by wife. Patient’s wife reported no instances of attempted sexual intercourse. The patient had no recollection of the episodes. The frequency and nature of the episodes were causing personal and marital distress. Patient was also concerned about work responsibilities, since he was periodically required to sleep in open environments. After initial clinic evaluation, patient underwent a video polysomnography (vPSG) with an extended EEG montage. No parasomnia activity was captured on vPSG but patient was diagnosed with moderate OSA. He was started on continuous positive airway pressure (CPAP) therapy, resulting in decreased number of episodes with relapses corresponding to nights without CPAP usage.

Conclusion

Sexsomnia cases require careful history taking and evaluation. The nature of the episodes and the sleep environment of the patient must be examined for any medico-legal ramification as there are court precedents of sexual assault charges made in sexsomnia-related cases. The military environment is unique with group-sleeping conditions, often in austere environments. If sexsomnia were to be misinterpreted as indecent exposure, under the military code of conduct, this could have significant career implications.
0124 A Prefrontal-Amygdala Network Model of the Cellular and Circuit-Level Mechanisms of Emotional Memory Consolidation During the Awake State and REM Sleep
Authors: Rho Y , Vijayan S
Published: May 2020

Introduction

Rapid eye movement (REM) sleep has been implicated in the consolidation of emotional memories. Our recent work found a candidate system for REM-related memory consolidation. We showed that during REM sleep, the frontal cortices are dominated by theta (4–8 Hz) oscillations and bursts of beta (15–35 Hz) activity. Studies suggest that rhythmic interactions between the frontal cortices and limbic structures, in particular the amygdala, play a critical role in the consolidation of emotional memories. However, the mechanisms responsible for memory consolidation during these rhythmic interactions during REM sleep remain unknown.

Methods

We used biophysically based neural models to build a large-scale network model of the prefrontal cortex (PFC) and amygdala (AMY) and incorporated synaptic plasticity mechanisms, such as spike-timing dependent plasticity (STDP), into the connections between these two regions. Norepinephrine (NE) and serotonin (SE) levels were manipulated to mimic the different physiological conditions during the awake state and REM sleep.

Results

We were able to reproduce the oscillatory dynamics observed in experimental studies and identify cell-type specific synaptic changes caused by STDP. During the awake state, PFC connections to all cell types of the AMY become strengthened when PFC neurons provide theta frequency inputs, with the connections strengthening to a greater extent when inputs are in burst mode rather than single spike mode. When the PFC provides beta inputs, we see the exact opposite relationship: synaptic strengths become weaker when inputs are in burst mode rather than single spike mode. During REM sleep conditions, the connections to all principal cell types of the AMY become strengthened, with synaptic connections to some subtypes of pyramidal cells becoming stronger than others. Surprisingly, however, the synaptic connections to the interneurons become weaker in response to theta frequency inputs.

Conclusion

Using our large-scale network model, we show how the levels of the neurotransmitters NE and SE during the awake state and REM sleep affect oscillatory dynamics and in turn influence the strengthening or weakening of connections related to emotional memories.

Support

United States Army Research Office, Award number ARO W91lNF-17-1-0300
1230 An unusual presentation of dementia with Lewy bodies in a septuagenarian
Authors: Geil Eric S , Agudelo Christian , Ascher Kori , Sun Xiaoyan , Velez-Ruiz Naymee , Ramos Alberto R
Published: May 2020

Introduction

Dementia with Lewy bodies (DLB) can be associated with degeneration of the hypocretin system and reduced hypocretin levels. However, reports of DLB initially presenting with narcolepsy with cataplexy symptoms are sparse.

Report of Case

A 77-year-old man presents with two years of new onset hypersomnia, tremors, memory difficulties, and gait instability. Before his sleep evaluation, he was started on levetiracetam for suspected seizures and levodopa for suspected Parkinson’s disease, without improvement. During his evaluation for hypersomnia, he reported loud snoring, witnessed apneas, sleep maintenance difficulty, hypnagogic hallucinations of well-formed images, and vivid dreams with dream enactment behavior occurring almost nightly. He had witnessed episodes of cataplexy described as transient lower extremity weakness with associated bifacial weakness, inability to speak, and no loss of consciousness, self-injury, loss of bowel/bladder control, or post-event symptoms. These events completely resolved after 1-minute, occurred while sitting or standing, and were spontaneous or triggered by anger or anxiety. His Epworth Sleepiness Scale was 18 and Ullanlinna Narcolepsy Scale was 35, suggestive of narcolepsy with cataplexy. Physical examination did not reveal Parkinsonism or resting tremor. He subsequently underwent a baseline polysomnogram that showed an apnea-hypopnea index of 32.7 events/hour. During an in-laboratory titration study, he had REM sleep without atonia. A 30-minute EEG was interpreted as normal and a typical cataplexy-like event captured during continuous EEG monitoring had no ictal correlate. Despite adherence to positive airway pressure therapy, he continued to have hypersomnia, cataplexy, and visual hallucinations during transitions from wake to sleep. He was tapered off levetiracetam and levodopa with a plan for further evaluation of probable DLB.

Conclusion

Narcolepsy with cataplexy symptoms is an uncommon presentation of probable DLB as seen in this case with two core clinical features of DLB (RBD and visual hallucinations), suggesting neurodegeneration of the hypocretin system.
1240 Obstructive Sleep Apnea Management in Weill-Marchesani Syndrome: A Case Report
Authors: Monceaux Brittany , Smalley Megan , Okorie Ugorji , Roberts Edmond , Liendo Cesar , Asghar Sheila , Chernyshev Oleg
Published: May 2020

Introduction

Weill-Marchesani Syndrome (WMS) is a rare systemic genetic connective tissue disorder which usually presents with symptoms of short stature, limited joint movement, and eye problems such as glaucoma and microspherophakia. This genetic condition is associated with fibrous tissue hyperplasia. WMS is inherited as autosomal dominant or autosomal recessive patterns in families leading to a variability in presenting phenotype. Few papers have been written on airway management during anesthesia but as far as we know, this is the first case report on obstructive sleep apnea management in a patient with WMS.

Report of Case

A 9 year old boy with a past medical history of Methylene THF Reductase deficiency, von Willebrand’s Disease, seizure disorder, premature birth, developmental delays and Weill-Marchesani syndrome was referred to Sleep Medicine due to tonsillar hypertrophy (3+), snoring and witnessed apneas. Upon physical examination, patient had mid-facial hypoplasia, retropositioning of the mandible, high arched palate, Mallampti class IV, maxillary hypoplasia and mandibular hypoplasia. He had been evaluated by ENT which determined the patient to be too high risk due to his medical conditions for T&A. The patient had a polysomnogram in 2018 indicating OSA with an apnea-hypopnea index of 4.2 and a minimum oxygen saturation of 91%. After a CPAP titration study, the patient was started on Auto CPAP of 5-15 cmH2O and has shown improvement in symptoms based on subjective and objective compliance report. Patient has been able to tolerate PAP therapy well with 100% compliance greater than 4 hours per night.

Conclusion

This case is the first illustrating OSA in a patient with Weill-Marchesani Syndrome. In WMS, the causes of OSA are not only due to tonsillar hypertrophy, but multifactorial, including craniofacial abnormalities. Given the high risk of surgical complications in WMS patients, PAP therapy appears to be a reasonable option for OSA management.
1244 A Curious Case of ASV Failure
Authors: Chaudhary Nishant , Ayache Mirna , Carter John
Published: May 2020

Introduction

Positive airway pressure-induced upper airway obstruction has been reported with the treatment of obstructive sleep apnea (OSA) using continuous positive airway pressure (CPAP) along with an oronasal interface. Here we describe a case of persistent treatment emergent central sleep apnea (TECSA) inadequately treated with adaptive servo ventilation (ASV), with an airflow pattern suggestive of ASV-induced upper airway obstruction.

Report of Case

A 32-year-old male, with severe OSA (apnea hypopnea index: 52.4) and no other significant past medical history, was treated with CPAP and required higher pressures during titration sleep studies to alleviate obstructive events, despite a Mallampati Class II airway and a normal body mass index. Drug-Induced Sleep Endoscopy (DISE) showed a complete velopharynx and oropharynx anterior posterior (AP) collapse, long soft palate, which improved with neck extension. CPAP therapy, however, did not result in any symptomatic benefit and compliance reports revealed high residual AHI and persistent TECSA. He underwent an ASV titration sleep study up to a final setting of expiratory positive airway pressure 9 cm H2O, pressure support 6-15 cm H2O (auto-rate), with a full-face mask due to high oral leak associated with the nasal interface. The ASV device detected central apneas and provided mandatory breaths, but did not capture the thorax or abdomen, despite normal mask pressure tracings. Several such apneas occurred, with significant oxyhemoglobin desaturation.

Conclusion

We postulate that the ASV failure to correct central sleep apnea as evidenced by the absence of thoracoabdominal inspiratory effort, occurred due to ASV-induced upper airway obstruction. Further treatment options for this ASV phenomenon are to pursue an ASV-assisted DISE and determine the effectiveness of adjunctive therapy including neck extension, nasal mask with a mouth closing device and a mandibular assist device.
1246 Resolution of Cyclical Ventricular Ectopy with ASV Therapy in a Patient with Cheyne-Stokes Respirations
Authors: Rupani Nawaz , Massoud Mona , Bhura Sajeer , Kaplish Neeraj
Published: May 2020

Introduction

Nocturnal cardiac arrhythmias, ranging from ventricular ectopy to heart blocks, have been commonly reported in patients with obstructive sleep apnea syndrome (OSAS). Potential mechanisms for these rhythm disturbances include OSA-associated hypoxemia, arousal trigger increased sympathetic activity and alterations in intrathoracic pressures leading to cardiac mechanical structural changes. A beneficial effect of CPAP treatment on rhythm abnormalities in patients with obstructive sleep apnea has also been demonstrated. However, the relationship of cardiac arrhythmias and central sleep apnea is not well established.

Report of Case

We report an 82-year-old male with CAD and Atrial fibrillation s/p PPM who presented for management of his sleep disordered breathing (SDB). Upon review, his original sleep studies performed at an outside facility revealed obstructive sleep apnea and central sleep apnea with Cheyne-Stokes Respirations. The patient presented to us on treatment with an auto-adjusting PAP (APAP) of 7-15 cmH2O with an average delivered pressure of 12 cmH2O. A re-titration study was recommended and demonstrated persistent central sleep apnea with Cheyne-Stokes breathing despite treatment with CPAP 12-18 cmH2O. During this time, EKG monitoring revealed an atrial paced rhythm with frequent premature ventricular beats (PVBs) which occurred in a cyclical pattern. After initiation of Adaptive Servo-Ventilation (ASV), periodic breathing was well controlled and cyclical ventricular ectopy had completely resolved.

Conclusion

Although CPAP therapy has been shown to improve nocturnal arrhythmias in patients with obstructive sleep apnea, the same relationship, to our knowledge, has not been reported in patients with central sleep apnea and Cheyne-Stokes breathing. This case demonstrates the improvement of cyclical ventricular ectopy with ASV therapy.
1257 Low Nocturnal SpO2 and Daytime Sleepiness in a Child
Authors: Pi M Y , Han F
Published: May 2020

Introduction

Patients with nocturnal oximetry shows SpO2 during sleep of ≤ 90% in children for ≥ 5 minutes and sleep related hypoventilation is not documented could be diagnosed as sleep related hypoxemia (ICSD-3). However, known physiological causes should be indicated.

Report of Case

A 5-year-old Chinese boy was referred to sleep lab for daytime sleepiness for three months. Type I narcolepsy was confirmed.

Nocturnal PSG indicated a continuous low SpO2 baseline around 82%, with a nocturnal mean SpO2 of 83%, but no respiratory events. Voluntary hyperventilation made SpO2 increase from 83% to 95%, and hypoventilation syndrome was considered. PtcCO2 during PSG maintained 40mmHg, and no sleep related elevation observed. BPAP treatment had no effect on both SpO2. No dyspnea was complained. When he was 12 years old, follow-up PSG and MSLT indicated narcolepsy remained. During the past 7 years, no comorbidities occurred. Hb 104 g/L, RBC 3.53 × 1012/L, Hct 31%. ABG showed SaO2 of 97%, PaO2 98mmHg and PaCO2 40mmHg. Inconsistency between SpO2 and SaO2 reminds the existence of abnormal hemoglobin.

A positive isopropanol precipitation test and further hemoglobin electrophoresis showed abnormal Hb and HbA were 37.6% (normal 0%) and 58.4% (normal 94.3–98.5%), respectively, but HPLC did not identify. Spectrophotometric analysis indicated that the absorption spectra were significantly different at 450nm~540nm and 600nm~1000nm. Hemoglobin structure analysis found the abnormal site. Gene sequencing identified a novel HBB: c.212 C>A mutation, resulting in amino acid 71 to change from alanine(Ala) to aspartic(Asp) acid as a de novo mutation. A diagnosis of Hemoglobin Seattle [β71:Ala→Asp；HBB:c.212C>A] was confirmed.

Conclusion

Pediatric sleep medicine has a rapid development. Before a diagnosis of sleep related hypoxemia is made, in rare situation, abnormal hemoglobin should be considered.
1260 High Tidal Volume Non-invasive Ventilation Required to Treat Obesity Hypoventilation
Authors: Rezayat Talayeh , Beggs Abigail , Avidan Alon Y , Javaheri Shahrokh
Published: May 2020

Introduction

Current guidelines recommend CPAP or non-invasive ventilation with tidal volume (VT) <10ml/kg of ideal body weight (IBW) for the treatment of obesity hypoventilation. However, in select patients with significant obesity hypoventilation, this recommendation may not be sufficient to resolve nocturnal hypoventilation.

Report of Case

A 35 y/o male with hypertension and class III obesity (BMI 58 kg/m2) was referred for evaluation of acute respiratory failure with hypoxia and hypercapnia. ABG demonstrated daytime PCO2 of 71 mmHg. Patient reported sleep fragmentation, snoring, choke awakenings, poor concentration, depression and sleep attacks. PSG demonstrated severe OSA, with an AHI of 154 events/hour, persistent hypoxia and hypercapnia with a SpO2 nadir of 50% and ET-CO2 of 83 mmHg during REM sleep. Respiratory events persisted with CPAP and bilevel, up to a setting of 25/16. Average volume assured pressure support (AVAPS) S/T titration study was performed and resolved sleep apnea at settings of IPAP 24-30, EPAP 4-15, VT 790 (10 mL/kg IBW), 0.5 LPM O2, rate 16. The patient reported having had the best sleep of his life at the end of this study and has since been started on treatment.

Conclusion

Treatment of OHS should be individualized and may require use of tidal volumes above 10ml/kg for effective treatment. We suggest that in super morbidly obese patients, with extremely noncompliant respiratory system, larger than recommended tidal volume is necessary to ventilate the patient and improve gas exchange. The sustained higher pressures achieved by AVAPS to impose the augmented tidal volume more effectively ameliorate OSA, by keeping the upper airway open. Higher pressures achieved also could elevate FRC, not only increasing oxygen stores, but also contributing to maintenance of open upper airway through its tethering effect. Further physiological studies are needed in super morbidly obese patients comparing low and high tidal volumes.
1261 The Long Term Exhaustion of a Viral Infection
Authors: Mulhern Kellen
Published: May 2020

Introduction

Narcolepsy is a rare condition affecting only 0.02% to 0.18% of United States and Euro-pean populations. Throughout the years, hypersomnolence in the form of narcolepsy or idiopathic hypersomnia has been identified as a post infectious syndrome in rare instances. In this case, we observe a child with excessive daytime sleepiness after an infectious rash.

Report of Case

A 4 year old male presented to clinic for evaluation of excessive daytime sleepiness for the past 10 months. At that time, he developed a full body rash that lasted for about 1 week, and was treated with diphenhydramine and prednisone. No imminent cause was identified. For the preced-ing weeks, he was taking frequent and longer naps, and complained of difficulty with keeping his head up and his eyes open.

He was evaluated for possible seizures via EEG with no seizure activity seen. Blood work was unremarkable, and a lumbar puncture showed highly elevated IgG for EBV, and low IgM for EBV, indicating a prior infection.

His excessive somnolence persistent, and he was referred to undergo actigraphy, poly-somnography (PSG), and a multiple sleep latency test (MSLT). Actigraphy demonstrated disrupt-ed nocturnal sleep, PSG showed an elevated periodic leg movement index of 8.6/hr, and MSLT showed reduced sleep onset latency and sleep onset REM on 2 of 4 naps.

During his physical exam, he had drooping eyelids and tongue protrusion, concerning for cataplectic facies, highly suspicious for Narcolepsy Type 1. Further confirmatory testing is pend-ing, including HLA subtype testing and hypocretin levels in CSF.

Conclusion

This case shows a strong association with a subacute EBV infection and the development of nar-colepsy. There are multiple cases involving the development of hypersomnolence conditions as a consequence of viral infections. Further cases would be beneficial to form additional associations.
1270 Wobbly Knees: Cataplexy Or Seizure? A Case Report
Authors: Nadhim A , Wong J , Gupta D
Published: May 2020

Introduction

Cataplexy (associated with narcolepsy) is difficult to differentiate from conditions such as seizure, syncope or TIA, but using validated clinical tools can help. We report a case that was mistakenly diagnosed as cataplexy, delaying diagnosis and treatment of his underlying seizures.

Report of Case

A 42 years old male presented with “freezing spells” described as spontaneous episodes of weakness in his knees. He may stagger and drop objects but had never fallen. He denies loss of consciousness. Post-ictally, he takes a moment to readjust his body and returns to baseline. There was no warning or aura before the episodes. These spells initially occurred 1-2 times/year in 2002, then progressed to 1/month by 2006 and then increased to 15 times/day in Jan 2019, lasting 5-10 seconds at a time. He became hesitant to drive. He was evaluated by a pulmonologist/sleep specialist. PSG showed Mild OSA but MSLT wasn’t suggestive of Narcolepsy. He was prescribed CPAP but stopped after 6 months since it didn’t improve his symptoms. He was prescribed Venlafaxine to treat presumptive Cataplexy, without any benefit. Eventually, he was referred to neurology/sleep clinic. Cataplexy questionnaire was administered and was negative: specifically, there were no emotional triggers of his episodes, such as hearing a joke, laughing or crying. Due to the stereotyped nature of his spells, he was referred to epilepsy specialist. He underwent 72 hours video EEG monitoring which showed that his clinical episodes were associated with EEG abnormality, suggestive of frontal lobe epilepsy. He was placed on Keppra and Oxcarbazepine. On follow up visit, he reported improvement in seizure frequency from 10-20/day to 1-2/day.

Conclusion

A validated1 clinical Tool such as Stanford Cataplexy questionnaire helps in differentiation of Cataplexy from other forms of transient muscle weakness. It can prevent 15 years delay in diagnosis and treatment of patients, or use of unnecessary medication.
0134 Self-Reported Sleep is Associated with Central, But Not Peripheral Blood Pressure Values in Healthy Children
Authors: Berube F R , Katulka E K , D’Agata M N , Patterson F , Ives S J , Farquhar W B , Witman M A
Published: May 2020

Introduction

Shortened and poor quality sleep have emerged as nontraditional risk factors for the development of high blood pressure (BP) in adults, but it is unclear if these relations exist in younger children. Self-report and objective sleep measurements are both clinically relevant and may inform interventions to improve sleep in this population, but do not always coincide with one another. The purpose of this study was to evaluate both self-reported and objective sleep metrics and their associations with central and peripheral BP values in younger children.

Methods

Participants included 21 healthy 7-12-year-old children (10±0.5 yrs, 10M/11F). Self-reported sleep was evaluated using the Children’s Sleep Health Questionnaire and a total sleep score was generated, where a higher score indicates worse sleep (a score >41 indicates a pediatric sleep disorder). Objective sleep was recorded for 7 consecutive days and nights outside of the laboratory via wrist accelerometry and reported as sleep duration (SD) and sleep efficiency (SE). Following sleep monitoring, peripheral BP was measured and using pulse wave analysis (PWA) central BP was estimated, both of which were averaged over 3 trials. Pearson’s r correlations were used to assess relations between self-reported sleep score, objective sleep metrics, and BP values. Significance was set at p<0.05.

Results

Self-reported sleep score averaged 40±1 points, objective SD averaged 7.9±0.1 hours/night, and SE averaged 82±2%. Sleep score was significantly associated with central systolic and diastolic BP (r = .485, p = 0.03, and r = .517, p = 0.02, respectively), but not peripheral BP values. Objective SD and SE were not significantly associated with central or peripheral BP values.

Conclusion

In this sample, self-reported sleep score, but not objective sleep metrics, was associated with higher central BP values in healthy children age 7–12.

Support

Provided in part by P20GM113125.
0136 Bright Light Could Be an Alternative to the Caffeine for Improving Driving Performance in Chronically Sleep-Deprived Young Drivers
Authors: Shekari Soleimanloo S , Garcia-Hansen V , White M , Smith S S
Published: May 2020

Introduction

Young drivers are over-involved in sleepiness-related crashes. Daytime and nighttime exposure to light might shift the human circadian phase and alertness. The alerting effects of bright light were compared with those of caffeine in young drivers.

Methods

In a within-subjects study, 30 chronically sleep-deprived non-professional drivers (aged 18–24 years) completed two simulated daytime driving sessions per day across three consecutive days. Participants completed the first drive under a Baseline condition (non-caffeinated gum, 555 nm light, 0.3 µW/cm²), and the second drive under the randomized conditions of Light (500 nm, 230 µW/cm²), Caffeine (100 mg caffeinated gum) or the combination of Light and Caffeine. Using mixed-effects models, the alerting effects of these conditions on objective sleepiness (ECG beat-to-beat intervals), driving performance (lateral lane variability) and subjective sleepiness (scores on the Karolinska sleepiness scale; KSS) were examined.

Results

Compared to the Baseline condition, lateral lane variability decreased under the Light (P=0.011), Caffeine (P=0.0001), and the combination of Light and Caffeine (P=0.046). Lateral lane variability was lower under Caffeine when compared with the Light (P=0.009) or the combination of Light and Caffeine (P= 0.0001). Average beat-to-beat intervals increased from the Baseline condition to the Light (P=0.017), Caffeine (P=0. 0.0001), and the combination of Light and Caffeine conditions (P=0.0001). All three conditions significantly reduced subjective sleepiness compared to the Baseline condition (KSS= 4–5 vs KSS=6, P= 0.0001).

Conclusion

Bright light, either alone or combined with caffeine, improves driving performance and subjective sleepiness during daytime drives. Light might better improve objective sleepiness and other sleepiness indicators during nighttime when drivers are sleepier and have an increased sensitivity to the light. Further research would clarify how the circadian effects are aligned with the alerting effects of the light. Bright light, as an alternative to or combined with caffeine, could reduce sleep-related crashes on the road.

Support

NA
0137 Self-Reported Sleep Quality is Associated with Central Hemodynamics in Healthy Individuals
Authors: Culver M N , Flatt A A , Grosicki G J
Published: May 2020

Introduction

Insufficient sleep is associated with arterial stiffness and elevated cardiovascular disease risk. Central hemodynamics are influenced by arterial stiffness, yet independently predict cardiovascular risk. Relationships between sleep characteristics and central hemodynamic parameters are largely unexplored. We aimed to characterize the relationship between self-reported sleep quality and central hemodynamics in healthy individuals. To explore the hypothesis that impairments in glucose metabolism, resulting from lack of sleep, may underlie relationships between sleep and central hemodynamic variables, we also examined associations between self-reported sleep quality and fasting blood glucose values.

Methods

Thirty-one healthy subjects (14 females /17 males; 20–69 years) that were free from metabolic or cardiovascular disease, and that did not take sleep medication were included in the study. Relationships between self-reported sleep quality, obtained using the Pittsburgh Sleep Quality Index (PSQI), with central hemodynamic profiles(systolic and diastolic blood pressures, pulse and augmentation pressures, augmentation index) estimated from oscillometric pulse wave analysis, and fasting blood glucose values were assessed.

Results

Central pulse pressure was significantly elevated (P<0.05) in poor (PSQIscore >5) compared to normal (PSQI score 0–5) self-reported sleepers. Linear regression models, adjusted for age, gender, and body mass index, demonstrated PSQI score to be an independent predictor (P<0.05) of both central pulse (β=0.469) and augmentation (β=0.364) pressures. Global PSQI scores were not related to fasting blood glucose values (r=0.045; P>0.05).

Conclusion

Significant relationships between central pulse and augmentationpressures and self-reported sleep quality highlight the importance of considering sleep when examining lifestyle contributors to central hemodynamics.

Support

No funding.
0143 Vigilance Declines Following Sleep Deprivation are Associated with Two Previously Identified Dynamic Connectivity States
Authors: Teng J , Ong J , Patanaik A , Zhou J , Chee M , Lim J
Published: May 2020

Introduction

Dynamic functional connectivity (DFC) analysis of resting-state fMRI data has been successfully used to track fluctuations in arousal in the human brain. Changes in DFC have also been reported with acute sleep deprivation. Here, we demonstrate that dynamic connectivity states (DCS) previously related to arousal are reproducible, and are associated with individual differences in sustained attention declines after one night of total sleep deprivation.

Methods

32 participants underwent two counterbalanced resting-state fMRI scans: during rested wakefulness (RW) and following total sleep deprivation (SD). They also completed the Psychomotor Vigilance Test (PVT), a sustained attention task that is highly sensitive to the effects of sleep loss. SD vulnerability was computed as the decrease in response speed (∆RS) and increase in lapses (∆lapse) in SD compared with RW.

Dynamic functional connectivity analysis was conducted on rs-fMRI data. Connectivity matrices were clustered to obtain 5 prototypical DCS. We calculated the proportion of time participants spent in each of these DCS, as well as how often participants transitioned between DCSs. Relationships between SD vulnerability and connectivity metrics were then correlated.

Results

We recovered two DCS that were highly similar (ρ = .89-.91) to arousal-related DCS observed in previous work (high arousal state (HAS); low arousal state (LAS)).

After sleep deprivation, the proportion of time spent in the LAS increased significantly (t29=3.16, p=.0039), while there was no significant change in HAS (t29=-1.43, p=.16). We observed significantly more state transitions in RW compared with SD. Change in LAS and HAS across sleep conditions correlated significantly with SD vulnerability (ΔLASxΔRS: r=-0.64, p<.0001; ΔLASxΔlapse: r=0.43, p=.018; ΔHASxΔRS; r=0.43, p=.019; ΔHASxΔlapse; r=-0.39, p=.033). Finally, Δ%transitions was correlated with ΔRS but not Δlapse.

Conclusion

This study adds to the evidence that two specific reproducible DCS are robust markers of arousal and attention, and may be useful indicators of SD vulnerability.

Support

This work was supported by the National Medical Research Council, Singapore (STaR/0015/2013), and the National Research Foundation Science of Learning (NRF2016-SOL002-001).
0144 Relationship Between Sleep EEG K-Complex Slow Wave Coupling and Next-Day Thalamic Activity During Psychomotor Vigilance Test in Obstructive Sleep Apnea
Authors: Parekh A A , Kam K , Mullins A , Fakhoury A , Castillo B , Roberts Z , Hedden T , Varga A W , Rapoport D M , Ayappa I
Published: May 2020

Introduction

There is large inter-individual variability in the relationship between obstructive sleep apnea (OSA) severity and lapses in vigilance as measured using psychomotor vigilance test (PVT). We have previously shown that overnight sleep EEG K-complex slow wave coupling (∆SWAK) exhibits a dose-responsive relationship with next-day lapses in vigilance in OSA on and off treatment. We hypothesized that a variable thalamic dysfunction in OSA explains difference in lapses in vigilance and alterations in ∆SWAK across individuals.

Methods

Five newly diagnosed severe OSA subjects (mean apnea-hypopnea index [AHI4%=57.1±22.8/hr.]) with excessive daytime sleepiness (Epworth Sleepiness Scale=11±3.4) underwent nocturnal polysomnography followed by PVT testing within a 3T SKYRA MRI scanner. The PVT task inside the scanner (PVT-fMRI) was adapted to match the gold standard PVT-192 device. Each fMRI scanning session consisted of 2 10-min PVT runs interleaved with 2 control conditions wherein the subject pressed the response button at random intervals absent of a visual stimulus. fMRI data was analyzed in 2-step procedure (individual time-series followed by group analysis) using Analysis of Functional Neuroimages (AFNI) software package. To estimate thalamic activity during PVT-fMRI, parameter estimates of the %change in blood-oxygen-level-dependent (BOLD) signal using the contrast PVT-Control were used as the primary metric. The region of interest was limited to the bilateral thalamus using the Eickhoff-Zilles macro labels from the MNI N27 template.

Results

In a preliminary test, PVT performance for the subjects inside the scanner was not significantly different from that outside the scanner (PVTLapsesfMRI=7.3±2.1 vs. PVTLapsesPVT192=6.4±3.6 mean±std; PVTLapses=reaction time > 500 ms.). Within subjects, a trend toward lower thalamic recruitment was observed during PVT-fMRI (-0.17±0.2%; p=0.1). Further, lower thalamic activity during PVT-fMRI also showed a trend to lower overnight ∆SWAK (mean -1.2±1.4) values (r = 0.61, p = 0.17).

Conclusion

In severe OSA subjects with excessive daytime sleepiness, we observed a trend to reduced thalamic activity during daytime PVT. Overnight EEG K-complex slow wave coupling showed a similar trend with next-day thalamic activity during PVT, however the small sample size may have limited our ability to detect this association with statistical significance.

Support

AASM Foundation 199-FP-18; NIH K24HL109156
0146 Efficacy and Safety of Single Dose of TS-142, a Novel and Potent Dual Orexin Receptor Antagonist, in Insomnia Patients
Authors: Uchiyama M , Kambe D , Imadera Y , Sunaga H , Hasegawa S , Nogi T , Kajiyama Y , Yoshida S , Ogo H , Uchimura N
Published: May 2020

Introduction

TS-142 is a novel dual orexin receptor antagonist (DORA) developed for the treatment of insomnia. Here we report its pharmacokinetic profile in the healthy subjects and its efficacy and safety in patients with insomnia.

Methods

A phase1 study was conducted to clarify pharmacokinetic profile, in which various doses of TS-142 (1–30 mg) were orally administered once to thirty two healthy subjects. Subsequently, a phase 2a study utilizing polysomnography (PSG) was carried out in patients with primary insomnia, in which 5, 10, or 30 mg of TS-142, or placebo was randomly administered in a double-blind manner. Karolinska Sleepiness Scale (KSS) and Digit Symbol Substitution Test (DSST) were also examined in the morning after PSG.

Results

Following single administration of TS-142, plasma concentration of unchanged compound reached maximum within 2.50 h (median), and then eliminated rapidly, giving mean elimination half-life between 1.32 and 3.25 h. Twenty-three patients with insomnia completed the Phase2a study. Both latency to persistent sleep (LPS) and wake after sleep onset (WASO) were significantly improved with TS-142 at all doses, in comparison with placebo (-42, -42 and -45 for LPS [min] and -28, -35 and -55 for WASO [min] in 5, 10, 30 mg, respectively). KSS and DSST administered in the morning indicated no serious hangover effects. No serious adverse events were observed in these trials.

Conclusion

The phase 1 trial showed favorable pharmacokinetic profiles. The phase 2a trial demonstrated that TS-142 was efficacious in objective sleep onset and maintenance with minimal next-day residual effects. TS-142 was generally well tolerated in both studies.

Support

Taisho Pharmaceutical. Co., Ltd.