bluuebunny/crossref_metadata_2025 huggingface dataset:
0117 Circadian- and Wake-Dependent Effects on Recall for Face-Name Pairs
Authors: Yuan R K , Münch M Y , Cain S W , Ronda J M , Czeisler C A , Duffy J F
Published: May 2020

Introduction

The ability to remember the face and name of a person we have recently met is a critical skill often impacted by cognitive impairment and Alzheimer’s disease. We used a forced desynchrony protocol to explore whether recall of recently-learned face-name pairs is affected by time awake and/or circadian phase in healthy adults.

Methods

13 healthy, cognitively normal adults (20-70yrs; 7F) participated in a 39-day inpatient protocol with 3 baseline days (10h time-in-bed/24h) and a 3-week forced desynchrony (FD) segment, where they lived on a 28-h day with sleep restriction (6.5h time-in-bed/28h, equivalent to 5.6h/24h). Core body temperature was collected throughout to estimate circadian period and phase. The face-name test was administered every 4h, beginning 3h after wake. Each test included a learning session with 6 novel face-name pairs. Recall was tested 2h later, when each face was presented twice in random order, once with a correct and once with an incorrect name. Participants were asked to respond whether each face-name pair was correct. Data were averaged across 4-h circadian phase or time awake bins and normalized as a percentage of each participant’s baseline performance.

Results

Face-name recall varied by time awake (p<0.05), with performance deteriorating ~12% over the course of 12h of wakefulness. Face-name recall also varied by circadian phase (p<0.05), with a ~10% difference in recall performance from the peak at circadian phase 240° (corresponding to the early biological evening) to the nadir at circadian phase 60° (corresponding to the early biological morning).

Conclusion

Both duration of prior wake and biological time of day impact the ability to correctly recall face-name pairs. Under normal entrained conditions, opposing circadian- and wake- dependent effects on memory for face-name associations may interact to produce stable performance across the day.

Support

Study supported by P01 AG009975 and conducted at Brigham and Women’s Hospital Center for Clinical Investigation, part of Harvard Clinical and Translational Science Center supported by UL1 TR001102. Authors supported by T32HL007901 and F32HL143893 (RKY); fellowships from the Novartis Foundation, the W.&T. La-Roche Foundation, and Jazz Pharmaceuticals (MYM); a fellowship from the Natural Sciences and Engineering Research Council of Canada (SWC).
1158 Daytime Sleepiness, Depression, And Post-concussive Symptoms Improve Following Prescribed Morning Exposure To Blue Light
Authors: Raikes A C , Dailey N S , Alkozei A , Vanuk J R , Grandner M A , Killgore W D
Published: May 2020

Introduction

Long-term sleep disruption, fatigue, and depression are common after mild traumatic brain injuries (mTBIs). Efficacious treatments for these disturbances in the context of mTBIs are lacking. Morning blue light therapy (BLT) effectively treats sleep disruption and improves mood. This study evaluated the treatment effects of morning BLT on post-mTBI daytime sleepiness, depression, and post-concussion symptoms.

Methods

62 individuals (Boston: n=31; age: 23.11±7.20y; 17 females; days post-injury: 236.00±121.40; Tucson: n=31; age: 26.35±8.08y; 20 females; days post-injury: 272.94±167.69) received either BLT (n=30) or placebo amber light therapy (ALT; n=32). All participants completed the Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and Rivermead Post-concussion Symptom Questionnaire (RPQ3 and RPQ13 subscales) pre- and post-treatment. Treatment consisted of direct exposure to either blue or amber light (30 minutes each morning), delivered via tabletop light-box, over six weeks. Baseline and post-treatment values were compared to a non-mTBI, non-treated control sample (Tucson: n=32, age: 23.94±5.41y; 19 females).

Results

Baseline scores were higher in both mTBI light groups (BLT, ALT, respectively) than controls for the ESS (Cohen’s d=0.83, 0.83), PSQI (d=1.45, 1.71), BDI (d=1.46, 1.62), RPQ3 (d=1.72, 1.62) and RPQ13 (d=1.86, d=1.76). BLT resulted in lower within-group ESS (d=-0.58), BDI (d=-0.50), PSQI (d=-0.57), and RPQ13 (d=-0.45, p=0.005) scores. No improvements were seen following ALT. Minimal ESS score differences between the BLT and controls were observed after treatment (d=0.25).

Conclusion

Daily morning BLT resulted in moderate improvements in post-mTBI daytime sleepiness, sleep quality, depression, and post-concussion symptoms. These improvements may contribute to enhanced academic and job performance, post-mTBI quality of life, and general recovery. Future work is needed to clarify optimal dosage and precision medicine factors indentifying those most likely to benefit from morning BLT.

Support

This research was supported by multiple grants from the US Army Medical Research and Materiel Command (USAMRMC) to Dr. William D. S. Killgore, including W81XWH-11-1-0056 and W81XWH-14-1-0571.
1161 Tasimelteon Shows Persistence Of Efficacy In Improving Sleep Disturbances In Patients With Smith-Magenis Syndrome (SMS) In Open-Label Extension Study
Authors: Brooks J , Gibson M , Kite K , Czeisler E , Fisher M , Xiao C , Polymeropoulos C , Polymeropoulos M
Published: May 2020

Introduction

Smith-Magenis Syndrome (SMS) is a rare (1/15,000 - 25,000 births) neurodevelopmental disorder resulting from an interstitial deletion of chromosome 17p11.2, or from a point mutation in the RAI1 gene. Severe sleep disorder is almost universal in patients with SMS and poses a significant challenge to patients and their families. Tasimelteon improved sleep symptoms in a randomized, double-blind, two-period, crossover study; and here we show that this effect persists for up to four years in an open-label extension. To our knowledge, this is the largest interventional study of SMS patients to date.

Methods

Following the 4-week crossover study, all eligible participants had the option to enroll in an open-label extension. 31/39 (79.4%) of all individuals who participated in the efficacy study have continued on tasimelteon treatment. Participants in the open-label extension provided daily diary sleep quality (DDSQ), and daily diary total sleep time (DDTST) measures via parental post sleep questionnaire and characterized behavior using the Aberrant Behavior Checklist (ABC).

Results

In the open-label extension, tasimelteon continued to show improvement in the primary endpoints of 50% worst sleep quality (mean = 0.7, SD = 0.94) and 50% worst total nighttime sleep duration (mean = 53.3, SD = 59.01) when compared to baseline. Tasimelteon also improved overall sleep quality (mean=0.7, SD=0.83) and overall total nighttime sleep duration (mean = 51.9, SD=53.03). ABC scores also improved with tasimelteon (mean= -16.3, SD = 15.82).

Conclusion

Tasimelteon continues to demonstrate persistence in efficacy (longest approximately 4 years) with similar magnitudes observed in the 4-week crossover study for sleep quality and total sleep time. Interestingly, daytime behavior also demonstrates long-term improvement in patients with SMS treated with tasimelteon. These results further confirm tasimelteon as a novel therapy for the treatment of sleep disorders in patients with SMS and may provide benefit for behavioral symptoms.

Support

This work was supported by Vanda Pharmaceuticals Inc.
1170 Trends in Sleep Apnea Testing Among Veterans Participating in a Rural Health-Focused Telesleep Medicine Program
Authors: Atwood C W , Boudreau E , Folmer R , Kuna S T , Pineda L , Reichert J , Sarmiento K , Thompson W , Whooley M , Zhang N , Yarbrough W C
Published: May 2020

Introduction

The Department of Veterans Affairs has pioneered the use of home sleep apnea testing (HSAT) across many of its medical centers over the past 15 years. Here we report trends regarding diagnostic sleep apnea testing in rural and urban Veterans served by the TeleSleep Program, a VA telehealth initiative focused on increasing access to sleep care for rural Veterans. Rurality is a risk factor for use of polysomnography and is associated with longer wait times for testing and initiation of PAP therapy.

Methods

We used a VA administrative database search of patients enrolled in sleep medicine clinics from fiscal years (FY) 2016-2019 at 7 TeleSleep Hubs: San Francisco, Portland, Phoenix, Boise, Philadelphia, Spokane, and Pittsburgh. Individual encounters were coded locally and transmitted to VA’s corporate data warehouse. HSAT codes included 95800, 95801, 95806, G0398, G0399, and G0400. Polysomnography codes included 95807, 95808, 95810, and 95811.

Results

Total number of unique Veterans served increased between FY16 and FY19 from 28,941 to 43,044 (149%); rural Veterans served during this time increased from 9,386 to 14,329 (153%). The total number of annual sleep medicine encounters for all Veterans served increased from 89,870 to 138,127 (154%); rural Veteran visits increased from 29,825 to 50,342 (169%). Unique urban Veterans tested by HSAT increased from 2,158 in FY16 to 4,398 in FY19 (203%) while polysomnography decreased from 5,011 to 3,253 (35%). Unique rural Veterans tested by HSAT increased from 1,102 to 2,768 (251%) and polysomnography decreased by 42% (1,565 to 909 Veterans) during this same time.

Conclusion

Among VA sleep medicine programs with TeleSleep funding, HSAT became the most common approach to diagnostic sleep apnea testing, particularly in rural Veterans. Although polysomnography was widely used at the beginning of the TeleSleep Initiative, use declined as HSAT became more widely implemented.

Support

VA Office of Rural Health
1173 Reducing Cancellation and Improving the Patient’s Experience Through Quality Improvement Process
Authors: Mullen L , Cole A , Parsons J , Sabla G , Tiemeyer K , Simakajornboon N
Published: May 2020

Introduction

Sleep study volume in our system has increased by 23% from 2017 to 2019 which makes unfilled sleep beds a significant concern. Cancellation rate impacts our sleep bed access. We hypothesized cancellation can be improved through quality improvement process which could ultimately lead to improve patient satisfaction.

Methods

A multi-disciplinary team was assembled to examine potential contributing factors. Using the Model for Improvement we developed, tested and implemented interventions using tools such as PDSA cycles, process map and a simplified FMEA (Failure Modes and Effects Analysis). A Key Driver Diagram helped guide our journey to improve the cancellation rate. We developed a Parent Advisory Group to help us with ideas to identify how we could improve the cancellation rate.

Results

The cancellation was 21% prior to the implementation of our interventions. To improve these measures, we have implemented several interventions. The content of our sleep study preparation handbook was improved, increased distribution of the education handbook and developed a series of sleep study videos which are available for viewing prior to the study to prepare patients and families. In addition, we standardized our process of reminder calls in the call center and sleep lab by defining roles and responsibilities. This improved our ability to answer questions and identify and mitigate barriers they may have. We implemented transportation assistance to patients who have transportation barriers and created a waitlist protocol to assist families with a preferred date. After 2 years of interventions, the cancellation rate has decreased from 21% to 14.7%. Interestingly, as we improved our cancellation rate, the overall patient satisfaction has been improved from 83% to 88%.

Conclusion

Using the Model for Improvement, we improved education, communication and scheduling processes, which has reduced cancellation rate and consequently improved patient satisfaction.

Support
1176 Survey Of Knowledge Of Pediatric Trainees Regarding Obstructive Sleep Apnea In Children
Authors: Gummalla P , Lee S , Soriano S , Concepcion E
Published: May 2020

Introduction

Obstructive sleep apnea (OSA) causes significant morbidity in children. Very few studies were conducted among pediatricians regarding sleep and sleep disorders in children and adolescents. They demonstrated significant gaps in knowledge in the recognition and management of OSA.

Methods

We conducted a survey among the pediatric residents in the screening and diagnosis of OSA. The survey consist of 15 questions related to OSA in children. It aimed at identifying gaps in their knowledge and educating them accordingly. Following the survey, core lectures were included in the pediatric curriculum which aimed at educating them with the causes, diagnosis, management and sequelae of untreated OSA.

Results

37 pediatric residents took part in the survey. They were from first, second and third year of the pediatric residency training program respectively in an university hospital. 45% of them belong to the first year, 29% of them belong to the second year and 24% of them belong to the third year of training.Only a quarter of them had completed rotations in Pediatric Pulmonology for at least two weeks at the time of the survey. Three questions related to identifying at risk groups, four questions related to identification of the signs and symptoms, and three questions related to the diagnostic criteria and five questions related to the treatment and follow up of OSA.

46% of the residents accurately answered the questions related to screening and identifying children at risk of OSA. 57% of them identified the signs and symptoms of OSA in children.41% of them answered the questions related to diagnosis appropriately and 49% had correct responses for the questions related to treatment of OSA and follow up.

Conclusion

Less than 50% of the pediatric trainees could accurately identify the at risk groups and symptoms of OSA. These pediatric trainees who are future pediatricians form the referral source for children with OSA and educating them is vital.This reemphasizes the need for the pediatric training programmes to include mandatory training modules related to Pediatric sleep disorders, OSA in particular in the pediatric core curriculum.

Support

None
1181 Community-based Organizations Seek Sleep Health Education
Authors: Fleshman C , Wolfson A , Ripple C H , Bonuck K , Hale L , Donskoy I , Robbins R , McGlinchey E , Jean-Louis G , Owens J
Published: May 2020

Introduction

Increasing attention to the importance of sleep among children raises questions about how to implement accessible, effective interventions. Part of answering those questions rests in determining interest in and demand for programming. Pajama Program (PJP), a 501(c)(3), works with nearly 4,000 community-based organizations (CBOs) nationally that work with children exposed to adversity, including: foster care/child welfare; shelters; low-income schools, after-school, and early care and education programs; and social-service providers. Anticipating its launch of sleep health education programs, PJP and its Good Night Advisory Council of sleep experts designed a CBO needs assessment.

Methods

The survey was distributed electronically to staff at 3,911 CBOs; 1,635 organizations responded (42%).

Results

Across respondents, 65% work with children birth to 18 in settings that were non-residential (39%), residential (18%), or both (43%); most (91%) worked with participants for over one month. CBOs included child welfare/foster care (20.6% of respondents); transitional housing/shelter (20.5%); social services (15.6%); and early care and education (12.7%). Interest in sleep health education was high across all program types: 80 to 89% of programs within each type wanted information for staff and/or caregivers, specifically handouts (among 93% of programs), articles (88%), videos (85%), and workshops (70%). At least 90% of respondents who provided early care and education, parenting, and crisis services were interested in sleep health education for program staff. These program types also had high interest in sleep health education for caregivers, as did child welfare/foster care, school/after school, and shelters (all at least 90% of respondents).

Conclusion

The CBOs in this sample recognize sleep is an issue among the children they serve, but most did not have access to information on sleep health. These results establish the need for sleep health education and suggest preferred modalities. The project is a model for partnerships involving researchers, nonprofits, and community-based organizations.

Support

Funding for this project was provided by Pajama Program, a national 501(c)(3) non-profit.
0120 Association Between Sleep Duration and Daytime Memory and Cognition Depends on Sleep Quality: Data from the 2017 Israel Social Survey
Authors: Wills C C , Rosenberg E A , Perlis M L , Parthasarathy S , Chakravorty S , Grandner M A
Published: May 2020

Introduction

This study examines the relationship between sleep duration, sleep disturbance, and cognitive problems in a representative sample of the Israeli population.

Methods

7,230 Israelis responded to an Israeli Bureau of Statistics population-based survey of households from the year 2017. All variables were self-reported. Outcome of interest was difficulty with memory/concentration (none, mild, or severe). Predictors included previous month sleep duration (<=5hrs, 6hrs, 7hrs [reference], 8hrs, or >=9hrs) and sleep disturbance (none [reference], mild [1/week], moderate [2–3/week], or severe [>3/week]). Covariates included age, sex, ethnic group, and financial status. Multinomial logistic regressions evaluated the relationships between variables, and post-hoc testing identified relationships within specific subgroups.

Results

72.9% denied cognitive problems, 22.2% reported mild problems, and 4.9% severe problems. In adjusted analyses, Sleep <=5hrs and >=9hrs were associated with mild (RRR=1.39, p<0.0005), (RRR=1.46, p=0.004) and severe (RRR=2.75, p<0.0005), (RRR=3.24, p<0.0005) cognitive problems, respectively. Mild, moderate, and severe sleep difficulties were associated with mild cognitive problems (RRR=2.09, p<0.0005), (RRR=2.22, p<0.0005), (RRR=2.44, p<0.0005), and severe cognitive problems (RRR=1.77, p=0.001), (RRR=3.04, p<0.0005), (RRR=4.22, p<0.0005), respectively. There was an interaction between sleep duration and sleep difficulties (p<0.05). Among those denying sleep difficulties, only >=9hrs of sleep was associated with cognitive problems. Among those with mild, moderate, and severe sleep difficulties, both short and long sleep were associated with cognitive problems.

Conclusion

In an Israeli population sample, both sleep duration and quality were associated with cognitive problems. Among those with sleep difficulties, short and long sleep duration were associated with cognitive problems, but among those denying sleep difficulties, only long sleep was associated with cognitive problems. These results suggest that the impact of sleep loss on real-world cognition may also rely on the presence of poor sleep quality.

Support

Dr. Grandner is supported by R01MD011600
1193 Accuracy of a Commercial Wearable in Detecting Sleep Stages Compared to Polysomnography in Adults: Considering Sleep Classification Methods and Effects of Evening Alcohol Consumption
Authors: Menghini L , Alschuler V , Claudatos S , Goldstone A , Baker F , Cellini N , Colrain I , de Zambotti M
Published: May 2020

Introduction

Commercial wearable devices have shown the capability of collecting and processing multisensor information (motion, cardiac activity), claiming to be able to measure sleep-wake patterns and differentiate sleep stages. While using these devices, users should be aware of their accuracy, sources of measurement error and contextual factors that may affect their performance. Here, we evaluated the agreement between Fitbit Charge 2™ and PSG in adults, considering effects of two different sleep classification methods and pre-sleep alcohol consumption.

Methods

Laboratory-based synchronized recordings of device and PSG data were obtained from 14 healthy adults (42.6±9.7y; 6 women), who slept between one and three nights in the lab, for a total of 27 nights of data. On 10 of these nights, participants consumed alcohol (up to 4 standard drinks) in the 2 hours before bedtime. Device performance relative to PSG was evaluated using epoch-by-epoch and Bland-Altman analyses, with device data obtained from a data-management platform, Fitabase, via two

methods

one that accounts for short wakes (SW, awakenings that last less than 180s) and one that does not (not-SW).

Results

SW and not-SW methods were similar in scoring (96.76% agreement across epochs), although the SW method had better accuracy for differentiating “light”, “deep”, and REM sleep; but produced more false positives in wake detection. The device (SW-method) classified epochs of wake, “light” (N1+N2), “deep” (N3) and REM sleep with 56%, 77%, 46%, and 62% sensitivity, respectively. Bland-Altman analysis showed that the device significantly underestimated “light” (~19min) and “deep” (~26min) sleep. Alcohol consumption enhanced PSG-device discrepancies, in particular for REM sleep (p=0.01).

Conclusion

Our results indicate promising accuracy in sleep-wake and sleep stage identification for this device, particularly when accounting for short wakes, as compared to PSG. Alcohol consumption, as well as other potential confounders that could affect measurement accuracy should be further investigated.

Support

This study was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) grant R21-AA024841 (IMC and MdZ). The content is solely the responsibility of the authors and does not necessarily represent the official views the National Institutes of Health.
1194 An Open-Label Study of Treating Traumatic Nightmares With an Investigational Smartwatch Based System
Authors: Stephan J T , Davenport N , Evans-Lindquist M K , Hiltner R K , Karlin D R
Published: May 2020

Introduction

Nightmares are a common problem affecting 2-8% of the general population with the prevalence of comorbid nightmares in those with post-traumatic stress disorder (PTSD) being significantly higher at 72%. The negative sequelae of nightmares are myriad including impaired quality of life, sleep deprivation, insomnia, daytime sleepiness, fatigue, and suicidal ideation. This study investigated a novel approach for the treatment of nightmare disorder in military veterans.

Methods

All participants in this study were veterans receiving care at the Minneapolis Veterans Affairs Health Care System (VAHCS), diagnosed with PTSD, and had self-reported nightmares. At the baseline assessment, eligible participants were given a digital smartwatch preloaded with an application designed to arouse but not awaken the user out of the nightmare. Paired t-test analysis was used to compare the participants’ baseline and follow-up responses.

Results

A significant decrease in participant Pittsburgh Sleep Quality Index (PSQI) scores (13.6 to 7.4, p < 0.001), PTSD Checklist for DSM-5 (PCL-5) scores (45.8 to 25.1, p < 0.0025) and Patient Health Questionnaire (PHQ-9) scores (12.2 to 6.1, p < 0.002) was observed over the sixty day trial. All 9 participants experienced a decrease in the Epworth Sleepiness Scale (ESS) upon completion of the trial, with an average decrease of -2.5 ± 1.4.

Conclusion

These results demonstrate that a novel digital therapeutic smartwatch application is effective in improving sleep quality, reducing the burden associated with PTSD symptoms, and lowering depressive symptoms in those with nightmare disorder within an open label study. These results have initiated further investigation into efficacy of digital therapeutic smartwatch applications in nightmare intervention and improved sleep quality.

Support

NightWare, Inc.
0121 Effect of Total Sleep Deprivation on Word Recognition of Previously Studied Words with Different Emotional Valence
Authors: Hudson A N , Whitney P , Hinson J M , Hansen D A , Van Dongen H , Honn K A
Published: May 2020

Introduction

Stimuli with an emotional valence tend to produce better recognition from memory than neutral stimuli. Sleep loss is believed to increase reactivity to negative stimuli, as compared to positive stimuli, which may comparatively enhance subsequent recognition from memory for negative stimuli. We investigated the impact of total sleep deprivation (TSD) on recognition accuracy for words with different emotional valence using the Affective Item Source Memory Task (AISM).

Methods

N=14 adults (ages 21–39; 7 females) completed a 4-day in-laboratory study with 9h baseline sleep (22:00-07:00), 39h acute TSD, and 9h recovery sleep. The AISM was administered at 16:30 during baseline and after 34h TSD. During a 5min study phase, participants heard a list, twice, of 20 positive, 20 negative, and 20 neutral words spoken with a male or female voice. During an immediately subsequent 8min recognition phase, participants heard 120 words (50% new) and judged whether each word had been presented in the study list (item memory). For words judged to have been presented previously, participants indicated whether those were presented by a female or male speaker (source memory).

Results

Mixed-effects ANOVA showed effects of session (p<0.001) and valence (p<0.001) on item memory. At baseline, accuracy was greatest for neutral and positive words compared to negative words. During TSD, accuracy declined for all three valences, and no interaction of session by valence was detected. No effects of TSD or valence on source memory were observed.

Conclusion

Sleep deprivation reduced item memory for words of all valence types. However, there was no comparatively greater impact on item or source memory for negative words nor any differential effect of TSD for different valences. Whether our results would hold with longer time intervals between task phases or an intervening sleep period remains to be determined.

Support

Jazz Pharmaceuticals
1200 Seasonal Variation In RHR Measured By A Wearable Ring
Authors: Koskimaki H , Kinnunen H , Ronka S , Smarr B
Published: May 2020

Introduction

Resting heart rate (RHR) associates with cardiovascular fitness, acute and chronic health status, and mental stress. Nightly sleep provides an excellent measurement time because ambient conditions are constant and confounding factors are controlled. Relatively low RHR is seen as a mark of better health, performance, and recovery levels. Over the past few years, development of wearable devices has made it possible to follow the course of individual RHR as long-term time series, which enables observation of how behavioural, societal and seasonal factors affect RHR at population scale.

Methods

In this study, mean individual nightly RHR of each calendar day was studied from all Oura ring users starting from July 2016 (n=1415) and ending at March 2019 (n=57.278). The subjects were 36 percent female and 64 percent male, mostly in working age: 20-30-year (15%), 30-50 years (60%), and 50-60-years (16%). Majority of the ring users live in the Northern Hemisphere, and minority (n = 1.500) in the Southern Hemisphere.

Results

With users from Northern Hemisphere, the yearly RHR peaks in December and lowers between April and August. The magnitude of seasonal variation was observed to be roughly 2 bpm: In 2018, March averages 1.6 bpm higher than August, and December averages 2.1 bpm higher than August. Looking at subjects from New Zealand and Australia, exactly opposite phase was observed, so that both hemispheres followed the length of the day. Apparently, RHR yearly fluctuations are based on biological factors like Sun light and ambient temperature. Both hemispheres also demonstrated weekly peaks at weekends (+1.6 bpm), and a most district peak at each New Year night.

Conclusion

The long-term RHR was shown to be affected by biological, societal, and lifestyle factors. We find that long-term wearable data from the Ring can reveal health related physiological effects across large populations, including seasonality.

Support

This work was supported by Oura Health Ltd.
1202 Validation Of A Novel Wearable Home Sleep Testing Device For Assessment Of Obstructive Sleep Apnea
Authors: Yeh E , Wong E , Strohl K , Gu W , Tsai C , Leung L , Yar W , Chiang A
Published: May 2020

Introduction

There is a substantial need for an accurate and easy-to-use tool for obstructive sleep apnea (OSA) assessment. Belun Ring Platform (BRP), a novel photoplethysmography (PPG)-based home sleep apnea testing system with a proprietary deep learning algorithm, has been shown to have good sensitivity and specificity in predicting OSA in subjects without significant comorbidities and medications known to affect heart rate (HR). In this study, we further tested its performance in subjects referred for in-lab polysomnography (PSG) assessment of sleep disorders without excluding those with non-arrhythmia comorbidities or the subjects on HR-affecting medications.

Methods

PSG was recorded simultaneously with the Ring in the sleep lab and the studies were manually scored by certified sleep technicians according to the AASM Scoring manual version 2.4. Exclusion criteria include age <18, unstable cardiopulmonary status, recent hospitalization within 30 days, significant arrhythmias, baseline HR <50 or >100, home oxygen use, pacemaker/defibrillator, post-cardiac transplantation or Left ventricular assist device.

Results

A cohort of 78 individuals (26 males and 52 females, age 50.5) were studied with 26 taking HR-affecting medications. Of these, 35 (45%) had AHI < 5; 14 (18%) had AHI 5-15; 15 (19%) had AHI 15-30; 14 (18%) had AHI > 30. The Ring-REI correlated well with the PSG-AHI (r =0.83, P <0.001). The accuracy, sensitivity, specificity in categorizing AHI >15 were 0.808, 0.931, and 0.735 respectively. The positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio were 0.675, 0.947, 3.509, and 0.094 respectively. The use of HR-affecting medications did not significantly affect the sensitivity and specificity of BRP in predicting OSA (P =0.16 and 0.44 respectively).

Conclusion

BRP is promising as a reasonable tool for OSA assessment and can potentially be incorporated into a broad spectrum of clinical practices for identification of patients with OSA.

Support

This study is supported by a Grant from Belun Technology Company Limited.
1205 Activity Trackers As A Tool In Sleep Research: Determining Discrepancies In Trackers Vs. PSG
Authors: Pollet E P , Pollet D P , Long B , Qutub A A
Published: May 2020

Introduction

Fitness-based wearables and other emerging sensor technologies have the potential to track sleep across large populations longitudinally in at-home environments. To understand how these devices can inform research studies, limitations of available trackers need to be compared to traditional polysomnography (PSG). Here we assessed discrepancies in sleep staging in activity trackers vs. PSG in subjects with various sleep disorders.

Methods

Twelve subjects (age 41-78, 7f, 5m) wore a Fitbit Charge 3 while undergoing a scheduled sleep study. Six subjects had been previously diagnosed with a sleep disorder (5 OSA, 1 CSA). 4 subjects used CPAP throughout the night, 2 had a split night (CPAP 2nd half of the night), and 6 had a PSG only. Activity tracker staging was compared to 2 RPSGTs staging.

Results

Of the 12 subjects, eight subjects’ sleep was detected in the activity tracker, and compared across sleep stages to the PSG (7 female, 1 male, ages 41-78, AHI 0.3-87, RDI 0.5-94.4, sleep efficiency 74%+/-18, 4 PSG, 1 split, 3 CPAP). The activity tracker matched either tech 52% (+/- 13). The average difference in score tech and activity tracker staging for sleep onset (SO) was 16 +/- 15 minutes and wake after sleep onset was 43.5 +/- 44 minutes. Sensitivity, specificity, and balanced accuracy were found for each sleep stage. Respectively, Wake: 0.45+/-0.27, 0.97+/-0.03, 0.71+/-0.12, REM: 0.41+/-0.30, 0.90+/-0.06, 0.60+/-0.28, Light: 0.71+/-0.09, 0.58+/-0.19, 0.65+/-0.10, Deep: 0.63+/-0.52, 0.88+/-0.05, 0.59+/-0.49.

Conclusion

From this study of 12 subjects seen at a sleep clinic for suspected sleep disorders, activity trackers performed best in wake, REM and deep sleep specificity (>=88%), while they lacked sensitivity to REM and wake (<=45%) stages. The tracker did not detect sleep in 4 subjects who had elevated AHI or low sleep efficiency. Further analysis can identify whether discrepancies between the Fitbit and PSG can be predicted by distinct patterns in sleep staging and/or identify subject exclusion criteria for activity tracking studies.

Support

This project in on-going with the support of Academy Diagnostics Sleep and EEG Center and staff.
1217 Obesity Hypoventilation Syndrome in a 4-Year-Old Child
Authors: Wang Grace , Guevarra Jay , Bronstein Jason
Published: May 2020

Introduction

four-year-old boy with morbid obesity was referred to pediatric sleep for nocturnal hypoxemia during inpatient admissions. He was found to have daytime hypoventilation, likely secondary to obesity hypoventilation syndrome (OHS).

Report of Case

During two inpatient admissions (wheezing, gastroenteritis), he desaturated to the 70s during sleep. At home, he received blow-by oxygen as he could not tolerate other interfaces. He underwent adenotonsillectomy. However, snoring, daytime sleepiness, hyperactivity and aggressive behavior persisted.

Birth history was unremarkable, though he became progressively more obese over time. His father had obesity and obstructive sleep apnea. Physical exam was notable for elevated blood pressure of 122/68 mmHg (above 99th percentile), weight and height above 99th percentile, and BMI of 32 kg/m2 (z-score ~4.3).

Despite extensive counseling, family declined polysomnography and labs. Awake end-tidal CO2s were elevated at 47 mmHg. Echocardiogram showed half-systemic PA pressures, right ventricular hypertrophy, and right atrial dilation.

Family began desensitization protocol in preparation for future PAP therapy and polysomnography. Pediatric endocrinology consultation revealed low suspicion for hormonal/metabolic concerns. He entered a pediatric weight loss program.

Conclusion

This 4-year-old boy demonstrated daytime hypoventilation, systemic and pulmonary hypertension, likely consequences of his severe obesity. OHS is defined as BMI >95th percentile in children and awake hypercapnia (PaCO2 > 45 mmHg) in absence of alternative hypoventilation causes (e.g. pulmonary, cardiac, neurologic, pharmacologic). Presenting symptoms may include hypersomnolence, morning headaches, cognitive deficits, and signs of cor pulmonale1. The literature consists primarily of case reports; prevalence of pediatric OHS is unknown. Obesity afflicts 18.5% of children in the United States2. Given the severity of OHS sequelae, maintaining a high index of suspicion is crucial. Consider further work-up in patients with unexplained low oxygen saturations, signs of pulmonary hypertension (unexplained dyspnea on exertion, pedal edema), polycythemia, and elevated bicarbonate1.
1231 Slurred Speech- Unusual Presentation of Cataplexy in Childhood Narcolepsy
Authors: Reddy Abhishek , Maddox Mary Halsey
Published: May 2020

Introduction

Narcolepsy, a chronic neurological disorder of excessive daytime sleepiness, cataplexy, sleep paralysis, and hypnagogic/hypnopompic hallucinations, frequently presents in late childhood/early adolescence. Cataplexy, the most specific symptom, presents as transient loss of muscle tone causing weakness. Approximately 80% of children with narcolepsy present with cataplexy1.

Report of Case

Eight year old African American boy presented to sleep clinic with concerns for excessive daytime sleepiness and slurred speech. Teachers initially referred to speech therapy because of slurred speech. There, speech got noticeably worse with frustration. Subsequently, sleepiness developed, and his pediatrician referred him for polysomnogram (PSG) and Mean Sleep Latency test (MSLT). After unremarkable PSG, MSLT demonstrated mean sleep latency of 10 minutes with no SOREM sleep. Patient came for evaluation in Sleep Medicine clinic where family reported worsening speech with extreme emotions and profound sleepiness, Epworth of 20. Because of the presentation and lack of REM sleep on MSLT, brain MRI was ordered and was normal. HLA typing for narcolepsy positively showed HLA haplotype associated with narcolepsy. Patient was diagnosed with narcolepsy with cataplexy and started on Modafinil 50 mg. Modafinil was progressively increased to 200 mg in a.m. and 100 mg at noon. To address cataplexy symptoms, he started Venlafaxine 12.5 mg and increased to 25 mg. Epworth score improved on Modafinil, his cataplexy symptoms, including speech difficulties, subsided on Venlafaxine. Patient’s communication improved, as did school performance and social life, and patient is currently thriving in 10th grade. Current Epworth is 5 and current medications include Modafinil 200 mg in the morning, 100 mg at noon and Venlaflaxine 25 mg at night.

Conclusion

This case report highlights the importance of recognizing unusual presentations of cataplexy and the impact of treatment. These symptoms can be easily missed and erroneously attributed to developmental delay or behavioral issues.
1235 REM Sleep Associated Hypoventilation
Authors: Rojanapairat Oragun , Beggs Abigail , Chang Melisa , Thomas Aaron
Published: May 2020

Introduction

Hypoventilation is a spectrum of respiratory disorders that is frequently found in patients with chronic obstructive pulmonary disease, restrictive lung disease (eg obesity, neuromuscular, severe interstitial lung disease, and chest wall disease), chronic sedative use, and hypothyroidism. Rapid eye movement (REM) sleep hypoventilation may be the first manifestation of hypoventilation prior to development of non-REM sleep hypoventilation and eventual awake alveolar hypoventilation.

We present a case of hypoventilation during REM sleep with mild restriction on pulmonary function testing, prior to the development of obesity hypoventilation syndrome (OHS).

Report of Case

68-year-old male with past medical history of diastolic heart failure, class Ill obesity (BMI 46), hypertension, chronic kidney disease lllb, and diabetes mellitus underwent split night polysomnography for evaluation of snoring, witnessed apneas and excessive daytime sleepiness. The study was significant for an apnea hypopnea index of 105/hour, and REM sleep sustained desaturation to a nadir of 72% without apneas or hypopneas, suspicious for hypoventilation. The derangements during REM sleep did not correct during PAP titration despite CPAP and supplemental oxygen. End tidal capnography was not available for the study. Follow up PFT demonstrated normal spirometry, mild restrictive lung volumes, ERV 27%, and severely depressed DLCO which corrected for alveolar volume. Daytime arterial blood gas did not reveal hypercapnia or hypoxemia (7.37/39/78/23). He underwent successful nocturnal titration with average volume assured pressure support with the final settings of IPAP 24-30, EPAP 20, VT 560 (8 ml/kg IBW), rate of 12 breaths per minute and no supplemental oxygen.

Conclusion

This patient demonstrates REM sleep hypoventilation without overt OHS during all stages of sleep, which likely would progress to OHS over time. OHS is associated with increased rates of chronic heart failure, pulmonary hypertension, hospitalizations for respiratory failure, and mortality. Early recognition and treatment are important in improving morbidity and mortality.
1251 Management Considerations in an Adolescent with Kleine-Levin Syndrome
Authors: George Alisha , Chopra Nikki , Afolabi-Brown Olufunke
Published: May 2020

Introduction

Kleine-Levin syndrome (KLS) is a central disorder of hypersomnolence characterized by recurrent episodes of excessive sleepiness and sleep duration, along with varying degrees of cognitive dysfunction, altered perception, disinhibited behaviors, and eating disorders. Individuals with KLS are reported to be asymptomatic between episodes. KLS has a male preponderance with symptom onset typically during adolescence. A genetic basis has been suggested due to clustering of cases in certain ethnic populations and families. Purported triggers include viral infections, physical exertion, head trauma, and sleep deprivation.

Report of Case

A 15-year old male developed sudden-onset hypersomnolence with sleep duration of 20-23 hours per day. While awake, he had altered mentation and personality changes; parents reported aggression, hypersexual behaviors, hyperphagia, and derealization. During this 2-week episode, he underwent an extensive, yet unrevealing work-up and eventually experienced symptom resolution. Over 16 months, he has had 5 discrete episodes of hypersomnolence with abnormal wake behaviors, all preceded by viral illnesses and/or significant physical exertion and felt to be consistent with KLS. He has reported ongoing, albeit less severe, excessive daytime sleepiness between episodes. Polysomnography and multiple sleep latency testing, both performed while asymptomatic, were largely unremarkable. As episodes have decreased in duration and intensity over time, trials of lithium and stimulant therapy have been deferred per family preference, though the patient was started on a short course of azithromycin during his last episode for anti-inflammatory properties. Notably, the patient has developed significant anxiety due to fear of recurrence and is now engaged in therapy.

Conclusion

KLS is a rare disorder that tends to have shorter and less severe manifestations over time. To date, very few systematic studies have been done to evaluate potential treatments, such as lithium and macrolide therapy. Avoidance of triggers and adequate sleep are encouraged, and mental health support should also be considered.
1254 Sleep Related Hallucinations As Presenting Symptom Of Dementia With Lewy Bodies: A Case Report
Authors: Mallapareddi Arun Nag Santhosh , Judd Brooke
Published: May 2020

Introduction

Visual hallucinations are one of the prominent symptoms of Dementia with Lewy Bodies (DLB). These hallucinations are often vivid and bothersome to patients. There is limited literature regarding patients with DLB presenting with hypnopompic/hypnagogic hallucinations as the initial chief complaint. We report a case of a 77 year old female patient presenting to sleep medicine clinic with history of newer onset sleep-related hallucinations as well as concerns for sleep-disordered breathing, but was subsequently diagnosed with DLB.

Report of Case

77 year old female patient initially presented to PCP with a one year history of disturbing hallucinations while falling asleep. Additionally, patient had excessive daytime sleepiness along with family history significant for obstructive sleep apnea (OSA). Given the concerns of parasomnias and OSA, patient was referred to Sleep Medicine clinic. On presentation, patient continued to have hypnogogic/hypnopompic hallucinations along with symptoms concerning for OSA. An in-lab polysomnogram (PSG) was performed, which demonstrated evidence of a moderate to severe degree of OSA. Patient reported hypnopompic hallucination on the night of PSG. CPAP therapy was initiated. Despite treatment, her sleep-related hallucinations continued. She also began to have daytime hallucinations as well as cognitive impairment. Due to progression of symptoms despite treatment of OSA, neurology consultation was recommended. Per neurology evaluation, patient received PET CT metabolites which demonstrated changes consistent with DLB.

Conclusion

DLB should be considered as one of the differential diagnosis in patients presenting with hypnagogic/hypnopompic hallucinations especially if the patient has other signs of dementia.
1255 Previously unknown ventricular arrhythmia in a globally delayed pediatric patient with tuberous sclerosis
Authors: Madhavarapu Sumith , Casturi Lata , Malhotra Sonal
Published: May 2020

Introduction

We present a case of previously unknown ventricular ectopy in a pediatric patient who is globally delayed. As the patient is non-verbal, it is possible the patient may have ultimately experienced heart failure or a lethal arrhythmia were it not for the polysomnogram (PSG).

Report of Case

A four year old female with Tuberous Sclerosis (TS) was referred to our pediatric sleep center for snoring. Her past medical history includes intracardiac tumors, daily seizures, and global developmental delay. Initial PSG showed moderate obstructive sleep apnea defined by an obstructive Apnea-Hypopnea Index of 6.89 and no cardiac arrhythmias. Positive airway pressure titration study was performed one year later. Premature ventricular contractions were noticed during the setup while patient was awake. Intermittent couplets and triplets occurred during sleep as well as a prolonged run of bigeminy that initiated during a period of wake after sleep onset and persisted into non-rapid eye movement sleep. She was escorted to the emergency room where a 12-lead electrocardiogram (EKG) showed sinus rhythm with non-specific interventricular conduction delay and right ventricular hypertrophy. She was discharged with a Holter monitor and subsequent analyses was concerning for frequent ventricular couplets and non-sustained runs of ventricular tachycardia. She required admission to initiate anti-arrhythmic therapy. Imaging revealed stable intracardiac tumors, but revealed scarring within sites of intramyocardial lesions. She failed different anti-arrhythmic agents before settling with amiodarone.

Conclusion

Sleep disordered breathing (SDB) can cause or worsen cardiac arrhythmias. This case highlights the importance of routine surveillance in patients with both known cardiac disease who have or are at risk of having significant cardiac arrhythmias and suspected SDB. Additionally, current guidelines for TS patients recommend EKG once every 3 to 5 years. This case may also highlight the importance of increased cardiac surveillance in this population group.
1267 Severe Obstructive Sleep Apnea in Patient with Large Multinodular Goiter
Authors: Macias Maria , Agrawal Ritwick
Published: May 2020

Introduction

Obstructive sleep apnea (OSA) is characterized by upper airway narrowing or closure during sleep. Age and obesity are common contributors, but large thyroid goiters have also been shown to contribute to OSA.

Report of Case

We report a case of a 65 year-old-man (BMI 47 kg/m2) who presents with dyspnea and intolerance to PAP therapy. He had a slowly progressive goiter which was first noticed at age 45. He declined thyroidectomy due to concern of complications. A recent CT reported markedly enlarged thyroid (right thyroid lobe 10.9 x 8.5 cm, left thyroid lobe 7.0 x 6.5 cm and thyroid isthmus 4.0 cm). It had extension into the superior mediastinum and circumferential encasement of the subglottic trachea with effacement involving the lateral walls. In past, he was non-tolerant with BPAP therapy due to high pressure settings (24/14 cm water). Multiple attempts to desensitize were not successful.

Most recent diagnostic polysomnography reported an apnea hypopnea index (AHI) of 35.2/ hour, oxygen nadir of 77%. Supplemental oxygen was titrated upward to 5 LPM due to persistent oxygen desaturations in the absence of obstructive events. In the PAP titration study, despite multiple efforts and patient’s poor tolerance, the titration study was suboptimal. He was titrated to BPAP 15/11 and still had a residual AHI of 28.4/hour.

Considering these findings thyroidectomy was again discussed which could potentially reduce OSA severity significantly. After long discussion, unfortunately the patient declined this recommendation. Other surgical options such as hypoglossal nerve stimulation was not technically feasible due to large goiter. Ultimately, he decided to remain on nightly supplemental oxygen.

Conclusion

Large multinodular goiters with retropharyngeal extension can worsen obstructive sleep apnea and pose unique diagnostic and therapeutic challenges. In this case, thyroidectomy may have led to improvement of degree of sleep disordered breathing.