bluuebunny/crossref_metadata_2025_split huggingface dataset:
844 Pediatric Vagus Nerve Stimulator-Induced Obstructive Sleep Apnea
Authors: Nouraddin Nouraddin , Amos Louella 
Published: May 2021

Abstract

Introduction
Vagus nerve stimulation (VNS) is an adjunct treatment for seizures refractory to medications. VNS in children with epilepsy can reduce seizures by up to 90%. VNS settings include stimulation on-time, off-time, frequency and output current. Complications of VNS include sleep-disordered breathing due to laryngopharyngeal dysfunction, which can also cause voice alteration, hoarseness, and cough. Both obstructive apneas (more common) and central apneas can be seen in those patients who have VNS-induced sleep-disordered breathing.

Report of case(s)
A 14-year-old male with Lennox-Gastaut syndrome treated with multiple antiepileptic drugs and VNS was admitted to the PICU with worsening seizures. He developed acute respiratory failure due to status epilepticus, requiring intubation. After extubation, he was observed to have repetitive respiratory obstruction at regular intervals, occurring throughout the day and night, and associated with mild oxygen desaturations. Polysomnography showed cyclical obstructive respiratory events lasting 30 seconds followed by approximately 2-minute intervals of regular breathing. Interrogation of his VNS device revealed the following settings: output current of 1.75 mA, 30 seconds on, and 1.8 minutes off. CPAP therapy improved his oxygen saturations, but he continued to clinically exhibit the repetitive obstructive apneas even on positive pressure. However, after his VNS device settings were decreased, repeat polysomnography showed resolution of his obstructive breathing.

Conclusion
This case report demonstrates pediatric VNS-induced obstructive sleep apnea. Activation of the vagus nerve can cause laryngopharyngeal dysfunction, including laryngospasm and vocal cord dysfunction, with subsequent upper airway obstruction, causing obstructive apneas or hypopneas. Treatment options for pediatric VNS-induced OSA include CPAP, decreasing the VNS settings and adenotonsillectomy.
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845 Progressive external ophthalmoplegia in sleep apnea presenting as floppy eyelid syndrome
Authors: Anne Pratibha , Koothirezhi Rupa , Okorie Ugorji , Tam Ho Minh , Monceaux Brittany , Liendo Cesar , Asghar Sheila , Chernyshev Oleg 
Published: May 2021

Abstract

Introduction
Floppy eye lid syndrome (FES) is known to be associated with Obstructive sleep apnea (OSA) and chronic progressive external ophthalmoplegia (CPEO) is a rare genetic disorder with mitochondrial myopathy that may present with isolated eye lid ptosis in the initial stages. In a patient with loud snoring and obesity, treating obstructive sleep apnea may improve Floppy eyelid syndrome.

Report of case(s)
52-year-old African – American male with past medical history of Hypertension, obesity, glaucoma, CPEO status bilateral blepharoplasty with failed surgical treatment. Patient was referred to Sleep medicine team to rule out Obstructive Sleep Apnea aa a cause of possible underlying FES and residual ptosis. On exam, patient was noted to have bilateral brow and eyelid ptosis and mild ataxic gait. MRI brain with and without contrast was unremarkable. Deltoid muscle biopsy was suggestive of possible congenital myopathy and mild denervation atrophy. Polysomnogram showed severe OSA with AHI of 74.1 per hour and patient was initiated on Auto CPAP at a pressure setting of 7–20 cm H2O. CPAP treatment improved snoring, OSA and subjective symptoms of excessive day time sleepiness but did not improve the residual ptosis.

Conclusion
Treatment of severe OSA in a patient previously diagnosed with CPEO and failed surgical treatment with bilateral blepharoplasty, did not alter the course of residual ptosis/ floppy eyelids even though his other sleep apnea symptoms have improved.

Support (if any)
1. McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthalmic Plast Reconstr Surg. 1997 Jun;13(2):98–114. doi: 10.1097/00002341-199706000-00005. PMID: 9185193.
849 REM Behavioral Disorder as a Predictor of Lewy body Dementia- A Case Report
Authors: Koothirezhi Rupa , Anne Pratibha , Ho Minh Tam , Monceaux Brittany , Liendo Cesar , Chernyshev Oleg , Kilaikode Sasikumar , Okorie Ugorji 
Published: May 2021

Abstract

Introduction
Dementia with Lewy bodies (DLB) is one of the most common types of degenerative dementia after Alzheimer’s dementia. The core clinical features for diagnosis includes cognitive fluctuations, visual hallucinations, rapid eye movement (REM) sleep behavior disorder (RBD), and parkinsonism. Other symptoms include daytime drowsiness, longer daytime naps, prolonged staring spells, and episodes of disorganized speech. REM behavioral disorder (RBD) is commonly associated with DLB, occurring in 85 percent of individuals, often early in the course of the disease. It can precede the clinical diagnosis of DLB by up to 20 years.

Report of case(s)
A seventy-six-year-old female with a history of well controlled obstructive sleep apnea was diagnosed with REM behavioral disorder in 2012. She had presented with episodes of screaming, attempt to ambulate during sleep, resulting in injury. Her polysomnogram revealed evidence of REM without atonia and a screaming episode during REM. Her RBD symptoms were controlled with clonazepam and melatonin with less frequency of the RBD episodes. The patient gradually started noticing memory issues and by January 2020 she was diagnosed with dementia and was initiated on Aricept. Within 7 months of diagnosis of dementia, she started reporting vivid hallucinations that were not threatening or violent compared to her violent content of RBD. Physical exam revealed impaired cognitive function and mild intermittent resting tremor of the right hand. The neurological exam was normal including normal tone, strength, and gait. She also reported repeated falls and fractures. The diagnosis of Lewy body dementia was made based on the presence of 2 core clinical features.

Conclusion
The current management of these conditions is mainly symptomatic. In the evolution of neurodegenerative disorder, RBD precedes other conditions like LBD, parkinsonism, etc. Research suggests that alpha-synuclein neurodegeneration is the common pathology behind these conditions. The understanding that RBD presents at the beginning of the evolution, provides us with a unique opportunity for preemptive treatment to prevent further degeneration in turn preventing the debilitation consequence like dementia, parkinsonism, neuroleptic sensitivity, and dysautonomia. Further research is needed for developing these early interventional strategies.

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NOne
854 Sexsomnia in a Divorce Proceeding and its Custody Implications
Authors: Uppalapati Madhuri , Strohl Kingman , Sibilia Robert 
Published: May 2021

Abstract

Introduction
Sexsomnia is a NREM parasomnia under the subtype of Confusional Arousals, defined as abnormal sexual behaviors emerging from partial arousals during slow-wave sleep. Case reports suggest that is more common in men. Precipitating factors include Obstructive Sleep Apnea, insufficient sleep, alcohol and fatigue/stress and history of NREM parasomnias.

Report of case(s)
A 37-year-old male with bruxism (using mouth guard) and anxiety for 7 years, who presented to the sleep clinic for a second opinion to discuss concerns around the safety of his children due to his sleep related sexual behavior. Sexsomnia was first noted with the stressors related to becoming a parent (fostering children and having biological children). Sexual behavior reported by the couple was mostly provoked with spouse’s touch during sleep. Behaviors ranging from fondling to aggressive sexual intercourse were reported to occur 1 to 3 times/week. There were no injuries during episodes which only occurred in the bedroom with the spouse and the patient was amnestic of his behavior. Due to marital discord provoked by other stressors, he began to sleep alone in the basement. A video-polysomnogram revealed no parasomnia, sleep apnea, or other sleep arousal disorders. Normal REM with atonia was observed. The patient was treated with Duloxetine 20mg for anxiety after the initial sleep visit. His condition contributed to marital separation. In the divorce proceedings, the spouse argued for denial of visitation rights related to his sleep-sexual behaviors noting that the children may be at risk. After separation, his anxiety and stress levels lowered in conjunction with therapy and medication. Follow up after 2 months found the patient asymptomatic. He placed an alarm on his bedroom door, to alert him and others during sleep. There are no published reports to provide a prediction as to whether his condition would-be supporting restrictions in overnight visitation by the foster and biological children.

Conclusion
In this case, there was a precedent condition (bruxism) and precipitating stress and anxiety, known to provoke NREM parasomnia. The absence of polysomnographic evidence is not unusual. Forensic repercussions, in particular prospective calculations of risk, are poorly described in the literature.
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855 Sexsomnia: A Case Series Looking at a Rare Parasomnia
Authors: Ku Brian , Mujuruki Cephas , Patel Abha , Carter Gregory 
Published: May 2021

Abstract

Introduction
Sexsomnia is a male predominant, rare subset of NREM parasomnia involving sleep-related sexual activity. Symptoms can range from individual sexual acts, such as masturbation, to acts involving bed partners, often without recollection. Sexsomnia results in profound personal, social, and legal ramifications. Though typically treated with benzodiazepines, here we present three patients that were managed nontraditionally.

Report of case(s)
Case 1 A 34-year-old man with a history of optimized obstructive sleep apnea (OSA), alcohol abuse, and bipolar disorder reported eight-years of parasomnia characterized by fondling, sexual intercourse, and aggressive sexual acts, despite treatment with benzodiazepines. His fiancé noted that his advances when sleeping were atypical for their normal intimate interactions. He was observed to have frequent arousals from N3 sleep during PSG. The patient denied current substance use, but did report bilateral foot discomfort leading to sleep disturbance. His ferritin was 38 ng/mL, and he was started on oral iron and vitamin C. Case 2 A 41-year-old woman with a history of anxiety, psoriatic arthritis, insomnia and childhood somnambulism presented with parasomnia ranging from fondling to sexual intercourse. Her husband noted that during the episodes, her mannerisms and speech pattern were vastly different from normal. She endorsed difficulty initiating sleep, with a sleep latency of one hour and frequent arousals despite using trazodone nightly. She consumed two to five glasses of whiskey in the evenings several nights a week. Parasomnia events were more prevalent on nights that she partook in alcohol and improved with alcohol cessation. Case 3 A 44-year-old man with a history of optimized mild OSA presented with parasomnias characterized by somnambulism with goal-directed behavior and sexual activity, with a family history of violent parasomnias. Given the atypical nature of his events, he was referred to the epilepsy monitoring unit, which was ultimately nondiagnostic. Benzodiazepine therapy was ineffective. He chose to defer further medical management, leading the patient to pursue cognitive behavioral therapy, with moderate benefit. He reports infrequent parasomnias off medications.

Conclusion
Sexsomnia remains a rare, and likely under reported phenomenon. In each of the highlighted cases, the patients responded to treatment without the use of standard benzodiazepine therapy.
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859 Trial of average volume-assured pressure support (AVAPS) to treat hypoventilation in a child with rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) and systolic heart failure
Authors: Reiling Krista , Sagar Malvika , Finch Robert , Typaldos Marlene , McHugh Erin , Spielberg David , Malhotra Sonal 
Published: May 2021

Abstract

Introduction
ROHHAD syndrome is a rare disorder of respiratory control and autonomic nervous system regulation with endocrine abnormalities. Although children may present with obstructive sleep apnea, their blunted respond to hypoxemia and hypercapnia is a life-threating feature, often leading to cardiorespiratory arrest. There is limited literature regarding non-invasive positive pressure ventilation (NIPPV) in these children. We report a trial of AVAPS in a child with ROHHAD syndrome.

Report of case(s)
Our patient is a 6-year-old male with history of rapid weight-gain (49.9 kg in 2.5 years), type-2 diabetes, and mild OSA who presented to an outside hospital (OSH) in March 2020 with acute hypercapnic hypoxemic respiratory failure. He required bilevel PAP therapy, steroids, and bromocriptine for thermoregulatory dysfunction. His clinical presentation, along with negative PHOX2B gene mutation and absence of parenchymal lung disease on chest computerized tomography suggested a diagnosis of ROHHAD syndrome. Outpatient, he was successfully transitioned to empiric AVAPS therapy. In November 2020, he presented again to an OSH in hypercapnic hypoxemic respiratory failure with new systolic heart failure with ejection fraction of 28%. After clinical stabilization, he was transferred to our hospital on CPAP 10 cmH20 with 100% FiO2 for further management. Awake blood gas was consistent with chronic hypercapnic respiratory failure; therefore, the patient was placed initially on bilevel PAP therapy empirically until an inpatient bilevel PAP titration polysomnogram was conducted. The patient remained hypercapnic and was converted to continuous AVAPS therapy starting at a tidal volume of 8.6mL/kg based on ideal body weight. AVAPS was titrated until achieving adequate ventilation, but the patient was unable to tolerate continuous NIPPV. Because of his heart failure in the setting of expected worsening respiratory failure, the decision was made to pursue tracheostomy placement for invasive positive pressure ventilation.

Conclusion
ROHHAD syndrome is a rare disorder that begins within the first decade of life, making adherence to daytime NIPPV difficult. This case illustrates a trial of AVAPS in a child with ROHHAD syndrome prior to tracheostomy placement. It highlights the need for future research in advanced ventilatory support strategies in children.
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863 When sleep takes you to unwanted places?
Authors: Araji Fayruz , Patel Abha 
Published: May 2021

Abstract

Introduction
Somnambulism is a parasomnia occurring in non-rapid eye movement sleep, and is characterized by ambulation as a disorder of arousal regulation. Sleep deprivation, alcohol abuse, fragmented sleep and certain medications can increase the risk of sleep walking.

Report of case(s)
Here we present a 35-year-old man with multiple triggers for sleep walking, resulting in recurrent parasomnia events over fifteen years. He had a history of bipolar disorder, post-traumatic stress disorder (PTSD), chronic insomnia, moderate untreated obstructive sleep apnea (OSA), anxiety with violent daytime behaviors, and prior alcohol abuse status post six years of sobriety. He was sent to our clinic due to increased frequency and severity of events, with nightly events for the last five years. Episodes were characterized by walking around the home, leaving the home, and driving on occasion. He reported at least one minor car accident as a result of sleep driving. He also reported an injury resulting from a fall in his home while sleep walking. Several security measures were implemented, including door gates, door alarms, and hiding car keys. His family slept in different bedrooms with locked doors for safety. The patient’s chronic insomnia improved with cognitive behavioral therapy, leading to an average sleep time of five hours per night with no reported hypersomnia or daytime fatigue. After his initial evaluation, he was referred for a mandibular advancement device for treatment of his OSA, due to prior poor compliance with positive airway pressure therapy related to his PTSD. Optimizing his OSA helped decrease arousals that might trigger sleep walking events. He also maintained close follow up with mental health for pharmacotherapy and psychological therapy. Treatment with clonazepam 0.25 mg at bedtime was initiated given the severity of his somnambulism.

Conclusion
The use of a benzodiazepine can reduce slow wave sleep duration by its effect on the inhibitory neurotransmitter gamma aminobutyric acid (GABA). Our patient had multiple risk factors for parasomnias, with severe, frequent episodes of sleepwalking leading to self-injury. His treatment involved both pharmacotherapy as well as optimization of underlying triggers.
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722 Sleep Loss in Healthcare Workers During the COVID-19 Pandemic
Authors: Stewart Nancy , Koza Anya , Dhaon Serena , Shoushtari Christiana , Martinez Maylyn , Arora Vineet 
Published: May 2021

Abstract

Introduction
During the pandemic, healthcare workers have shared their stresses on social media, including regarding sleep disturbances. However, an assessment of sleep using validated measures among healthcare workers on social media is lacking.

Methods
A restricted, self-selection survey was distributed on Facebook, Twitter, and Instagram for 16 days targeting healthcare workers who were clinically active during COVID-19. In addition to demographics and career information, participants completed the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index. Poor sleep quality was defined as PSQI &gt; 5. Moderate-to-severe insomnia was defined as an ISI &gt; 14. Multivariate logistic regression tested the association between demographics and career characteristics and sleep outcomes.

Results
Of the 983 who clicked our link, 906 completed the survey. Participants were mostly white (70%), female (75%), physicians (64%). Mean sleep duration was 6.1 (SD1.2) hours. Nearly 90% experienced poor sleep (PSQI). One third reported moderate or severe insomnia. Many (60%) reported sleep disruptions due to device usage or due to bad dreams at least once per week (45%). In multivariable regression, non-physicians (OR 3.5, CI: 2.5, 5.0), Hispanic ethnicity (OR 2.2; CI: 1.44, 3.45), being single (1.5, CI: 1.03, 2.21), and youngest age group (18–24) (OR 9.9; CI: 1.44, 68.09) had increased odds of insomnia. In open-ended comments, sleep disruptions mapped to 5 categories: (1) Work demands (“The volume of calls and messages from my patient and caregiver population is through the roof”); (2) Pandemic related (“I never had sleep issues prior to the COVID-19 pandemic. Suddenly I had issues with sleep initiation.”; (3) Children and family (“COVID plus home stress plus stress over my kids, my job, my marriage.”); (4) Personal health (“Insomnia predating COVID, but worsened with COVID.”); (5) Responses to the pandemic (“I worry about how COVID is being managed by the President...This does keep me awake at night.”).

Conclusion
During the COVID-19 pandemic, 90% of healthcare workers surveyed on social media reported poor sleep, with over one-third of participants reporting moderate-severe insomnia. Online sleep interventions for healthcare workers are urgently needed.
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Molecular and microscopic prevalence of intestinal microsporidia among HIV+/AIDS patients in the Alborz province, Iran
Authors: Hosseini Parsa Maryam , Bahadory Saeed , Heidari Aliehsan , Khatami Alireza , Bairami Amir 
Published: May 2021

AbstractBackgroundMicrosporidia are a large family of obligate intracellular protozoa; these medically important species are recognized as opportunistic agents in intestinal complications in HIV+/AIDS patients.MethodsThe current cross-sectional study was designed and conducted from October 2018 to June 2019 to determine intestinal microsporidia in HIV+/AIDS patients by trichrome/Zeihl-Neelsen staining and SYBR Green-based real-time PCR.ResultsOut of 80 HIV+/AIDS patients, 23.75% (n=19) and 12.5% (n=10) were identified by molecular and microscopic methods, respectively. The predominant species in patients was Encephalitozoon (94%), which was found by quantitative real-time PCR and its high resolution melting tool.ConclusionAs far as we know, this is the first report from the Alborz region. The prevalence of intestinal microsporidiosis in this area in HIV+/AIDS patients was higher than both the global and national average. In addition to the need for further studies to prove protozoan pathogenicity in the aforementioned group, preventive measures should be considered.
Selective transperineal prostate biopsy for fluoroquinolone-resistance patients reduces sepsis and cost
Authors: Al-Mitwalli Abdullah , Kyriazis Grigorios , El-Taji Omar , Chandra Elizabeth , Deborah Wearmouth , Burns Phillipa , Fady Youssef , Simms Matthew , Nicholas Smith 
Published: May 2021

Abstract

Background:
Urosepsis is a recognized complication of transrectal ultrasound-guided prostate biopsy (TRUS-Bx). Pre-biopsy rectal swabs have been used to identify patients with microorganisms in the rectal flora resistant to the conventionally used empirical prophylaxis. The transperineal route of biopsy (TP-Bx) has a lower complication risk but comes at an increased cost.

Materials and methods:
Retrospective cohort study including patients undergoing prostate biopsies between October/2015 and April/2018. The intervention cohort, a rectal swab was performed, the result of which dictated the biopsy route; TRUS-Bx against TP-Bx. TP-Bx for patients with fluoroquinolone resistance or extended-spectrum β-lactamase. The control cohort underwent TRUS without a rectal swab receiving empirical antibiotics—oral ciprofloxacin and intravenous gentamicin.

Results:
Total 1000 patients were included in which 500 underwent a swab, 14 (2.8%) developed post-TRUS biopsy infective complications with 3 having positive bacteremia (0.6%); 500 had no swab, 47 (9.4%) developed post-TRUS biopsy infective complications with 22 (4.4%, p < 0.05) having positive bacteremia. Three patients (0.6%) of patients who underwent swab developed urinary tract infection symptoms whilst 12 (2.4%) had urinary tract infection in the control group. In those patients that underwent a swab, 14 required hospitalization with mean length of stay of 2.5 days versus 43 patients of the control with 3.6 days. Cost analysis concluded savings of this strategy was £18,711.

Conclusions:
We have demonstrated a protocol that reserves template biopsies for higher risk patients and can significantly reduce sepsis and other infectious complication rates whilst also proving to be a cost-efficient strategy. We recommend that units not utilizing rectal swabs to uncover the fluoroquinolone resistance rate by introducing them. We advocate units that already utilize rectal swabs, to introduce transperineal biopsy for their higher risk patients.