bluuebunny/crossref_metadata_2025_split huggingface dataset:
826 Central Sleep Apnea associated with Sodium Oxybate– A Case Series
Authors: Rath Subhendu , Binns Lizabeth , Kaplish Neeraj 
Published: May 2021

Abstract

Introduction
Sodium oxybate (SO) is indicated to treat cataplexy and excessive daytime sleepiness (EDS) in patients with narcolepsy. Only a handful of cases have been reported of new-onset Central Sleep Apnea (CSA) in the setting of SO use. We present 3 patients who developed CSA in the setting of use of SO.

Report of case(s)
Patient 1: A 25-y/o man presented with hypersomnolence. His diagnostic polysomnogram (PSG) showed moderate Obstructive Sleep Apnea (OSA), and he was placed on Continuous Positive Airway Pressure (CPAP) therapy. Due to persistent hypersomnia in the setting of effectively treated OSA, he had a Multiple Sleep Latency Test (MSLT), which revealed pathological sleepiness with a mean latency of 3.8 minutes with a sleep-onset REM on the overnight polysomnogram. SO was started for clinical diagnosis of Narcolepsy after he failed other stimulant medications. Hypersomnolence improved though data from his PAP device, home sleep studies, re-titration studies performed when he was on SO demonstrated CSA following 1st or 2nd dose of SO. Patient 2: A 17-y/o man was diagnosed to have Narcolepsy with Cataplexy, based on PSG followed by MSLT. 20 years later, he was diagnosed with OSA based on a PSG and was treated with CPAP. A few years later, he was started on SO for fragmented sleep and EDS. A home sleep study performed when he was on SO, revealed CSA. Later, an in-lab titration study showed CSA with Cheyne-Stokes respiration (CSR), treated with Adaptive Servo-Ventilation (ASV) therapy. Patient 3: A 15-y/o man initially presented after several cataplectic episodes and was diagnosed with Narcolepsy with Cataplexy. His initial PSG showed no evidence of sleep-disordered breathing. A few years later, for persistent cataplectic events, he was started on SO with improvement in the episodes’ frequency. Several years later, a baseline PSG demonstrated OSA and CSA, with frequent CSA events soon after taking SO. The CPAP titration study, performed following the PSG, also revealed frequent CSA following the second dose of SO.

Conclusion
Close monitoring is warranted with SO use, given some narcolepsy patients’ predisposition to develop CSA. Follow-up studies are needed to address the pathogenesis and management strategies.

Support (if any)
None
828 Challenges of artifact in Polysomnography-An LVAD Story
Authors: Koothirezhi Rupa , Anne Pratibha , Okorie Ugorji , Ho Minh Tam , Monceaux Brittany , Liendo Cesar , Chernyshev Oleg 
Published: May 2021

Abstract

Introduction
Congestive heart failure and sleep-disordered breathing frequently coexist. Many of these patients are referred for polysomnography(PSG). Left ventricular assist device (LVAD) is increasingly used as a destination therapy or as a bridge to transplant. This can lead to artifacts in EEG and EKG. The artifact can mask pathological waves or over-reading of pathology. We present a case report of a patient who underwent a PSG on LVAD.

Report of case(s)
Sixty-six-year old male with severe heart failure with reduced ejection fraction (EF) of 15 % presented with snoring and witnessed apnea. The patient was diagnosed with predominant central sleep apnea (92%) but never initiated BPAP/ST due to an unstable heart. He was placed on LVAD (HeartMate III LVAD, oscillatory speed of 5300 rpm/83.3Hz) as the heart status deteriorated. Repeat polysomnography was done for persistent snoring but improved witnessed apneas revealed a newly appearing artifact. EEG showed a diffuse low amplitude,6–7 Hz frequency waves, and a regularly appearing high voltage sharp-peaked wave. The morphology of alpha wave, K wave, spindles, and delta waves could not be appreciated and hence was unable to perform sleep staging. EKG had electrical artifacts. All troubleshooting maneuvers were unsuccessful in eliminating artifacts. The artifact is generated by the impeller rotational speed of LVAD that ranges from 2400 rpm to 10,00 rpm(oscillation frequencies of 40 Hz to 166.7 Hertz,1Hz == 60 rpm). The device’s artificial pulse causes additional minor peaks. EEG artifact can be improved by moving the amplifier away from the heart and repositioning the patient. Adjusting the low-frequency filter can affect the nasal pressure tracing, delta waves, and stage 3 recognition. Reducing the high-frequency filter frequency by 10 from the LVAD oscillation frequency improves the EKG signal. But this may cut off the frequency component of pathologies like left ventricular hypertrophy.

Conclusion
The LVAD has been increasingly used in the United States. It is important to improve awareness regarding the artifacts among sleep techs and physicians. Unresolved artifacts may lead to missing serious pathologies in EEG and EKG and also can lead to misreading the waves as pathological leading to unnecessary treatment.

Support (if any)
An image of EEG and EKG
830 Combined Phototherapy and Melatonin for treatment of Circadian Rhythm Disorder in a Patient with Cornelia de Lange Syndrome
Authors: Emanuel Hina , Revana Amee , Te Tue , Kaplan Kevin 
Published: May 2021

Abstract

Introduction
Cornelia de Lange syndrome (CdLS) is a rare genetic disorder characterized by variable physical, cognitive, and behavioral characteristics. Sleep disturbances have been frequently reported in CdLS including insomnia, sleep-disordered breathing, intrinsic sleep disorders, and circadian rhythm disorders (CRDs). The characterization and prevalence of CRDs in CdLS remain ill- defined. We report a case of a 13-year-old female with CdLS presenting with advanced sleep wake phase disorder (ASWPD).

Report of case(s)
A 13-year-old female with a past medical history of CdLS, developmental delay, bilateral cleft palate status post repair presents with inability to fall asleep at night and excessive daytime sleepiness.(EDS) Her sleep history consists of going to bed at 4 pm with no delayed sleep onset. She wakes at 2:30 am which has occurred since infancy. Mother reports the patient will remain awake from 2:30 am until she goes to school at 7:30 am. History is consistent with EDS and sleeping during the day while at school. Total sleep time of approximately 11–12 hours was reported in 24-hour period. History of obstructive sleep apnea, parasomnias, insomnia, restless leg syndrome, and psychotropic medications were not reported. Patient was treated with timed low dose melatonin therapy 0.5 mg at 4 pm and bright light therapy using 10,000 lux for 30 minutes at 7 am and 4 pm. Dim lights starting at 7:30 pm with structured scheduled sleep hygiene ensuring consistent bedtime at 9:30 pm. A consistent wake time at 7 am and no naps during the day was recommended. Follow up visits report successful response to therapy with attainment of desired sleep wake rhythm (bedtime at 9:30 pm and wake time at 7 am) and resolution of sleepiness during the day. Our patient was able to be weaned off of melatonin and light therapy and her circadian rhythm remained entrained.

Conclusion
Patients with disorder such as CdLS are at risk for circadian rhythm disorders. Our patient responded well to treatment with combined timed phototherapy and low dose melatonin therapy. Better knowledge and characterization of typology of CRDs in CdLS patients could permit a more specific therapeutic approach to sleep disorders in this population.

Support (if any)
None
837 Narcolepsy in a toddler
Authors: Sekhon Anupamjeet , Prero Moshe , Ross Kristie , Ibrahim Sally 
Published: May 2021

Abstract

Introduction
Narcolepsy is a central disorder of hypersomnia with a bimodal peak incidence at ages 15 and 35. Onset in early childhood has been reported, but rarely under the age of 5. We present a case of Narcolepsy Type 1 in a 2.5-year-old with dropping spells.

Report of case(s)
A 2.5-year-old African American healthy male presented with acute onset sudden drops, unsteady gait, and staring spells. These episodes lasted a few seconds, occurred multiple times a day, and were associated with eye fluttering and dysarthric speech. History was notable for increased daytime sleep/sleep attacks, disrupted nocturnal sleep with confusional arousals, nightmares and sleepwalking, weight gain and mood instability with aggressive behavior. No preceding head injury or illness. Physical examination demonstrated frequent atonic episodes with loss of deep tendon reflexes. A clinical suspicion of myoclonic/atonic epilepsy prompted video- electroencephalogram (EEG) which showed frequent bursts of generalized intermittent slowing representative of NREM 1 sleep lasting several seconds. Magnetic resonance imaging of the brain and infectious workup was unremarkable. Cerebrospinal fluid (CSF) Orexin was &lt;50 pg/mL. While 76–98% of patients with narcolepsy type-1 have HLADQB1*06:02, our patient tested negative. Due to lack of MSLT validity at this age, only diagnostic PSG was performed which showed REM without atonia and sleep fragmentation. Prior to sleep onset, cataplexy was observed in the patient while laughing, though EMG tone was relatively preserved during this episode. We had limited treatment options considering lack of FDA approved medications for ages less than 7. A helmet was prescribed to prevent head injury. Methylphenidate 5mg/day improved sleepiness and slightly stabilized mood. For cataplexy, neither Fluoxetine nor Imipramine helped. His mother disapproved further medication trials. Continuing methylphenidate, the family was referred to behavior psychology for support, coping with the diagnosis and behavioral changes.

Conclusion
This case demonstrates an unusual presentation of Narcolepsy Type 1 in a toddler initially thought to have epilepsy. Video-EEG and low CSF orexin led to the diagnosis. His age, severity of cataplexy, mood changes, and parental concerns made treatment challenging. Furthermore, this case highlights the importance of early recognition of Narcolepsy in young children to provide appropriate treatment during critical developmental stages.
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839 Not Your Everyday Daytime Sleepiness: Two Peas in a Pod
Authors: Stuewe Elena , Ostrow Peter , Grover Aarti , Schumaker Greg , Oster Joel , Zacharias Rajesh 
Published: May 2021

Abstract

Introduction
Obstructive sleep apnea (OSA) and narcolepsy are both causes of excessive daytime sleepiness (EDS). OSA is a more prevalent diagnosis, but it can coexist with narcolepsy and confound diagnosis. We present a case of a delayed diagnosis of type 2 narcolepsy in a patient with known OSA.

Report of case(s)
A 31-year-old man with depression treated with sertraline and prior history of severe OSA diagnosed at an outside facility presented to our clinic for residual excessive daytime sleepiness. He demonstrated adequate adherence to continuous positive airway pressure (CPAP) of 13 cmH2O over a period of one year, good sleep hygiene and adequate sleep duration. He reported vivid dreams and sleep paralysis in the past, but none recently. There was no history of a delayed sleep phase. He denied hypnagogic or hypnopompic hallucinations or cataplexy. An in-lab polysomnogram (PSG) followed by multiple sleep latency test (MSLT) was ordered for further evaluation. Sertraline was held 2 weeks prior to the study. Overnight PSG on CPAP showed adequate treatment of OSA on CPAP pressures of 13–16 cmH2O. MSLT showed 3/5 sleep-onset rapid eye movement periods with a mean sleep latency of 5.8 minutes. A diagnosis of coexisting type 2 narcolepsy was made. Treatment was initiated with modafinil; however, his symptoms of EDS persisted and he was changed to methylphenidate with subsequent improvement.

Conclusion
The case above highlights the importance of maintaining a broad differential when investigating the etiology of EDS. In particular, patients with narcolepsy often experience a significant delay between onset of symptoms and receiving a diagnosis. Diagnosis can be confounded by a lack of classic symptoms and/or the presence of another sleep-related breathing disorder, as in the patient above. Residual EDS can be seen in patients with adequately treated OSA. There is sparse data regarding the co-prevalence of narcolepsy as the etiology of residual EDS in adequately treated OSA. Patients should still be screened for symptoms suggestive of narcolepsy. Persistence of EDS symptoms in young adults with adequately treated OSA should raise suspicion for another sleep-related disorder and merits further investigation.
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864 New-onset Obstructive Sleep Apnea Diagnosis in a COVID-positive Patient
Authors: Nguyen Nobel , Mebust Kimberly 
Published: May 2021

Abstract

Introduction
Risk factors for the mortality of COVID-19, such as cardiovascular and lung disease, are commonly seen in patients with obstructive sleep apnea (OSA). Patients with OSA experience approximately 8-fold greater risk for COVID-19 infection compared to a similar age population. Among patients with COVID-19 infection, OSA was associated with an increased risk of hospitalization and approximately doubled the risk of developing respiratory failure. However, there is little information on whether COVID-19 can directly develop OSA. To the best of our knowledge, we describe the first case-presentation of a positive COVID-19 patient who developed sudden-onset OSA.

Report of case(s)
NL is a 47-year-old female who complains of new-onset snoring, excessive daytime sleepiness, and witnessed apnea events after testing positive for COVID-19 seven months prior after developing mild symptoms. Her ESS score is 12/24, neck circumference is 14.75 cm, BMI is 27.9, and Mallampati II. She has no pertinent PMH and is not a tobacco user. In regards to her sleep, she has no symptoms of restless legs, narcolepsy, or periodic limb movements. She denies any physical disturbances, psychiatric conditions, environmental factors, or medical issues that might affect her sleep. There is no family history of sleep apnea, snoring, or other sleeping disorders. The patient's presentation at the initial sleep visit prompted a home sleep study. Results of her home sleep study revealed 131 total number of sleep-related respiratory events, with an apnea-hypopnea index of 11.9 per hour. Mean oxygen saturation was 94% and the minimum oxygen saturation was 83%. Total estimated sleep time was 7 hours, 59 mins, and sleep quality and duration were deemed adequate. The results from NL's sleep study gave the final diagnosis of mild OSA.

Conclusion
Besides having a slightly overweight BMI, NL had relatively few risk factors for developing OSA (no family history, no comorbidities, and normal physical exam findings). The link between the virus and the development of OSA in healthy individuals is not readily apparent. We recommend sleep studies for healthy patients who develop OSA like-symptoms after being infected with COVID-19 to prevent unwanted health risks associated with OSA.
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A Novel Teaching Strategy in Nursing Pharmacology: Learning Using Cognitive Load Theory
Authors: Mauldin Betsy 
Published: May 2021

Abstract
Nursing pharmacology is a complex and content-dense course that is often difficult for educators and students. Cognitive load theory explains why utilizing slide decks for instruction overloads the working memory and impedes processing information into long-term memory. An instructional design change in a baccalaureate nursing pharmacology course provided an example of understanding the impact of cognitive load theory. The Pharmacology Phamily Project is a multimodal, multiphase assignment in which students created a case study video about a unique medication and presented it via discussion board for peer feedback and learning. Student investment improved over traditional past semesters, and student-to-instructor feedback was positive.
Providing Mentorship and Support for ADN-BSN Students Enrolled in a Partnership Model
Authors: Johnson M. Deonne , Kumm Sharon 
Published: May 2021

Abstract
In response to the Institute of Medicine Future of Nursing report goal to increase the proportion of baccalaureate degree nurses to 80 percent, a plan known as the “Partnership Model” was implemented to allow students accepted into community college programs to enroll concurrently in university courses. The plan enabled students to complete a cost-effective baccalaureate degree and associate degree in nursing simultaneously. All 66 students participating in spring 2019 were encouraged to complete a survey to evaluate support and stressors associated with the program. Results from 54 respondents were used to improve the Partnership Model experience.
Progression of Tibia Fracture Healing Using RUST: Are Early Radiographs Helpful?
Authors: Wojahn Robert D. , Bechtold Daniel , Abraamyan Torgom , Spraggs-Hughes Amanda , Gardner Michael J. , Ricci William M. , McAndrew Christopher M. 
Published: May 2021

Objectives:
To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs.

Design:
Retrospective case series.

Setting:
Urban academic Level 1 trauma center.

Patients/Participants:
Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up.

Intervention:
Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure.

Main Outcome Measurements:
Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure.

Results:
The fifth percentile and median times, respectively, for reaching “any radiographic healing” (RUST = 5) was 4.0 weeks and 8.4 weeks, “radiographically healed” (RUST = 9) was 12.1 and 20.9 weeks, and “healed and remodeled” (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs.

Conclusions:
The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection.

Level of Evidence:
Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Extracorporeal Cytokine Adsorption Therapy As a Preventive Measure in Cardiac Surgery and As a Therapeutic Add-On Treatment in Sepsis: An Updated Systematic Review of Comparative Efficacy and Safety*
Authors: Goetz Gregor , Hawlik Katharina , Wild Claudia 
Published: May 2021

OBJECTIVES:
Evaluating whether there is a clinical benefit of using extracorporeal cytokine adsorption therapy in two indications.

DESIGN:
Systematic review.

SETTING:
Search on four databases, Medline, Embase, The Cochrane Library, and the European Network for Health Technology Assessment planned and ongoing projects database.

PATIENTS:
Patients with sepsis/septic shock; patients undergoing cardiac surgery

INTERVENTIONS:
Cytokine adsorption.

MEASUREMENTS AND MAIN RESULTS:
Randomized controlled trials and prospective studies with concurrent control were eligible for the evidence synthesis. The quality of the individual studies and the strength of the available evidence were assessed using the Cochrane risk of bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach, respectively. For the preventive treatment of extracorporeal cytokine adsorption therapy in patients undergoing cardiac surgery, we found very low-quality inconclusive evidence for mortality (five randomized controlled trials, n = 163), length of stay in the ICU (five randomized controlled trials, n = 163), and length of hospitalization (three randomized controlled trials, n = 101). Very low-quality inconclusive evidence was found for (serious) adverse events (four randomized controlled trials, n = 148). For the therapeutic treatment of extracorporeal cytokine adsorption therapy in patients with sepsis/septic shock, we found very low-quality inconclusive evidence for mortality up to 60-day follow-up (two randomized controlled trials, n = 117), organ function (two randomized controlled trials, n = 117) and length of stay in the ICU (one randomized controlled trial, n = 20). Very low-quality inconclusive evidence was found for (serious) adverse events (two randomized controlled trials, n = 117).

CONCLUSIONS:
Given the available evidence, the efficacy and safety of extracorporeal cytokine adsorption therapy in combination with standard care in the investigated indications was not established. We strongly recommend considering well-powered studies with patient-relevant endpoints instead of investing further research funds on studies that may not shed light on the clinical benefit of extracorporeal cytokine adsorption therapy.
Application of Full-Spectrum Rapid Clinical Genome Sequencing Improves Diagnostic Rate and Clinical Outcomes in Critically Ill Infants in the China Neonatal Genomes Project*
Authors: Wu Bingbing , Kang Wenqing , Wang Yingyuan , Zhuang Deyi , Chen Liping , Li Long , Su Yajie , Pan Xinnian , Wei Qiufen , Tang Zezhong , Li Yangfang , Gao Jin , Cheng Rui , Zhou Wei , Wang Zhangxing , Qiu Gang , Wang Jian , Yang Lin , Zhang Ping , Zhao Xuemei , Wang Yao , Gan Mingyu , Li Gang , Liu Renchao , Ni Qi , Xiao Feifan , Yan Kai , Cao Yun , Lu Guoping , Lu Yulan , Wang Huijun , Zhou Wenhao 
Published: May 2021

OBJECTIVES:
To determine the diagnostic and clinical utility of trio-rapid genome sequencing in critically ill infants.

DESIGN:
In this prospective study, samples from critically ill infants were analyzed using both proband-only clinical exome sequencing and trio-rapid genome sequencing (proband and biological parents). The study occurred between April 2019 and December 2019.

SETTING:
Thirteen member hospitals of the China Neonatal Genomes Project spanning 10 provinces were involved.

PARTICIPANTS:
Critically ill infants (n = 202), from birth up until 13 months of life were enrolled based on eligibility criteria (e.g., CNS anomaly, complex congenital heart disease, evidence of metabolic disease, recurrent severe infection, suspected immune deficiency, and multiple malformations).

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Of the 202 participants, neuromuscular (45%), respiratory (22%), and immunologic/infectious (18%) were the most commonly observed phenotypes. The diagnostic yield of trio-rapid genome sequencing was higher than that of proband-only clinical exome sequencing (36.6% [95% CI, 30.1–43.7%] vs 20.3% [95% CI, 15.1–26.6%], respectively; p = 0.0004), and the average turnaround time for trio-rapid genome sequencing (median: 7 d) was faster than that of proband-only clinical exome sequencing (median: 20 d) (p < 2.2 × 10–16). The metagenomic analysis identified pathogenic or likely pathogenic microbes in six infants with symptoms of sepsis, and these results guided the antibiotic treatment strategy. Sixteen infants (21.6%) experienced a change in clinical management following trio-rapid genome sequencing diagnosis, and 24 infants (32.4%) were referred to a new subspecialist.

CONCLUSIONS:
Trio-rapid genome sequencing provided higher diagnostic yield in a shorter period of time in this cohort of critically ill infants compared with proband-only clinical exome sequencing. Precise and fast molecular diagnosis can alter medical management and positively impact patient outcomes.