bluuebunny/crossref_metadata_2025_split huggingface dataset:
401 Clinical Phenotypes of Obstructive Sleep Apnea in World Trade Center Responders
Authors: Parekh Ankit , Castillo Bresne , Kim Do Hyung , Black Kathleen , de la Hoz Rafael , Rapoport David , Sunderram Jag , Ayappa Indu 
Published: May 2021

Abstract

Introduction
The heterogeneity of symptoms in obstructive sleep apnea (OSA) patients has been recently formalized into 3 distinct clusters: Sleepy, Disturbed Sleep, and Minimally Symptomatic. Our previous data showed that OSA is highly prevalent (&gt;75%) in World Trade Center (WTC) responders, and positive airway pressure (PAP) treatment adherence is very poor (&lt;20%). To better understand the heterogeneity of OSA in the WTC cohort, here we sought to examine the distribution of these distinct clinical phenotypes.

Methods
643 subjects with no history of OSA or reported loud and frequent snoring before 9/11/2001 from the WTC health program clinical centers at Rutgers RWJMS, New Jersey, NYU School of Medicine, and Icahn School Medicine at Mount Sinai, New York underwent 2 nights of home sleep testing using the ARES unicorder (SleepMed, Inc., West Palm Beach, FL, USA). Epworth Sleepiness Scale (ESS), sleep onset insomnia, and sleep maintenance insomnia were assessed with questionnaires. OSA was defined as (AHI4%&gt;=5 or RDI&gt;=15/hr). The three clusters were defined as 1) Sleepy (ESS&gt;10 and/or sleep onset/maintenance insomnia); 2) Disturbed Sleep (not sleepy (ESS&lt;=10) and sleep onset/maintenance insomnia); and 3) Minimally Symptomatic (not sleepy (ESS&lt;=10) and no sleep onset/maintenance insomnia). Distribution of clusters in the WTC cohort was compared to published data from the Sleep Apnea Global Interdisciplinary Consortium (SAGIC) and the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Results
Among the subjects diagnosed with OSA (N 440; AHI4%=13(15); RDI =28(19); median(iqr); 81% men; age, 33–87 years; BMI, 27.4±3.7 kg/m2), the distribution of clinical phenotypes was 31.4% sleepy, 48.9% disturbed sleep, and 19.7% minimally symptomatic, and did not differ between OSA severity groups. In comparison to SAGIC and HCHS/SOL, the WTC cohort exhibited significantly increased prevalence of the disturbed sleep phenotype (WTC vs SAGIC: 48.9% vs. 19.8%, □2=54.9; p&lt;0.001; WTC vs. HCHS/SOL: 48.9% vs. 38.1%, □2=26.1, p&lt;0.001).

Conclusion
The predominant clinical phenotype of OSA in the WTC cohort is disturbed sleep (insomnia) and its prevalence is significantly greater than what has been observed in other large OSA cohorts. These findings may help explain the poor adherence to PAP treatment observed in the WTC cohort.

Support (if any)
NIOSH U01OH01415; AASM Foundation 233-BS-20.
405 The Effect of a Patient Survey in the Evaluation of Obstructive Sleep Apnea in a High Risk Cardiology Outpatient Population
Authors: Patel Dev , Patel Ishan , Cohen Marc , Patel Sunil 
Published: May 2021

Abstract

Introduction
Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. The estimated prevalence is approximately 15 to 30 percent in males and 10 to 15 percent in females. Patients with OSA have an increased propensity for cardiovascular diseases and obesity. Observational studies have demonstrated a consistent association between OSA and hypertension, coronary artery disease, cardiac arrhythmias, and heart failure. The purpose of this study is to evaluate if a patient survey can improve the diagnosis of OSA in a high-risk outpatient cardiac clinic.

Methods
In an outpatient cardiac clinic, a retrospective analysis of OSA evaluations was done before and after the use of patient surveys in a high-risk population. The high-risk patient group was defined by the presence of two or more of the following conditions: hypertension, heart failure, cardiac arrhythmias, atrial fibrillation, obesity with a BMI of 30 or more, coronary artery disease, diabetes mellitus, chronic lung disease, history of cerebrovascular accident (CVA), hypothyroidism and chronic renal insufficiency. The patient survey included questions on the presence of daytime sleepiness, presence of snoring, ESS score, choking in sleep, witness apnea, and frequent waking in sleep.

Results
During the four months of patient survey use, a total of 143 patients were evaluated as compared to 86 patients in the prior four months without the use of the survey. A significant increase (66.3%) of OSA evaluations was observed during the patient survey period.

Conclusion
The use of patient surveys showed a significant improvement in OSA diagnoses in the defined high-risk patient group. Patient surveys might be beneficial to improve the under diagnosis of sleep apnea in high-risk patient populations. Additional research needs to be done to establish the impact of such intervention on patient outcomes.
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410 Sleep and Stroke: Improved OSA Time to Diagnosis for Stroke Patients Using an Inpatient Diagnostic and Treatment Strategy
Authors: Naik Sree , Zand Ramin , El Andary Nada , Morse Anne Marie 
Published: May 2021

Abstract

Introduction
Obstructive sleep apnea (OSA) is an independent risk for development of stroke. Despite this known relationship there is insufficient screening of sleep apnea in many recognized stroke centers, including Geisinger. In 2016, 68 patients were admitted to Geisinger Wyoming Valley (GWV) with ischemic stroke. Less than 10% had a Sleep Medicine Referral. When referred, average time to CPAP initiation was 9–12 months. An ongoing quality improvement (QI) study implemented inpatient home sleep apnea testing (HSAT) for stroke patients and subsequent autoPAP, if positive. Interim analysis demonstrates high rates of OSA using this screening method, suggesting a viable mechanism for improved time to OSA diagnosis.

Methods
All patients at GWV evaluated by neurology due to acute neurologic change were considered for enrollment (9/1/2019-10/10/2020). Only patients 18 years and older hospitalized with diagnosis of ischemic stroke were included. Patients were consented for participation. The evening of enrollment an Alice NightOne HSAT device was applied by a respiratory technician. If OSA was identified, the patient was placed on APAP the following evening.

Results
A total of 302 patients were screened with 82 patients meeting criteria for enrollment (27%) and 64 consenting for participation and attempting HSAT (21%). 18 of the 82 (22%) eligible patients refused participation. 12 patients (19%) had insufficient HSAT studies to determine OSA diagnosis. Of the patients who successfully completed an adequate HSAT study 85% (44/52) had OSA identified.

Conclusion
OSA is highly prevalent in patients with ischemic stroke and represents a modifiable risk factor for recurrent stroke. At baseline, rate of and time to diagnosis of OSA was poor with less than 10% of stroke patients receiving a sleep referral and time to initiation of CPAP was approximately 1 year. Standard universal in hospital surveillance for OSA using an HSAT in admitted stroke patients appears to allow for an increased rate of capture, but perhaps also a shorter time to diagnosis. This data may also suggest that prevalence of OSA in this stroke population is similar to slightly higher than previously reported. Further analysis of this program is required to evaluate for statistical significance and impact of APAP use.

Support (if any)
Geisinger Health Plan
411 REM predominance of OSA: Associated with supine position, but not with CPAP adherence
Authors: Schecter Scott , Liu Junjie 
Published: May 2021

Abstract

Introduction
Obstructive sleep apnea (OSA) is a heterogeneous disease dependent on many factors including the sleep stage and the body position. OSA is often more severe during the rapid eye movement (REM) sleep stage, a phenomenon known as REM predominance. Prior studies suggested associations of higher REM predominance of OSA with younger age, higher obesity, and lower adherence to continuous positive airway pressure (CPAP) therapy, but these studies had small cohort sizes. Here we leverage home-based sleep tests (HST) that estimate REM sleep and measure body position to study REM predominance in a larger cohort of OSA patients.

Methods
We retrospectively reviewed patients who took HST at our clinic using devices based on peripheral arterial tonometry (WatchPAT, Itamar Medical). The HST results included estimated REM sleep periods and measured body positions. Auto-titrating CPAP therapy was prescribed for the majority of OSA patients diagnosed by the HST. Our inclusion criteria were: apnea-hypopnea index (AHI) above 5 /hour, estimated REM sleep time above 30 minutes, oxygen saturation below 90% (T90) for less than 10 minutes, and successful retrieval of CPAP usage data. CPAP adherence was defined as the percentage of nights with CPAP usage above four hours, and REM predominance as the ratio between REM AHI and non-REM AHI. Additionally, the percentage of estimated sleep time in supine position was calculated.

Results
Among 292 consecutive patients whose HST were reviewed, 113 patients met the inclusion criteria. The 25th-75th percentile ranges of age, body mass index (BMI), AHI, REM predominance, CPAP adherence and supine sleep percentage were 36–56 years, 28.1–38.4 kg/m2, 8.9–25.9 /hour, 1.27–2.89, 40%-97% and 28%-72%, respectively. REM predominance was not associated with CPAP adherence (P &gt; 0.05), but was significantly associated with lower age, higher BMI, and higher supine sleep percentage (all P &lt; 0.01).

Conclusion
We found that REM-predominant OSA is relatively more prevalent not only in young and obese patients, but in patients who sleep relatively more in the supine position. This association of REM predominance with body position is a novel finding to our knowledge. Contrary to prior studies, we did not find association of REM predominance with adherence to CPAP therapy.
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413 Inpatient Sleep Screens: Effective for Screening but Poor Follow Up
Authors: Chawla Upneet , Chadha Avneet , Martin Abigail , Culnan Elizabeth , Kirkpatrick Aaron , Arantes Henry , Lastra Alejandra 
Published: May 2021

Abstract

Introduction
Only 20% of adult Americans with Obstructive Sleep Apnea (OSA) are thought to have been diagnosed. Portable monitors (PM) can provide shorter time to diagnosis and treatment in at risk populations including inpatients. Data on inpatient sleep screen testing outcomes and population phenotypes are limited. We hypothesized that inpatients undergoing sleep screens via PM have higher disease severity but are less adherent to follow up.

Methods
We conducted a retrospective observational study comparing severity of OSA based on apnea-hypopnea index (AHI) and compliance with follow up between patients who received inpatient vs. outpatient sleep screens. There was a total of 347 patients, 18 years and older, who received a sleep screen from August 2017 to August 2018. Exclusion criteria were cancellations/no shows (13.56% inpatients vs. 13.51% outpatients) or loss of data (26.12% inpatients vs. 23.72% outpatients). For analysis, t-test and chi-square were used for continuous and categorical variables respectively.

Results
The patients diagnosed with severe OSA were more than double in the inpatient group vs. the outpatient group, 46.7% and 21.7% respectively. The inpatient group had a higher average AHI (30/h) compared to the outpatient group (20.3/h). 30.7% of the inpatient group were adherent with their follow up vs. 83.3% of the outpatient group. A chi-square test of independence demonstrated a significant difference between testing location and follow up (p &lt; .001). Those in the inpatient group were significantly older (mean 60.4 years old) than the outpatient group (47.5 years old). There was no significant difference in gender between the groups. The inpatient group had significantly higher average body mass index (39.9 kg/m2) when compared to the outpatient group (34.3 kg/m2).

Conclusion
Hospitalized patients screened for OSA with portable monitors are significantly more likely to have severe disease when compared to outpatients. Despite this, adherence to follow up is poor. Systematic evaluation of inpatient OSA screening program effectiveness and factors impacting adherence to follow up and treatment are needed.
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425 Investigating the Utility of Routine Carbon Dioxide Measurements During Polysomnography in the Evaluation of Obese Adult Patients
Authors: Nuzhny Valentin , Majid Ruckshanda , Imtiaz Komal , Mathew Reeba 
Published: May 2021

Abstract

Introduction
With the increasing prevalence of obesity, the diagnosis of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS) have also increased. Adding routine transcutaneous carbon dioxide (TcCO2) or end-tidal carbon dioxide sensors (EtCO2) may add beneficial information to the polysomnogram (PSG) and expand the diagnostic and treatment capabilities in this population. Our study looks at the use of this parameter in obese adults on whom CO2monitoring has been used.

Methods
We performed a retrospective chart review of obese adult patients (body mass index [BMI] &gt;30) undergoing a PSG. We documented the EtCO2 values at baseline (supine awake) and during sleep. Correlations between the EtCO2 readings and BMI were reviewed. We excluded patients that had poor EtCO2 waveforms and patients with known preexisting hypoventilation syndromes, such a COPD.

Results
Fifty patients were identified between January and November 2020 at the Memorial Hermann Sleep Center. 54% were female and 46% were male with an average age of 55.3 years (range 26–73) and an average BMI for the cohort of 40.1 (SD +/-9.5). The average AHI on the diagnostic study (CMS criteria) was 30.9 events/hour (SD +/- 43) and the average oxygen desaturation nadir was 79%. Sixteen patients (32%) met diagnostic criteria for OHS based on the baseline awake EtCO2 which would have otherwise been missed without CO2 monitoring. When comparing the mean values of the ETCO2 between Group 1 whose BMI was less than 40 kg/m2 (39.9 mmHg) to Group 2 whose BMI was greater than 40 kg/m2 (45.9 mm Hg), the difference was statistically significant with a p-value is 0.001.

Conclusion
OHS is reported to have greater mortality when compared to OSA. CO2 monitoring is currently only routinely required in pediatric PSGs. Our review suggests a higher diagnostic yield of OHS in adults with the use of CO2 monitoring especially when morbidly obese. Given the alarming trend towards obesity in the US, this advocates for the routine use of CO2 monitoring in adult obese patients. Although more research is needed, we may draw a conclusion that there is meaningful data to support the use of routine ETCO2 monitoring in this adult patient population.
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429 What are Patient Characteristics, Nursing Interventions and Patient Outcomes for Patients with Difficulty Adapting to CPAP?
Authors: Letourneau Marie , Dallaire Julie , Drummond Nicole , Gomes Nayomi , Parsons Marc , Benedetti Andrea , Kimoff Richard , Laizner Andrea 
Published: May 2021

Abstract

Introduction
A sleep nurse clinician was added to our care team to provide situationally responsive educational, behavioral and troubleshooting interventions and case management to patients identified as high risk for untreated SDB. The objective of this study was to describe the patient characteristics, nursing interventions, and impact on CPAP usage among patients referred to the nurse-clinician.

Methods
Descriptive exploratory retrospective chart review was used to identify patient characteristics for all new patients referred; in-depth extraction was conducted for patients who had home CPAP for ≥ 1 month and experienced difficulty using CPAP. We examined: issues using CPAP, frequency and types of nursing contacts, nursing interventions and CPAP usage. Patient characteristics of those with difficulty adapting to CPAP were compared to those referred for assistance to obtain CPAP. Change in objective CPAP usage before vs after sleep nurse case management was determined when possible.

Results
403 patients were referred, with mean (SD) age: 54.8 y (15.7), 56.1% men, RDI: 45.4 (31.4), 42.4% employed, 16.6% retired, 25% with ≥ 3 co-morbidities plus SDB. Difficulty adapting group (n = 204) had more women (p = 0.033), more employed (p = 0.03), and more insomnia (p = 0.001). CPAP issues included: mask (18%), ENT (14%), constraining beliefs (14%), access to treatment (12%), pressure intolerance (11%), comorbidities (11%), suboptimal usage (7%), insomnia (7%). Nursing contact: 74% subjects had ≤ 4 contacts (range: 1–16), 53% in-person, 25% telephone calls, 22% other. Nursing interventions were: educational (33%), troubleshooting (30%), behavioural (20%), liaison/coordination of care (13%), promoting self-management skills (3%). Preliminary mean CPAP usage (n = 18) improved by 40.0 (112.3) min and by 7.4 (31) % of nights used ≥ 4 hrs (p=NS; data extraction ongoing).

Conclusion
Demographic data identified women and insomnia to be significant characteristics in the difficulty adapting group. This model of care identified 2 types of interventions not previously recognized in typical interventions to promote CPAP adaptation: Liaison/coordination of care and promoting self-management skills. Some patients were able to increase their CPAP usage.

Support (if any)
MUHC Nursing Research Small Grants Award was supported by the Newton Foundation and the Montreal General Hospital Foundation.
433 Insomnia and Restless Legs Syndrome in Patients with Upper Airway Stimulation Therapy
Authors: Jomha Mohammed , Manchanda Shalini , Stahl Stephanie , Parker Noah 
Published: May 2021

Abstract

Introduction
Insomnia and restless legs syndrome (RLS) are common sleep disorders that may impact obstructive sleep apnea (OSA) treatment. To our knowledge, no studies have investigated whether these comorbidities affect upper airway stimulation (UAS) therapy adherence and outcomes. This study aims to explore possible effects of insomnia and RLS in patients using UAS therapy.

Methods
All patients who underwent UAS system implantation for treatment of OSA at our facility were retrospectively studied. Pre- and post-implant histories and data, including diagnostic sleep testing, otolaryngology evaluation, activation results, and treatment evaluation, were analyzed. Patients with no insomnia or RLS were compared to patients with insomnia, RLS, or both. Apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and adherence were compared pre- and post-treatment for each group.

Results
Sixty-four patients who have undergone UAS implantation at our center have completed post-treatment in-lab titration and evaluation of their UAS system. Insomnia was present in 47%, RLS in 28%, and both insomnia and RLS in 14%. In all groups, the overall AHI during in-lab titration was &gt;50% lower than the pre-treatment AHI (16.1+/-14.3/h vs 32.5+/-13.1/h, p&lt;0.001). While the trend in AHI reductions suggested a lower AHI in those without insomnia or RLS, the reduction did not reach statistical significance (no insomnia or RLS 15.7+/-12.9/h, insomnia 16.9+/-16.7/h, RLS 19.0+/-15.5/h, both insomnia and RLS 23.4+/-18.4/h). UAS therapy usage was reduced in patients with RLS (3.9+/-2.6 h/night, p=0.029) and in patients with both insomnia and RLS (3.9+/-1.3 h/night, p=0.046) compared to patients with neither comorbidity (5.9+/-1.9 h/night). Mean reduction in ESS was similar across groups, averaging from 11+/-5 pre-treatment to 7+/-5 post-treatment (p&lt;0.001).

Conclusion
Insomnia and RLS are common in patients using UAS therapy for OSA. Pre- and post-treatment residual AHI and ESS significantly improved in all patient groups assessed. A decrease in UAS usage was present in patients with RLS and both RLS and insomnia. Our study suggests that identification and treatment of RLS and insomnia may play an important role for UAS therapy adherence and efficacy, thus, optimizing care.
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440 A Multi-Center Preference study of a Novel Oral Appliance Design and Material
Authors: Murphy Mark 
Published: May 2021

Abstract

Introduction
AASM guidelines for OAT advise sleep medicine physicians to consider patient preference when determining the treatment modality for mild and moderate OSA. This investigation evaluates patient preference for a novel OAT device in comparison with CPAP and other legacy OAT devices.

Methods
A novel OA (ProSomnus EVOTM, Pleasanton, CA) was manufactured from digital records of U/L impressions and bite registrations. 31 Patients (all with one or more legacy OAs and 20 previous CPAP users) across 7 dentists were surveyed regarding preferences of this novel OA using a 0–10 scale. Samples were analyzed for stainability by mustard at 37C for 10 days against representative predicates using colorimetry.

Results
Patient Survey 100% Preferred the novel OA over CPAP, would wear it and easier to clean and preferred over their previous appliance This novel OA was comfortable and smaller 9.3 Easier to close my lips together 8.8 Confident in device durability/will not break 9.1 No crowns were removed/damaged Dentists Survey 81% no adjustment interventions for fit at delivery, average adjustment time was 3.1 min. 100% Would prescribe this novel OA again and recommend to colleagues This novel OA was easier to deliver than other devices 9.1 Retention was just right at delivery 8.9 Would use this novel OA on wider range of patients 9.8 This monolithic novel OA would be easy to keep clean 9.8 Stain Testing in □E from Colorimetry Milled PMMA 3.06 Milled novel OA 3.20 CPAP Mask plastic 7.54 Milled PMMA w/soft Liner/Fulcrum Strap 8.27 CPAP Mask silicone 11.60 PMMA +Liner Anterior Hook 19.05 PMMA with Liner Herbst 32.05 Nylon/Airway 90.70 Nylon/Strap 96.99

Conclusion
Patients preferred this novel OA over CPAP and all other devices similarly designed for comfortable easy fit and delivery (soft liners and printed nylon) without compromising the comfort, cleanability or strength. Liner-less milled devices outperform all other devices with less staining. Color stability from mustard was significantly better for the milled PMMA and this Novel OA materials than all other combinations

Support (if any)
None