bluuebunny/crossref_metadata_2025 huggingface dataset:
1064 Sleep Patterns Among Urban Haitian Earthquake Survivors Who Experienced the Trauma of Nonpartner Sexual Violence: A Latent Class Analysis Approach
Authors: Rahill G J , Joshi M J , Blanc J , Rice C
Published: May 2020

Introduction

Sleep health is crucial to recovery from trauma. Haiti’s Cité Soleil residents (approximately 350,000) live in extreme poverty and regularly experience or witness life-threatening events, including gang and non-partner sexual violence (NPSV). Differences in levels of sleep disturbance among men and women in resource-limited settings who survive disasters as well as NPSV are understudied. In a larger study in which we investigated trauma symptoms among 2010 Haiti earthquake survivors via the Trauma-symptom checklist -40 (N=526; 290 males, 236 females), we also assessed self-reported frequency of sleep disturbance symptoms using the measure’s sleep disturbance subscale, comparing the latter by NPSV victim status and by gender.

Methods

SAS enabled 3-Class Latent Class Analysis (LCA): Class 1 (“No symptoms”), Class 2 (“Some symptoms”), Class 3 (“All Symptoms)”.

Results

Distribution of class membership differed by gender (χ2 = 23.9, df = 2, p < .0001). Proportions of respondents assigned to the three classes differed between genders (Females: Class 1, 29.2%; Class 2, 35.5%; Class 3, 35.3%); Males: Class 1, 25.7%; Class 2, 54.4%; Class 3, 19.9%). NPSV status influenced levels of sleep disturbance symptoms, and membership distribution differed across classes by gender (χ2 = 23.9, df = 2, p < .0001). Class 2 membership was greater for men (65.9%), but class 3 membership was greater for women (59.3%). Women who experienced NPSV were statistically more likely members of sleep disturbance symptom classes (Class 2 or Class 3) than Class 1 (χ2= 14.9, df = 2, p = 0.0006). No difference was found in Class membership for men reporting NPSV (χ2= 1.6, df = 2, p = 0.45).

Conclusion

Investigating the sleep health of Cité Soleil residents adds to the body of literature on sleep health, sleep equity and gendered vulnerability. Findings suggest women in post-disaster settings, especially in LMICs, are at even greater risk for a variety of adverse health outcomes and for suboptimal sleep, even when local men have similar traumatogenic experiences, such as NPSV. Girls and women in post-disaster LMIC settings need trauma-informed sleep health promotion and NPSV-prevention.

Support

N/A
1081 Associations Among REM Density And Parasympathetic Activity, Nightmares, And Hyperarousal In Trauma-exposed Individuals
Authors: Oliver K I , Hinton J A , Daffre C , Dominguez J , Seo J , Gannon K , Lasko N B , Pace-Schott E F
Published: May 2020

Introduction

Individuals with posttraumatic stress disorder (PTSD) exhibit autonomic hyperarousal and nightmares. We hypothesized that REM density (REMD) and REM heart rate variability would predict self-reported hyperarousal, nightmares, and PTSD diagnosis in trauma-exposed individuals.

Methods

Ninety-nine individuals (aged 18-40, 68 females) exposed to a DSM-5 PTSD criterion-A trauma within the past two years (48 meeting PTSD criteria) completed a night of ambulatory polysomnography (PSG) preceded by an acclimation night. REMD in scored sleep recordings were computed using the Matlab program written by Benjamin Yetton. Indices of parasympathetic tone during REM were computed using Kubios software and included Average Root Mean Square of the Successive Differences (RMSSD) and High Frequency power (HFpower). Participants completed two weeks of sleep diaries with nightmare questionnaire and completed the Clinician-Administered PTSD Scale (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5). Hyperarousal-item scores were computed from the PCL-5 without the sleep item (PCLhyp) and from the CAPS-5 (CAPShyp), and these scores (with their sleep items) were combined into a Composite Hyperarousal Index (CHI). Nightmare rate was the proportion of sleep diaries reporting a nightmare. Simple regressions measured associations among REMD, REM parasympathetic indices, hyperarousal measures, and nightmare rate.

Results

REMD did not significantly predict PTSD diagnosis or hyperarousal scores but did predict decreased parasympathetic activity for both RMSSD (p= 0.002, R= -0.316) and HFpower (p= 0.016 R= -0.250). REMD predicted increased nightmare rate (p= 0.011 R= 0.262). Parasympathetic tone was negatively correlated with CAPShyp, PCLhyp, and CHI for both RMSSD (p= 0.04, 0.011, <0.000, respectively) and HFpower (p= 0.051, 0.021, 0.010, respectively). Lower parasympathetic tone also predicted PTSD diagnosis with both RMSSD (p=0.012, t=2.559) and HFpower (p=0.010, t=2.627), but did not predict nightmare rate.

Conclusion

REMD predicted decreased parasympathetic tone and higher nightmare rate. Parasympathetic tone, but not REMD, predicted hyperarousal and PTSD diagnosis.

Support

R01MH109638
1124 Central Sleep Apnea and Traumatic Brain Injury: A NIDILRR and VA TBI Model System Study
Authors: Gulati G , Schwartz D J , Nallu S , Bell K , Wittine L , Fann J R , Nakase-Richardson R
Published: May 2020

Introduction

Sleep-related breathing disorders are common after TBI. To date, two single site studies have reported divergent findings in post-TBI patients with one reporting predominantly obstructive sleep apnea (OSA, Holcomb et al., 2016) and the other central sleep apnea (CSA, Webster and Bell, 1998). The purpose of this analysis is to explore prevalence, demographics, and injury characteristics of patients with a clinical diagnosis of CSA in a recently-completed multicenter comparative-effectiveness trial during inpatient rehabilitation following moderate to severe TBI.

Methods

Participants in a six-center diagnostic comparative effectiveness trial underwent Level-1 polysomnography (PSG) during inpatient rehabilitation for TBI. Studies were scored at a centralized scoring center by one of two certified PSG technicians with final interpretation by a board-certified sleep medicine physician.

Results

21 of 248 (8.5%) participants evidenced elevated CSA indices >5. Predominant CSA was rare (n=3 [1.2%], age range: 36-59; 100% male; 33-52 days post-TBI). One participant was on opioid, anti-depressant and antiepileptic drugs, one was on an antiepileptic, and another was on an opioid. PAP therapy was not initiated during PSG thus there was no treatment-emergent CSA. All had a central apnea-hypopnea index (AHI) in the moderate to severe range (29-49). Two out of the three had a GCS <8 and one participant had a GCS of 14.

Conclusion

In this multi-center clinical trial, predominant CSA was rare. The common practice of reducing polypharmacy in order to minimize sedation and optimize mental status in specialized inpatient brain-injury rehabilitation programs may contribute to the low CSA incidence in this cohort. Attention to medication side-effects and their influence on sleep-related breathing should be routinely considered.

Support

PCORI (CER-1511-33005), GDHS (W91YTZ-13-C-0015) for DVBIC, NIDILRR (90DPTB0008-03-00; 90DPTB0013-01-00).
1129 Sex Dependent Effects on Sleep Architecture After Traumatic Brain Injury: Impact on Outcome
Authors: Griesbach G S , Robinson S E , Howell S
Published: May 2020

Introduction

Traumatic Brain Injury (TBI) is frequently associated with problems with sleep and diurnal somnolence. After determining if subjective somnolence was associated with sleep disturbances, we investigated if alterations in sleep architecture were associated with cognitive, social and emotional health in a sex dependent manner. For patients receiving positive airway pressure (PAP) treatment, we determined if lack of compliance contributed to cognitive and quality of life issues.

Methods

Adult TBI subjects (n=57) were assessed via overnight polysomnography. Mean age was 41 years and mean TBI chronicity was 2.5 years. Overall level of disability was determined by the Mayo Portland Inventory II. Sleep measures included slow wave sleep (SWS), REM latency, percent time in all sleep stages, apnea/hypopnea index, wake after sleep onset (WASO), and arousal index. Outcome measures were the California Verbal Learning Test (CVLT), Montreal Cognitive Assessment (MoCA), Trails A and B, Beck Depression Inventory, and Neuro-QoL.

Results

No sex effects for reporting somnolence were found. Besides being associated with increased subjective anxiety and stigma, somnolence was associated with increased arousals, decreases in SWS and higher incidence of REM AHI. WASO and number of arousals had a negative impact on the amount of SWS and sleep efficiency. Men spent significantly more time in REM sleep, which was correlated with higher scores on the MoCA and CVLT. Women showed more disability. Longer latencies to SWS were associated with increased CVLT performance. AHI was associated with increases in emotional/behavioral dyscontrol, fatigue and self-reported sleep disturbance. All effects were statistically significant.

Conclusion

Female TBI patients show significant impairments in REM sleep, which may impact learning and memory. Sleep disturbances were associated with poorer cognitive performance and may ultimately affect outcome, as indicated by lower scores on quality of life measures.

Support

Centre for Neuro Skills
1149 A Pilot Quality Improvement (QI) Study To Assess Whether Bilevel Positive Airway Pressure (bipap) Support In Acute Ischemic Stroke Patients With Sleep Disordered Breathing, Can Improve Neurological Recovery During Acute Stroke Care
Authors: Nadhim A N , wong J , Gupta D , Suhan L , Siegel M , Bhat S , strauss S , Fourcard F , Pandya V
Published: May 2020

Introduction

Obstructive sleep apnea (OSA) has been associated with adverse outcomes in patients with stroke. While data is limited, it suggests that treatment of OSA may improve neurological recovery. With this quality improvement (QI) project, we aim to develop an interprofessional-team workflow process for screening and correction of OSA in acute ischemic stroke, with the goal to improve outcomes of neurological recovery.

Methods

This is an ongoing study to screen all eligible patients admitted to JFK Medical Center stroke unit, with MRI-proven Supratentorial acute ischemic stroke. The patients are screened using an overnight Pulse Oximetry test. A 3% oxygen desaturation index (ODI) of ≥10/hr or 4% ODI of ≥ 5/hr is considered at high risk for OSA. Such Patients will receive nocturnal Auto-adjusting BIPAP therapy during their acute care stay, for up to 5 days, for at least 4 hours per night. Eligible Patients who refused BiPAP therapy or were non-compliant will be considered as a controls. Baseline NIH stroke scale (NIHSS), and bilateral MCA mean flow velocity (MFV) in the morning, by transcranial doppler (TCD) will be assessed at baseline for cases and controls, and after BiPAP therapy, for the case group. The two groups of patients will also be compared in terms of Modified Rankin Scale at time of discharge and at phone follow-up after 6 weeks.

Results

Between Oct 17th, 2019 to current, 15 patients were admitted to the stroke unit with MRI confirmed stroke. Ages ranged from 34 - 88 years (average age 66.5 years). 8 patients (60%) were female. Of those, 6 patients consented to being screened for OSA. Of these, 1 had 4%ODI >5/hr, and therefore received treatment with BIPAP. However, compliance was < 4 hrs on 2 consecutive nights.

Conclusion

This is ongoing QI project and results will be available after few more months of continued recruitment.

Support

Auto-adjusting BIPAP machines were provided by RESMED.
1165 Online CME-Certified Case Challenges Improve Competence for the Diagnosis and Management of Pediatric Narcolepsy Among Pediatricians
Authors: Finnegan T , Murray C F , Hughes S , Maski K
Published: May 2020

Introduction

Narcolepsy is a chronic neurologic sleep disorder that typically starts in childhood. Symptoms of narcolepsy in pediatric patients can differ from adult onset narcolepsy and few treatment options are approved for pediatric narcolepsy. Given the challenges of recognizing the condition in children and selecting an appropriate therapeutic intervention, we investigated whether a case-based educational activity was able to improve the competence of pediatricians to accurately diagnose and manage narcolepsy.

Methods

An online, text-based educational intervention comprised of 2 patient case scenarios was developed. Using a “test and teach” approach, clinicians were presented with multiple-choice questions to evaluate their application of evidence-based recommendations. Each response was followed by detailed, referenced, feedback to teach. Educational effect was evaluated with a repeated-pairs pre- to post-assessment study design in which each individual learner acts as his/her own control. A chi-square test was utilized to identify whether proportions of correct answers at pre and post were significantly different. Cramer’s V was used to calculate the effect size of the intervention. Data were collected between April 20, 2019 and September 17, 2019.

Results

The education resulted in an extensive educational effect for pediatricians (n=125; V =.424). Significant improvements were observed in several topics (P <.05 for all comparisons) including: the use of hypocretin cerebrospinal fluid testing as a diagnostic tool for patients with symptoms suggestive of type 1 narcolepsy; appropriate guidance to transition patients with type 1 narcolepsy from one therapeutic regimen to another; and therapeutic selection for a patient with type 2 narcolepsy. Overall, participation in the education resulted in 34% of pediatricians reporting increased confidence in diagnosing and managing sleep disorders in children.

Conclusion

This study demonstrated the success of a targeted, online, interactive, case-based educational intervention on improving awareness among pediatricians regarding the diagnosis and management of narcolepsy. The results indicated that pediatricians would benefit from continued education on the care of patients with narcolepsy.

Support

Support for this program came from an unrestricted educational grant from Jazz Pharmaceuticals, Inc.
1171 Commonly Encountered Yet Not Confident: Graduate Psychology Students’ Experience and Confidence Managing Sleep Disturbances
Authors: Meaklim H , Monfries M , Rehm I C , Junge M , Meltzer L J , Jackson M L
Published: May 2020

Introduction

Trainee psychologists receive minimal sleep education during graduate psychology training programs, despite the frequent co-occurrence of sleep disturbances in mental health conditions. This study aimed to explore graduate psychology students’ experience working with sleep disturbances and their perceived skills and confidence to assess and treat sleep problems in clinical practice.

Methods

Australian graduate psychology students (N = 163) completed a novel survey developed specifically for the study, inquiring about their experience, skills and confidence to manage sleep disturbances in clinical practice. Students perceived skills to manage sleep disturbances were recorded on a 7-point Likert scale, where 1 = ‘strongly disagree’ and 7 = ‘strongly agree’. Students’ confidence to treat specific sleep disorders was also recorded.

Results

Sixty-eight percent of students reported having already worked with a client who experienced a sleep disturbance as part of their training. However, students’ perceived skills to assess and treat sleep disturbances were low. Only 14.9% ‘agreed’ or ‘strongly agreed’ that they had the skills to assess and diagnose common sleep disorders (M = 3.22, SD = 1.75). Similarly, less than a quarter of students ‘agreed’ or ‘strongly agreed’ that they felt comfortable using common sleep-related assessments (23.7%; M = 3.56, SD = 1.96) or empirically-supported interventions for sleep disturbances (22.6%; M = 3.71, SD = 1.83). The majority of students reported they were ‘not confident at all’ to treat parasomnias (80.3%); hypersomnias (77.9%); OSA (71.3%); circadian rhythm disorders (50%) or insomnia (41%).

Conclusion

Graduate psychology students report low levels of confidence in assessing and managing sleep disturbances in clinical practice, despite over two-thirds of students already working with clients experiencing sleep difficulties. Clinical training in the management of sleep disturbances is required for graduate psychology students.

Support

N/A
1175 Sleep Disorders Screening in Primary Care: Prevalence of Diagnosis and Treatment in the EMR
Authors: Klingman K J , Morse A , Williams N , Grandner M , Perlis M L
Published: May 2020

Introduction

Undetected and untreated sleep disorders likely precipitate or exacerbate medical and/or psychiatric illnesses. Given this, primary care is an ideal point for managing sleep disorders, yet prior research shows that PCPs diagnose and/or treat sleep disorders at rates far below population prevalences. The purpose of this study was to determine the current rate of detection and treatment of sleep disorders within primary care settings.

Methods

EMR data from two health care systems was analyzed. The proportion of PCPs diagnosing and treating one or more sleep disorders was calculated (per year) for 5 years (2014-2018). Also calculated was the percent of PCP caseload diagnosed and/or treated for sleep disorders.

Results

The two systems comprised n=1021 PCPs. From 2014-2018, the proportion of PCPs diagnosing patients with sleep disorders fluctuated between 58-89%. The proportion treating sleep disorders fluctuated between 50-91%. Non-parametric one-sample run tests (SPSS) indicate these are random distributions (p>0.05). PCPs’ use of medications to treat sleep disorders is trending downward over time within one system (per linear regression, p=0.03, R-squared=0.8). Other temporal trends were not evidenced. The average percentage of diagnosed and treated patients per PCP was around 2.5% of their caseloads. Between-system differences were observed.

Conclusion

There is a profound mismatch between percentage of PCPs identifying patients with sleep disorders (60-90%) and the percentage of patient caseload diagnosed and/or treated for sleep disorders (2.5%). This suggests that the majority of PCPs are willing to assess for sleep health but do so in only a small minority of patients. These data, along with our survey data (elsewhere in this volume) suggest that the intention-action gap could be closed if PCPs were appropriately resourced.

Support

There was no funding for this study.
0123 Sleep Duration and Cognitive Performance on the Stroop Color-Word Task and Simple Reaction Time Task
Authors: Mullins K M , Reynolds A M
Published: May 2020

Introduction

Studies examining sleep factors and cognition suggest that sleep impacts cognitive performance in college students. The focus of the current study was to examine normal sleep patterns in college-aged students and how their sleep affected their cognitive performance.

Methods

Participants were 51 undergraduate students (18 males), average age M=20.25 (SD=1.78) years, who wore actigraph watches to measure their sleep. After one week, participants completed the Multidimensional Assessment of Fatigue (MAF) to assess fatigue and performed a series of cognitive tasks on the computer, including the Stroop Color-Word test. Participants responded to the color of the word presented on the screen instead of the word itself. Stimuli where the color and word did not match were considered incongruent stimuli. Participants also performed a simple reaction time task, where they reacted to an “X” stimulus on the screen.

Results

Mean sleep efficiency was 82.55% (SD=5.70), mean sleep duration was 6.59 hours (SD=79.19 minutes), and the mean MAF score was 21.17 (SD= 7.64). A Pearson correlation indicated a significant negative association between sleep duration and Stroop congruent errors r(49) = -.467, p = .001. Furthermore, a Pearson correlation indicated a significant positive association between sleep duration and incongruent reaction time, r(49)= .290, p= .039 and a significant positive association between sleep duration and simple reaction time, r(49)= .277, p= .049. MAF scores were positively correlated with simple reaction times, r(49)= .376, p=.008. Sleep efficiency was not correlated with any of the cognitive measures.

Conclusion

As expected, participants’ sleep was short and inefficient. Results were expected in that participants made fewer errors with increased sleep, but, unexpectedly, reaction times also increased with more sleep. Fatigue may have played a role in this relationship. It is important to continue this research in order to learn more about sleep factors and cognitive function in college students.

Support

None
1220 A CASE OF HYPOGLOSSAL NERVE STIMULATOR CERVICAL LEAD CUFF DISLODGEMENT
Authors: Ali Hamed , Duthuluru Sowjanya
Published: May 2020

Introduction

Hypoglossal Nerve Stimulation (HGNS) has become an alternative therapy for moderate to severe obstructive sleep apnea (OSA) patients intolerant to PAP therapy. HGNS devices typically comprise of implantable pulse generator (IPG) placed surgically in an infraclavicular subcutaneous pocket. An electrode cuff attached to the IPG wraps around the distal portion of the of the hypoglossal nerve. This device has an implantable chest sensor that monitors the respiratory efforts.

Report of Case

A 76-year-old male with history of severe OSA (AHI 39 /hour) was intolerant to PAP therapy. HGNS was implanted in the right infraclavicular pocket under general anesthesia without any complications. Patient had successful tongue motion to stimulus per protocol intra- operatively in the OR. However, no tongue movement was noted despite maximum stimulation up to 4.5 V at follow up clinic visit. Follow up C spine x ray showed very low-lying HGNS cervical lead cuff, and possible dislodgement. Patient was taken back to the OR. Intraoperatively it was noted that the previously placed cervical lead cuff has folded back and was lying on the surface of the submandibular gland /digastric anchor site. It was dissected free and replaced on the distal inclusion branches of the hypoglossal nerve with loupe magnification and EMG confirmation (tongue deviation at 1.5 volts). Patient developed tongue neuropraxia with difficulty swallowing, difficulty speaking and right sided tongue deviation lasting for months, that gradually improved. Patient had successful HNS activation 6 months later using 2.2 V.

Conclusion

(HGNS) failure secondary to cervical lead cuff dislodgement is a rare complication and should be taken in consideration. Post-operative imaging and comprehensive clinical examination are crucial in detecting such problems. Temporary tongue neuropraxia post Hypoglossal nerve stimulator placement is another possible complication.
1222 Does Creativity & “Dose” Enhance Outcomes in Imagery Rehearsal Therapy? A Case of Successful IRT
Authors: Roth Alicia J , Drerup Michelle
Published: May 2020

Introduction

Imagery Rehearsal Therapy (IRT) is an efficacious treatment for Nightmare Disorder. In IRT, patients practice pleasant guided imagery techniques, then use these skills to re-script recurring nightmares, which lowers the frequency and intensity of overall nightmare activity. However, the most efficacious methods and dosage of guided imagery and nightmare re-scripting is undetermined.

Report of Case

The patient was a 70-year-old male with Nightmare Disorder. Patient denied any precipitating event or trauma associated with nightmare onset. He has a longstanding history of depression and OSA (uses CPAP). He was taking Seroquel, which reduced severity of nightmares but not frequency. Trials of other medications for nightmares had failed (including prazosin, Depakote, and trazodone).

Patient presented as highly distressed, exhibited distrust towards medical providers, and was skeptical about the effectiveness of IRT. Despite his skepticism, patient self-initiated very detailed and media-enhanced methods for pleasant guided imagery and nightmare re-scripting, including written narratives, voice recordings, and created a movie of his re-scripted nightmare with pictures set to music. He listened to the recordings 2-3x/day. Themes of nightmares included lack of mastery over problems; patient’s re-scripted dreams put him back in control of frightening scenarios.

Nightmare logs at baseline showed sleep quality=1.9/5; average=2.0 nightmares/night; average intensity= 6.2/10. At week 15 of treatment, sleep quality=3/5; nightmares/night average=0.25; average intensity=6/10. Sleep disturbance also improved (ISI=18-moderately severe clinical insomnia to 11-subthreshold insomnia); mood was stable (PHQ=5-mild depression).

Conclusion

Previous studies have suggested that IRT increases patients’ sense of mastery or perceived self-efficacy over nightmares (Rousseau et al., 2018). Additionally, higher verbal memory in persons with trauma-related nightmares has been shown to improve nightmare frequency and severity in IRT (Scott et al., 2017). In this case study, self-efficacy may have been activated by the highly detailed and media-enhanced imagery the patient created. Further empirical research on the mechanisms for enhancing IRT is warranted.
1227 A CASE OF A FEARFUL SLUMBER
Authors: Asis Aristotle , Wilson Annise Georgette , Alapat Philip Mani
Published: May 2020

Introduction

Isolated sleep paralysis (ISP) occurs when rapid eye movement (REM)-based atonia intrudes into wakefulness, outside the context of narcolepsy, substance abuse, mental disorder or other medical conditions. No “gold standard” assessment and diagnostic instrument currently exists.

Report of Case

A 63-year old female with hypersomnia and positive airway pressure (PAP)-controlled obstructive sleep apnea was referred for recurrent episodes of paralysis during sleep-wake transitions, lasting 15-20 seconds, occurring every 2-3 years since the age of 15, and associated with fear and anxiety. Episodes were more frequent in the last 2 years after significant sleep deprivation and starting a weight loss supplement, BIO-X4, which contains green tea and probiotics. No cataplexy, or history of traumatic brain injury and stroke were identified. Epworth Sleepiness Scale score was 14 on armodafinil. Reported sleep amounts were regularly scheduled 6-7-hour periods, with no suggestion of circadian dysfunction. In 2016, polysomnogram showed Apnea-Hypopnea index of 2.6/hour, Respiratory Disturbance Index of 13.8/hour with oxygen nadir of 92% in the setting of hypersomnia. Continuous PAP of 11 cmH20 was initiated after a successful titration with controlled residual AHI during follow-ups. Multiple Sleep Latency Test during the same time revealed mean sleep latency of 5.5 minutes and no sleep-onset REM with 5 naps. Brain imaging and electroencephalogram were both normal as well as drug panel, blood counts, metabolic profile and thyroid function. Decreased episodes and severity of recurrent ISP were reported after discontinuation of the supplement. Apart from anxiety related to the episodes, the patient denied any interference with daytime function.

Conclusion

Isolated sleep paralysis is an important sleep disorder that requires proper evaluation to rule out competing diagnoses and consideration of therapeutic interventions. Likely associated with a lack of understanding and available literature, the prevalence in the general population is likely higher than what is currently perceived.
1228 A CASE OF PULMONARY HYPERTENSION AND SEVERE OBSTRUCTIVE SLEEP APNEA IN A PEDIATRIC PATIENT WITH DOWN SYNDROME
Authors: Asis Aristotle , Kaplan Kevin
Published: May 2020

Introduction

Children with Down syndrome (DS) are at risk for obstructive sleep apnea (OSA) and related health consequences. Adherence to treatment plans, especially positive airway pressure (PAP), can be difficult for people with DS. We present a case of a pediatric patient with DS who developed pulmonary arterial hypertension (PAH) due to poor adherence of OSA therapy.

Report of Case

A 4-year-old male with a past medical history of DS was diagnosed with severe OSA and hypoventilation at 18 months of age – AHI 27, (oAHI 27), CO2 above 50 mmHg for 53.2% of total sleep time (TST)). A titration study showed that on a bi-level pressure (BPAP) of 11/6 cm H2O his OSA was improved – AHI 5.9 (oAHI 3.7), O2 nadir of 93%. The family attempted PAP at home but discontinued after 2 weeks. He underwent an adenoidectomy at 22 months of age and tonsillectomy and repeat adenoidectomy at 40 months of age. Patient presents to the emergency center with respiratory distress. Chest films showed cardiomegaly. Echocardiogram revealed evidence of worsening PAH (tricuspid regurgitation of 3.5-3.8 m/s and flattening of the interventricular septum). He was admitted to the pediatric intensive care unit for further management of his PAH attributed to his underlying uncorrected OSA and hypoventilation. Repeat polysomnogram showed continue severe OSA and hypoventilation – AHI 30.3 (oAHI 30.3) CO2 above 50 mmHg for 89% of TST. Repeat titration study showed that a pressure of 11/7 cm H2O improved his OSA– AHI 6.4 (oAHI 6.4) CO2 max of 52 mmHg. Treatment with BPAP was initiated prior to discharge. Repeat echocardiogram 2 months after admission showed improvement of the PAH while on BPAP without additional vasoactive drug therapy.

Conclusion

Children with DS are at high risk for OSA. Although treatment can be difficult, proper management of the OSA essential to preventing potential serious health consequences.
1232 Improvement in Excessive Daytime Sleepiness in Two Narcoleptic Patients on Oral Contraceptives
Authors: Macias Maria , Singh Suprya , Patel Amee
Published: May 2020

Introduction

Narcolepsy is a chronic disorder characterized by excessive daytime sleepiness (EDS). We present two patients with narcolepsy with improvement in symptoms with the use of oral contraceptives.

Report of Case

Patient A is a 15-year-old female with a family history of narcolepsy who presents with excessive daytime sleepiness and cataplexic episodes (eye twitching, abnormal sensations of the face, drop attacks). Her pediatric daytime sleepiness scale score (PDSS) was 29. The polysomnography (PSG) did not record sleep disordered breathing. Multiple sleep latency test (MSLT) recorded 4 out 4 sleep onset rapid eye movement period (SOREMPS) and mean sleep onset latency (SOL) of 6.2 minutes. She was diagnosed with Narcolepsy Type 1 and started on stimulants as family was not interested in Xyrem. Over two years, her PDSS the doses of the stimulants were increased due to significant daytime sleepiness. Caregiver was not interested in Xyrem. Patient demonstrated increased sleepiness during menstrual cycles. She was treated with OCPs for menorrhagia. Her EDS improved, PDSS decreased from an average of 24.5 to 17.5 and the dose of the stimulants was decreased.

Patient B is an 11-year-old female with excessive daytime sleepiness and fragmented sleep with multiple awakenings. She took frequent naps during the day. Her PDSS was 29. The PSG showed mild OSA and the MSLT recorded 3 out of 4 SOREMPS and SOL was less than 1 minute. She was diagnosed with Narcolepsy Type 2. During her treatment course, several medication regimens were trialed but were not effective including stimulants, Modafinil, and Armodafinil. Caregiver was not interested in Xyrem. At the age of 13 years, she started OCPs for dysmenorrhea. Her EDS improved and PDSS decreased from an average of 29 to 16.75.

Conclusion

We present two patients with narcolepsy who continued to have EDS in spite of treatment with wake promoting agents and daytime naps. Their EDS and PDSS improved after initiating OCP therapy Pubertal changes may have a significant influence on narcolepsy patients. The use of OCPs may be beneficial in conjunction to wake promoting agents.
1239 Mind Blown: Exploding Head Syndrome as a Side Effect of Marijuana
Authors: Missak Christopher , George Jenie , Gurubhagavatula Indira
Published: May 2020

Introduction

Marijuana use is increasing the United States and has been associated with increased sensory perception, euphoria, and altered cognition. Exploding head syndrome is a parasomnia characterized by loud explosion-like noises occurring prior to or during sleep. This the first report to link marijuana use with the occurrence of EHS.

Report of Case

A 45-year-old man with depression, anxiety and multisubstance abuse reported two years of neuropsychiatric symptoms including: “fireworks going off in my brain,” visual hallucinations, and sudden arousals characterized by panic and vertigo. He reported bouts of occupational stress and severe anxiety previously treated with clonazepam for six months, but discontinued it due to poor clinical response. Normal findings were reported on a previous work-up including: MRI, EEG, and head CT Scan.

During his visit, he reported that he had been smoking marijuana three times a day for 24 years. One month prior to his visit he discontinued marijuana, stopped clonazepam, and started using mirtazapine with improvement in all aforementioned symptoms. During the same month, he relapsed and smoked marijuana once with a sudden return of all previously described symptoms on the night following its use. These symptoms then resolved and did not recur again until 9 months later, after another episode of weekend marijuana use. An in-lab polysomnogram revealed an apnea-hypopnea index 2.2 per hour, increased alpha intrusion throughout the study, and no epileptiform activity. No parasomnias were observed during rapid-eye-movement (REM) or non-REM sleep.

Conclusion

The etiology of EHS remains elusive. A review of the research has proposed five major theories and case reports suggest a complex etiology. Given the temporal correlation with marijuana use and symptom resolution with its cessation, we presume that EHS resulted from a complex interplay between neurons susceptible to cannabinoids and their derivatives.
1242 An Adult with ROHHAD Disease
Authors: Ahmad Hamna , Gohar Ashraf
Published: May 2020

Introduction

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation (ROHHAD) is an extremely rare and fatal disease presenting in early childhood.

Report of Case

A 25-year-old male, seen in our adult sleep clinic to establish care at the age of 21. He was previously followed by pediatric sleep department. He was diagnosed with ROHHAD syndrome in early childhood after presenting at the age of 18 months. At the time, he was diagnosed with central hypoventilation with multiple endocrinopathies. He was noted to have mild mental retardation and behavioral problems. He was initially worked up for multiple genetic disorders and was eventually diagnosed with ROHHAD syndrome. As a pediatric patient, he had a CPAP titration study that was unsuccessful with persistent central apneas. Eventually, he was treated with auto-SV (with minimum and maximum pressure support of 1 and +15 respectively, an EPAP max of +20, and EPAP min of +5). He has since been doing well with ASV. He also had insomnia and hypersomnia and is being treated with Modafinil for excessive daytime sleepiness and Zolpidem for the insomnia.

Conclusion

The mortality related to cardiorespiratory arrest in ROHHAD disease has been estimated to be 40-50%. To our knowledge, case reports of adult patients with ROHHAD in literature, are few and far between.
1253 Multiple sleep onset REM episodes in middle age woman with excessive daytime sleepiness – Is this automatically assumed narcolepsy?
Authors: Patel Kamal , Lang Bianca J
Published: May 2020

Introduction

Presence of sleep onset REM episodes often raises concerns of narcolepsy. However other conditions have shown to have presence of sleep on REM episodes which include but not limited to obstructive sleep apnea, sleep wake schedule disturbance, alcoholism, neurodegenerative disorders, depression and anxiety

Report of Case

Here we present a case of 30 year old female with history of asthma, patent foraman ovale, migraine headache, and anxiety who presented with daytime sleepiness, falling asleep while at work, occasional scheduled naps, non-restorative sleep, sleep paralysis, and hypnopompic hallucination. Pertinent physical exam included; mallampati score of 4/4, retrognathia, high arched hard palate, crowded posterior oropharynx. She had a score of 16 on Epworth sleepiness scale. Patient previously had multiple sleep latency test at outside facility which revealed 4/5 SOREM, with mean sleep onset latency of 11.5 minutes. She however was diagnosed with narcolepsy and tried on modafinil which she failed to tolerate. She was tried on sertraline as well which was discontinued due to lack of benefit. She had repeat multiple sleep latency test work up which revealed 2/5 SOREM, with mean sleep onset latency was 13.1 minutes. Her overnight polysomnogram prior to repeat MSLT showed SOREM with sleep onset latency of 10 minutes. Actigraphy showed consistent sleep pattern overall with sufficient sleep time but was taking hydroxyzine and herbal medication. Patient did not meet criteria for hypersomnolence disorder and sleep disordered breathing.

Conclusion

There is possibility her medication may have played pivotal role with her daytime symptoms. We also emphasize SOREMs can be present in other disorders such as anxiety in this case and not solely in narcolepsy
1258 No Laughing Matter - Laughter Induced Syncope (Gelastic Syncope) Mimicking Cataplexy
Authors: Belani Dinesh , Simon Edwin
Published: May 2020

Introduction

Laughter is a common emotion and may rarely be a manifestation of neurological illnesses. It has been associated with cataplexy as well. Cataplexy is usually triggered by strong emotions. Gelastic syncope is an uncommon phenomenon which may be mistaken for cataplexy. We summarize 3 cases referred to the Sleep Medicine clinic for evaluation for Narcolepsy.

Report of Case

55 yo male comes with 2 episodes of blacking out and falling down relating to episodes of laughter in 3 months. Patient describes loss of consciousness and no episodes of freezing. Reported 15 years of snoring and witnessed apneas along with grinding his teeth while sleeping. Polysomnogram revealed Obstructive Sleep Apnea (OSA) with an AHI of 20.

60 yo male comes with episodes of loss of consciousness over the past 6 months, including sitting in a chair, laughing, urinating, washing dishes while standing, expressing strong emotions (father’s funeral), etc. Also reports bugs crawling over his legs when trying to sleep, loud snoring and waking up choking while sleeping. Polysomnogram revealed OSA with an AHI of 20.

43 yo male comes 3 episodes of loss of consciousness, 2 of them related to laughing and the last one related to stretching his arms out. He passes out for 5-10 seconds at a time and a period of 20-30 seconds before passing out where he feels dizzy when he is unable to respond at this time, no post episode confusion. Positive on the Cataplexy Emotional Trigger Questionairre. Reported witnessed apneas, snoring and sleep talking. Polysomnogram revealed OSA, hence the Multiple Sleep Latency Testing ordered was not completed.

Conclusion

While the first two episodes point towards Gelastic Syncope based on symptoms, the third did warrant MSLT if there was no OSA on PSG. It is important to recognize gelastic syncope as an entity and differentiate it from cataplexy.
0131 Decreased Habitual Sleep Efficiency is Associated with Increased Insulin Resistance in Healthy Adult Men
Authors: Kelly M R , O’Byrne N , Iranmanesh A , Martin J L , Liu P Y
Published: May 2020

Introduction

Partial sleep deprivation is associated with increased insulin resistance (IR), a metabolic disease risk marker. Little is known about habitual sleep patterns and IR in the absence of acute sleep restriction. We anticipated greater change in habitual sleep over one month would be associated with increased IR.

Methods

24 males (age=33.6±6.4 years; BMI=25.7±2.5kg/m2) completed baseline (T1) and follow-up (T2; ≥4 weeks post-T1) study procedures: actigraphy (one week) followed by polysomnography (PSG; one 10h sleep opportunity) and a next morning oral glucose tolerance test (OGTT; homeostatic model assessment insulin resistance [HOMA-IR], β-cell function [HOMA-β], and Matsuda Index). Weekly average actigraphy total sleep time (aTST; 291-511min) and sleep efficiency (aSE; 72–93%) were computed at T1 and T2, as well as across the 1, 2, and 3 days prior to PSG/OGTT. Pearson and Spearman correlations assessed the change (T1-T2) in actigraphy (aSEΔ, aTSTΔ, PSGΔ) or PSG sleep (PSG-TSTΔ, PSG-SEΔ, sleep stages) versus change in metabolic risk (HOMA-IRΔ, HOMA-βΔ, MatsudaΔ).

Results

There were significant correlations between HOMA-IRΔ and aSEΔ [r(22)=-0.42, p=0.01; rs=-0.45, p=0.03], PSG TSTΔ [r(22)=0.50, p=0.012; rs=0.41, p=.045], and PSG-SEΔ [r(22)=0.49, p=0.015; rs=0.43, p=.037]. No significant associations emerged between change in metabolic risk versus aTSTΔ one week prior to PSG/OGTT, aSEΔ or aTSTΔ across 1–3 days prior to PSG/OGTT, or PSG sleep stages.

Conclusion

Within-subject T1-T2 decrease in habitual sleep quality, but not TST, was associated with increased IR. T1-T2 PSG TST and SE were associated with following day IR. At home sleep 1–3 days beforehand were not correlated with IR. Although preceding night sleep quality and TST are associated with IR, habitual sleep quality, rather than TST, may be a more important determinant of metabolic risk in community dwelling middle-aged men.

Support

This work was supported by NIH/NHLBI R01HL124211, NIH/NHLBI K24HL138632, NIH National Center for Advancing Translational Sciences (NCATS) UCLA CTSI Grant UL1TR001881 (PI: Liu); and NIH/NHLBI K24HL143055 (PI: Martin). Dr. Kelly is supported by the VA Office of Academic Affiliations through the Advanced Fellowship Programs in Geriatrics.
0141 A Novel, Orally Available Orexin 2 Receptor-Selective Agonist, TAK-994, Shows Wake-Promoting Effects Following Chronic Dosing in an Orexin-Deficient Narcolepsy Mouse Model
Authors: Ishikawa T , Suzuki M , Kimura H
Published: May 2020

Introduction

The use of an orexin 2 receptor (OX2R) agonist may be a promising approach for the treatment of narcolepsy type 1. TAK-994 is a novel, orally available OX2R-selective agonist with >700-fold selectivity against orexin 1 receptor. Single administration of TAK-994 ameliorates narcolepsy-like symptoms such as fragmentation of wakefulness and cataplexy-like episodes in orexin/ataxin-3 mice, a narcolepsy mouse model with orexin deficiency. In this study, we evaluated the effect of chronic dosing with TAK-994 on sleep/wakefulness states in orexin/ataxin-3 mice.

Methods

Orexin/ataxin-3 mice were grouped into two cohorts: a control group and a 14-day treatment group. In the control group, vehicle was administered orally to mice three times a day: zeitgeber time 12 (ZT12), ZT15 and ZT18, for 14 days. In the 14-day treatment group, TAK-994 was administered orally to mice at ZT12, ZT15 and ZT18 for 14 days. Electroencephalogram/electromyogram analysis was performed on day 1 and day 14 (ZT12-ZT21), and the subsequent sleep phase (ZT0-ZT10).

Results

On day 1, TAK-994 significantly increased wakefulness time, accompanied by a decrease in non-rapid eye movement (NREM) sleep time and rapid eye movement (REM) sleep time, in orexin/ataxin-3 mice compared with the control group. On day 14, TAK-994 also significantly increased wakefulness time, and decreased NREM sleep time and REM sleep time in orexin/ataxin-3 mice. There were no changes in the time spent in wakefulness, NREM sleep and REM sleep during the subsequent sleep phase after chronic dosing with TAK-994.

Conclusion

Wake-promoting effects of TAK-994 were observed following chronic dosing for up to 14 days in orexin/ataxin-3 mice with no rebound of sleep. Overall, there was no clear difference in efficacy between the single and repeated administration of TAK-994 in orexin/ataxin-3 mice.

Support

This work was conducted by Takeda Pharmaceutical Company Limited.
0163 Investigating the Role of Vasoactive Intestinal Peptide-Containing Neurons of the Ventromedal Preoptic Area in Sleep-Wake Control
Authors: Venner A , Fuller P M
Published: May 2020

Introduction

A role for vasoactive intestinal peptide (VIP) in promoting rapid eye movement (REM) sleep has been suggested, but the anatomical location of the neurons that release VIP to promote REM sleep has not been identified. Here, we investigated the role of VIP-containing cell groups in the ventromedial preoptic area (VMPOVIP) in sleep-wake regulation. The VMPO has also previously been implicated in thermoregulation and the febrile response.

Methods

We first investigated the native firing activity of VMPOVIP neurons, over repeated sleep-wake cycles, using in vivo fiber photometry in VIP-ires-Cre mice. We next examined the afferent and efferent profile of this cell group using conditional retrograde (pseudotyped modified rabies) and anterograde (adeno-associated viral vector-based) tracers. We finally utilized a chemogenetic strategy to selectively activate VMPOVIP neurons cells while monitoring electroencephalogram/electromyogram activity and core body temperature, in order to determine their role in sleep-wake and thermoregulatory control.

Results

We found that VMPOVIP cells were predominantly and strikingly REM-active, that they received many synaptic inputs from surrounding hypothalamic regions (including the ventromedial hypothalamus, dorsomedial hypothalamus and the arcuate nucleus), and that they targeted established sleep-wake nodes, such as the ventrolateral preoptic nucleus, tuberomammillary nucleus, lateral hypothalamus and ventrolateral periaqueductal gray area. To our surprise, chemogenetic activation of the VMPOVIP cell population had little effect upon all measures of sleep-wake analysed and no effect upon core body temperature.

Conclusion

We conclude that VMPOVIP neurons do not promote REM sleep per se. However, their REM-active profile and anatomical connectivity suggest that these neurons may play a functional role in generating certain cardinal features of REM sleep, which is an active focus of on-going research in our laboratory.

Support

SRSF CDA #016-JP-17 to A.V. and NS073613, NS092652 and NS103161 to P.M.
0169 Disruption of Sleep Architecture and Circadian Rhythms Following High Frequency Head Impacts
Authors: Korthas H T , Main B S , Harvey A C , Wicker E W , Sloley S S , Burns M P
Published: May 2020

Introduction

Mild Traumatic Brain Injury (mTBI) can cause a broad array of behavioral problems including cognitive and emotional deficits. Sleep disturbances including disrupted sleep latency and efficiency are common amongst human mTBI patients. Crucially, sleep plays a key role in hippocampal learning and memory consolidation, yet the contribution of single and repetitive mTBIs influencing sleep related cognitive outcomes remains unclear.

Methods

To study the effect of repetitive mTBI on sleep and circadian rhythms, C57Bl/6 mice underwent sham or High Frequency-Head Impact (HF-HI, 30 closed head impacts, 5/per day for 6-days) procedures before brains were assessed at 1d, 1m and 2m using a combination of molecular neurobiology (RNA/protein), EEG/ EMG recordings and behavioral analysis.

Results

HF-HI induces learning and memory deficits in the Barnes and T-Maze at both 1d and 1m post injury, in the absence of axonal injury, inflammation, or protein deposition. Disruptions in circadian mRNA expression was identified at multiple time points post HF-HI. RNA analysis of mouse cortex, hippocampus, and hypothalamus for core circadian rhythm genes (Bmal1, Clock, Cryptochrome 2, Period1 and Period 2) was conducted at 1d and 1m post HF-HI. We found dysregulated expression of these core biological clock genes in these regions at both time points. Furthermore, we find distinct changes to sleep architecture chronically post injury. Animals were implanted with EEG and EMG for monitoring at 2m post injury. EEG and EMG signals were coded for wake, NREM, and REM. One-month post injury, HFHI injured mice showed dysregulated sleep architecture compared to sham mice, while both groups had the same total sleep time. We also demonstrate that HF-HI alters EEG activity in awake animals.

Conclusion

Overall, our data shows disruptions in both sleep architecture and expression of circadian rhythm genes following HF-HI. This opens up an important avenue of potential therapeutic intervention following injury.

Support

If deficits in sleep and circadian rhythms can be rescued after mTBI, it may assist in improving symptoms and chronic outcomes after injury.