bluuebunny/crossref_metadata_2025_split huggingface dataset:
781 Insomnia is Associated with Anger Expression in an Army Population
Authors: Estabrook Grace , Goldschmied Jennifer , Miller Katherine , Klingaman Elizabeth A , Gehrman Philip 
Published: May 2021

Abstract

Introduction
Emotion-regulation and sleep-related difficulties are intertwined. Most research has focused on the impact of poor sleep on internalizing symptoms (e.g. depression, anxiety) but a few studies have found a that increased insomnia is associated with more externalizing symptoms (e.g. anger). This relationship may be particularly salient for military personnel, for whom poor sleep is endemic. It is important that this relationship be further investigated in order to understand the issues that Army servicemembers face.

Methods
Data were acquired from the All Army Study of the Army Study to Assess Risk and Resilience in Servicemembers (STARRS; N=21,449; 18–61 years old; 86.5% male). Participants completed the Brief Insomnia Questionnaire, an 11-item irritability and anger-related questionnaire and a 10-item questionnaire on anger attacks. Pearson correlations were used to examine the relationship between insomnia symptoms and emotional and behavioral components of anger, while controlling for depressive symptom severity.

Results
Insomnia severity in the past 30 days was significantly correlated with both emotional and behavioral expressions of anger (all p&lt;0.001, r = .2 to .4). Overall insomnia severity and early morning awakenings (EMA) had the strongest relationships. These relationships were still significant after controlling for depression severity.

Conclusion
In a nationally-representative sample of Army servicemembers, insomnia severity, particularly EMA, was associated with higher levels of irritability and anger (outbursts and anger attacks) over and above the effects of depression. These findings highlight the importance of treating insomnia in order to regulate anger expression within a military population.

Support (if any)
This publication is based on public use data from Army STARRS (Inter-university Consortium for Political and Social Research, University of Michigan-http://doi.org/10.3886/ICPSR35197-v1), funded by U.S. NIMH-U01MH087981.
784 Naturalistic Measurement of Sleep/Wake Disturbance in Adults Receiving Methadone Treatment for Opioid Use Disorder
Authors: Skeiky Lillian , Hansen Devon , Layton Matthew , Quock Raymond , Van Dongen Hans , Wilson Marian 
Published: May 2021

Abstract

Introduction
Individuals with opioid use disorder (OUD) report significant sleep/wake disturbance, which continues even after stabilization on medication-assisted treatment (MAT). However, the nature of sleep/wake disturbance in this population has not been well documented objectively. Here we analyze naturalistic wrist actigraphy recordings in individuals with OUD receiving methadone-based MAT.

Methods
Seven adults undergoing methadone treatment for OUD (ages 26–50; 4 women) wore a wrist actigraph (Actiwatch-2, Philips Respironics) continuously for 7 days. They were asked to adhere to their normal sleep schedule in order to obtain naturalistic observations. Reference data were collected in a separate study of healthy controls, in which 14 hospital nurses (ages 20–60; 13 women) wore a wrist actigraph continuously for 7 days. In this reference group, 7 participants had a day shift schedule (07:00–19:00) and 7 had a night shift schedule (19:00–07:00), with six 12h shifts in a 2-week period. Actigraphic data were collected in 1min epochs, and the sleep/wake status for each epoch was estimated using Actiware 6.0.9 (Philips Respironics). The estimated sleep/wake patterns were subjected to cosinor analysis to assess 24h rhythmicity and analysis of the distribution of inactive periods to assess sleep continuity.

Results
For the reference group, nurses working day shifts displayed strong 24h rhythmicity, whereas nurses working night shifts showed blunted 24h rhythmicity (F[1,12]=66.11, p&lt;0.001). However, both day and night nurses exhibited high sleep continuity (KS test, p=0.82). By contrast, for the group with OUD receiving methadone, the strength of 24h rhythmicity was reduced to between that of the day and night shift nurses in the reference group, indicating weak regularity of sleep/wake patterns (F[2,18]=33.79, p&lt;0.001). Furthermore, individuals with OUD receiving methadone experienced low sleep continuity compared to the reference group (KS test, p=0.030).

Conclusion
These naturalistic observations confirm the presence of sleep/wake disturbance, resulting from both irregular sleep/wake patterns and low sleep continuity, in individuals receiving methadone-based MAT for OUD. Sleep/wake disturbance may interfere with the ability to achieve OUD recovery goals, and comparing sleep disturbance in MAT populations to reference data highlights the need to consider sleep in these populations as a clinical priority.

Support (if any)
State of Washington Initiative Measure No. 171
787 OSA Risk is Associated with Number of White Matter Hyperintensities, But History of Mild TBI is Not: A LIMBIC-CENC Study
Authors: Garcia Amanda , Wilde Elisabeth A , Tate David , Reljic Tea , Kenney Kimbra , Troyanskaya Maya , Agyemang Amma , Walker William C , Nakase-Richardson Risa 
Published: May 2021

Abstract

Introduction
Individuals with a history of mild traumatic brain injury (mTBI) have higher risk levels for obstructive sleep apnea (OSA). However, no studies have examined the association between OSA and white matter hyperintensities (WMHs) in this group. The purpose of this study is to explore the relationship between OSA risk, mTBI, and WMHs in a military cohort with a history of combat deployment.

Methods
Secondary analyses were conducted from a large clinical database of a multi-center, longitudinal study of current and former military personnel. Participants were included who had complete STOPBANG (sleep apnea risk) data and MRI. Univariable and multivariable regressions were conducted, including age, race, gender, education, hypertension, diabetes, history of mTBI, and STOPBANG score in the models.

Results
The final sample (N=1017) included participants with (n=823) and without (n=194) a history of mTBI. The sample was predominantly male (87%) with a median age of 38 (IQR; 32–48). WMHs were reported in 37% of the sample. Univariate analyses revealed that increasing age, female sex, hypertension, diabetes, and higher sleep apnea risk score were each positively associated with higher number of WMHs, while a history of lifetime mTBI exposure was not associated. Multivariable analyses revealed that of these factors, only age remained associated with WMH presence. When restricting the sample to the 37% with WMHs, OSA risk and female sex were each associated with higher number of WMHs (p&lt;.05), but history of mTBI was not.

Conclusion
Consistent with the literature in non-brain injured populations, age was the strongest predictor of WMH presence and number. In those with identified WMHs, OSA risk was a significant predictor of WMH number, while history of mTBI was not. Thus, in persons with mTBI, presence of WMHs may be linked to sleep comorbidities, providing potential treatment targets. Limitations include assessment of OSA rather than established diagnosis.

Support (if any)
Defense and Veterans Brain Injury Center (HT0014-19-C-004), DOD(W81XWH-13-2-0095), VA(I01 CX001135). The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICoEinfo@mail.mil. UNCLASSIFIED
796 Quantitative EEG Analysis in Angelman Syndrome
Authors: Hosamane Nishitha , Levin Yuval , McNair Taylor , Sidorov Michael 
Published: May 2021

Abstract

Introduction
Angelman syndrome (AS) is a neurodevelopmental disorder resulting from decreased expression of the maternal copy of the imprinted UBE3A gene on chromosome 15. This disorder is characterized by intellectual disability, impaired speech and motor skills, and sleep abnormalities but currently lacks any treatment. However, mouse models have shown that un-silencing the dormant paternal copy of UBE3A has been an effective mechanism to restore the functionality of the UBE3A protein, thus clinical trials using this approach are on the near horizon. Developing biomarkers is essential for assessing responses to treatment when clinical trials begin, and quantitative EEG analysis has shown great promise as a biomarker for AS.

Methods
Here, we sought to define EEG biomarkers directly linked to sleep impairments seen in up to 90% of individuals with AS (Trickett). We analyzed nine overnight sleep studies from patients with AS with age and sex matched Down syndrome and neurotypical controls. We specifically examined low-frequency delta rhythms and sleep spindles during NREM sleep.

Results
We confirmed that low- delta rhythms are increased during overnight sleep in AS, and that this biomarker appears more reliable than possible changes in sleep spindles.

Conclusion
Our results suggest that quantitative measurement of delta rhythms during sleep can be used as a potential biomarker for treatments in Angelman syndrome clinical trials.
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802 Seizure-Associated Central Respiratory Events: What’s Sleep Go To Do With It?
Authors: Mingbunjerdsuk Prompan , Andrews Noah , Wang Lu , Aboussouan Loutfi , Mehra Reena , Grigg-Damberger Madeleine , Foldvary-Schaefer Nancy 
Published: May 2021

Abstract

Introduction
Seizure-related respiratory dysfunction has been reported in patients with epilepsy(PWE) on scalp EEG. We assessed this in Stereo-EEG(SEEG) recordings in patients with pharmacoresistant focal epilepsy.

Methods
PWE undergoing SEEG wore temperature/pressure-based airflow,RIP belts, SpO2, and EtCO2/TcpCO2. Interpretable recordings required SpO2 and at least one airflow and effort channel. Respiratory events including apneas, hypopneas(3%) and central pauses (5 to&lt;10sec). Respiratory events, respiratory rate(RR), SpO2 nadir, total desaturation time, Peak EtCO2/TcpCO2, and hypercapnia duration were analyzed surrounding seizures. Frequency and duration of central events were compared in sleep-onset and awake seizures. Linear mixed-effects models evaluated relationships between respiratory variables and the frequency and duration of central events associated with seizures and compared respiratory variables between seizures with and without events.

Results
44 seizures were recorded in 23 patients. Seizures were focal-onset in 79.5%(n=35), GTC in 20.5%(9). Respiratory events accompanied 61.4%(27) of the seizures with median duration/seizure duration of 0.40(IQR: 0.27, 0.61). Of the 47 respiratory events, 42 were central events, and 66.6%(28) were central apneas. Respiratory events occurred during the seizure in 73.8%, postictal in 26.2%; median SpO2 nadir was 90%(77.0, 93.0), total desaturation duration 104.3(50.3, 195.0)sec, peak TcpCO2 41.3(38.7, 44.8) mmHg, hypercapnia duration 157.6(51.0, 367.9) sec, and ictal-postictal RR change 3.3 ± 4.0bpm. For every 1 sec duration increase in central event duration, there was a significant increase in peak TcpCO2 0.35(95%CI [0.09,0.62],p=0.015) and TcpCO2 change 0.25(95%CI [0.02,0.49],p=0.037). Presence of central events were associated with increased peak TcpCO2(9.82[3.77,15.9], p=0.006). Seizures with central events trended greater changes in RR, SpO2, and EtCO2/TcpCO2, desaturation and hypercapnia time, with negative changes in SpO2 nadir. No significant difference on central event frequency was found between sleep-onset and awake seizures.

Conclusion
Central events including apneas and pauses are common in focal seizures arising from sleep and wake and are associated with hypercapnia. In addition to the significant association between TcpCO2 and the frequency and duration of central events, there is a positive trend of association of other respiratory dysfunction parameters. These findings suggest that central events may lead to a cascade of respiratory disturbance that may participate in the pathophysiology of sudden unexplained death in epilepsy.
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805 Towards a more perfect union: interrater reliability between telemedicine and in-person evaluators in sleep disordered breathing
Authors: Yurcheshen Michael , Pigeon Wilfred , Marcus Carolina , Marcus Jonathan , Messing Susan , Nguyen Kevin , Marsella Jennifer 
Published: May 2021

Abstract

Introduction
Telemedicine has rapidly changed the landscape of all of clinical practice, and is now widely employed in sleep medicine. To date, the accuracy of telemedicine in identifying patients at risk for obstructive sleep apnea (OSA) is still unknown. Given differences in technique and fidelity, a perfect correlation between these two types of encounters cannot be assumed. We studied how providers using a telemedicine platform compared to providers using traditional in-person encounters in identifying risk for sleep disordered breathing.

Methods
90 participants referred to a comprehensive university sleep program were randomized to this interrater reliability study. Subjects were representative of the gender and ethnic breakdown of the outlying community. The subjects were evaluated by an in-person clinician investigator, then randomized to a second clinician investigator who performed an evaluation online using a common teleconferencing platform. Both types of evaluations included a history and physical exam. The primary outcome was pretest probability for obstructive sleep apnea. Secondary comparators included level of daytime sleepiness, snoring volume, apneas witnessed by a third party, modified Mallampati score, presence/absence of tonsils, degree of overjet bite, and severity of apnea based on home sleep testing.

Results
Interrater reliability for pretest probability of OSA was reflected in a weighted kappa value of 0.414 (SE 0.090, p=0.002). This suggests moderate agreement between the an in-person and telemedicine evaluator. Kappa values of our secondary outcomes ranged from -0.044 (degree of maxillary overjet) to 0.702 (apneas witnessed by a third party), and were generally higher for historical elements and lower for physical exam findings.

Conclusion
Evaluation for pretest probability for sleep apnea via telemedicine has a moderate interrater correlation with in-person assessment. A relatively high degree of interrater reliability for historical elements suggests that the accuracy of telemedicine for OSA is tempered by a suboptimal physical exam. Telemedicine evaluations might become more accurate through standardization. For instance, using validated scales for OSA or templated encounter scripts may help with risk-stratification, and ultimately lead to more uniform management.

Support (if any)
This study was supported by an AASM Foundation Focused Project Award
807 Diagnostic Pathways of Patients Authorized for Obstructive Sleep Apnea Testing and Treatment: A Retrospective Claims Analysis
Authors: Nguyen Binh , Gordon Aliza , Blake Stefanida , Kalluri Lakshmi , Chi Winnie , Power Thomas 
Published: May 2021

Abstract

Introduction
Obstructive Sleep Apnea (OSA) has been shown to reduce health-related quality of life and is associated with cardiovascular disease and other negative health outcomes. However, many patients with suspected OSA are never tested, thereby remaining undiagnosed and untreated. In this study, we explore the diagnostic pathways and eventual treatment of individuals with suspected OSA.

Methods
We conducted a retrospective, observational study, linking claims and prior authorization data of a large, geographically diverse health insurer’s commercial and Medicare Advantage members. Our sample included adults with suspected OSA and no prior OSA history, whose diagnostic testing had been approved through prior authorization (N=75,011). Using a 3-month time window following authorization, we searched for a claim to match the authorized service (home or laboratory sleep testing). We also looked for subsequent prior authorization for OSA treatment (Positive Airway Pressure (PAP) or oral appliance) and corresponding claims for those treatments within the 3-month authorization window.

Results
Among the study sample (N=75,011), 40,002 (53.3%) had home testing only, 17,319 (23.1%) had laboratory testing only, and 6,053 (8.1%) had a home test followed by a laboratory test. Only 476 (0.6%) had a home test after the date of a lab test. 11,161 individuals (14.9%) did not complete any sleep test. Of the 63,850 individuals with any sleep testing, 39,062 (61.2%) received prior authorization for initiating OSA treatment, and 36,158 (92.6%) of them had a corresponding claim for treatment.

Conclusion
One in eight adults with suspected OSA for whom diagnostic testing was authorized did not undergo testing; among those who tested, home testing was most common. While it is clinically appropriate to follow a negative home test with a lab test since a home test cannot rule out OSA (only confirm it), the study notes that a significant number of those with a home test require follow-up laboratory testing. Together, this represents an opportunity for reducing barriers to testing and improvement in home testing technology.

Support (if any)
This study was funded by Anthem, Inc.
821 An Unusual Pediatric PAP Compliance Obstacle, Even When the Mask Fits
Authors: Upchurch Andrew , Kasi Ajay , Harford Kelli-Lee , Leu Roberta 
Published: May 2021

Abstract

Introduction
Proper mask fitting is an important factor for compliant and effective use of PAP therapy. However, we present 2 patients whose masks became a barrier to PAP therapy despite a well-fitting mask.

Report of case(s)
Case 1 A 12-year-old female with ADHD, Chiari I malformation status-post decompression, and persistent mixed central and obstructive sleep apnea is managed with BPAP S/T. Despite absence of upper airway structural abnormalities, she is a mouth-breather during sleep and only tolerates full face masks. Despite ensuring a good mask fit and optimal BPAP settings to control her AHI, she sleeps with her neck hyperextended, resulting in her lower jaw pushing caudally and the mask liner slipping into her mouth. This stimulated chewing and resulted in damage to several masks. Case 2 An 8-year-old male with congenital central hypoventilation syndrome is managed with BPAP S/T during sleep. Similar to case 1, he is a mouth-breather during sleep and can only tolerate full face masks. Although his mask and headgear fit him well, he drools in sleep which results in the silicone liner slipping into his mouth, stimulating chewing. This has led to the need for replacement of several masks. Of note, drooling did not occur when he was previously using assisted ventilation via tracheostomy, and bruxism was not identified during polysomnography.

Conclusion
To our knowledge, this is the first report of PAP mask chewing, thus its incidence is unknown. We suspect that the mask liner slipping into the mouth touches the anterior surfaces of the teeth stimulating the chewing reflex. The frequency of mask chewing and consequent damage is unpredictable and often necessitates mask replacement. Insurance companies should consider this unique mask complication when determining their mask coverage policies since the typical 6-months interval for authorization of a new mask can impair the patient’s health, PAP compliance, and become an out-of-pocket financial burden for families. Although it did not occur in our patients, mask chewing may pose a potential choking hazard. Awareness of mask chewing may help in improving pediatric PAP mask development to ensure masks are safe.
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822 Apnea every 5 minutes
Authors: Sekhon Anupamjeet , Chiang Ambrose , Strohl Kingman , Yeh Eric 
Published: May 2021

Abstract

Introduction
Vagal Nerve Stimulators (VNS) are used in refractory epilepsy and depression. VNS are known to decrease airflow, oxygen saturation, and respiratory amplitude during sleep. We present a case of VNS induced OSA that was overlooked for 6 years.

Report of case(s)
A 63-year-old Caucasian female with refractory depression, hypothyroidism, and obesity presented with snoring and excessive daytime sleepiness (EDS). She had VNS implanted in a research trial for depression. She was on bupropion, duloxetine, lithium carbonate, lamotrigine, olanzapine, and levothyroxine. Polysomnography (PSG) showed moderate OSA with apnea-hypopnea index (AHI) of 25.8 and SpO2 nadir of 83%, and was titrated to bi-level positive airway pressure (PAP). She tried different masks and pressures but her leak and PAP intolerance persisted. There was no improvement in her EDS, and Armodafinil was prescribed for wake promotion. She struggled with bi-level PAP therapy for five years before being considered for hypoglossal nerve stimulator. But was turned down because of VNS presence. She was then recommended maxillomandibular advancement (MMA) but decided against it. She continued PAP therapy until a repeat PSG revealed mild to moderate OSA (AHI 10.9, RDI 17.8, and SpO2 nadir 79%), and it was noted that most of her respiratory events appeared in a regular fashion at 300-second intervals corresponding with the firing of VNS. PSG performed with VNS turned off showed no OSA (AHI 0.8 and SpO2 nadir 85%). PAP therapy was discontinued and subsequent nocturnal pulse oximetry showed normal oxygenation (ODI 15, RDI 17.8, SpO2 &lt;88% for only 1.7 minutes). Her EDS resolved and VNS was eventually removed as per patient’s preference. She was started on a new medical therapy for depression. She continues to be asymptomatic.

Conclusion
Ascertainment bias led to delay in recognition of the cause of OSA as focus was on treatment only. Lowering the VNS frequency, increasing cycle time, turning it off during sleep or removal can improve respiratory events. The decision to do so depends on perceived benefit and harm of continuing VNS therapy. This case highlights the importance of re-evaluation of causes and treatment strategies when the standard of care is ineffective.
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