bluuebunny/crossref_metadata_2025_split huggingface dataset:
1200 Seasonal Variation In RHR Measured By A Wearable Ring
Authors: Koskimaki H , Kinnunen H , Ronka S , Smarr B 
Published: May 2020

Abstract

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

Abstract

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 &lt;18, unstable cardiopulmonary status, recent hospitalization within 30 days, significant arrhythmias, baseline HR &lt;50 or &gt;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 &lt; 5; 14 (18%) had AHI 5-15; 15 (19%) had AHI 15-30; 14 (18%) had AHI &gt; 30. The Ring-REI correlated well with the PSG-AHI (r =0.83, P &lt;0.001). The accuracy, sensitivity, specificity in categorizing AHI &gt;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

Abstract

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 (&gt;=88%), while they lacked sensitivity to REM and wake (&lt;=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

Abstract

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 &gt;95th percentile in children and awake hypercapnia (PaCO2 &gt; 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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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

Abstract

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.
1273 Does a more personalized approach to desensitization and daytime titrations improve PAP compliance, PAP therapy satisfaction/efficacy, and perhaps even save resources?
Authors: Yeager K K , Kern J D , Cutrufello N J , Begay M N , Glasser J 
Published: May 2020

Abstract

Introduction
Seventy three patients at the Raymond G Sleep Center within the New Mexico VA Healthcare System were identified as patients who were at high risk for PAP therapy non-compliance, were invited to participate in a new patient service program.

Report of Case
This program included an individualized daytime desensitization process coupled with a potential daytime titration. The final analysis of these data revealed co-morbid conditions that may serve as barriers to PAP usage as well as medical conditions which are known to benefit from compliance on PAP therapy. Special attention was paid to co-morbid psychiatric conditions.

Conclusion
This process resulted in a roughly 25% increase in PAP compliance, a 30 % change in PAP modality and improved access to in-lab titrations. This study elucidated factors that may help predict success or failure regarding PAP therapy.