bluuebunny/crossref_metadata_2025_split huggingface dataset:
0729 Assessing the Diagnostic Benefit of Polysomnography with Routine Carbon Dioxide Measurements in Adolescent and Adult Obese Patients
Authors: Beshay Sarah , Bucovschii Serghei , Mathew Reeba , Majid Ruckshanda 
Published: May 2022

Abstract

Introduction
The diagnosis of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS) has increased with the increasing prevalence of obesity. Adding routine transcutaneous carbon dioxide (TcCO2) or end-tidal carbon dioxide sensors (EtCO2) to a polysomnogram (PSG) may expand the analytic capabilities of the study. Our study looks at the utility of using CO2 monitoring in obese adolescent (age 13-18 years) and obese adults in increasing the diagnostic yield of the polysomnogram.

Methods
A retrospective chart review was conducted on obese adolescents (13-18 years) and obese adults (body mass index [BMI] &gt; 95 percentile and &gt;30 kg/m2 respectively) undergoing a PSG with EtCO2 monitoring. The CO2 values were documented while supine (awake) and while sleeping. The EtCO2 value was correlated with the BMI but the adults were also compared between Group 1 (BMI 30-40 kg/m2) and Group 2 (BMI &gt;40 kg/m2). Patients with known hypoventilation syndromes or studies that had poor EtCO2 waveforms were excluded.

Results
72 patients were identified between December 2019 and November 2020 at the Memorial Hermann Sleep Disorders Center. Amongst the adults, 52% were men, with an average age of 55 years (range 26-77) and an average BMI 40.5 kg/m2 (SD +/- 8.8). The average AHI on the diagnostic study (CMS criteria) was 31 events/hour (SD +/- 34.1) and the average oxygen saturation nadir was 80%. Twenty patients (28%) met the diagnostic criteria for OHS based on the baseline awake EtCO2. The mean EtCO2 was 40.1 mmHg in patients with a BMI between 30 and 40 kg/m2 (Group 1) versus 45.1 mmHg in patients with BMI &gt;40 kg/m2 (Group 2) with a statistically significant p-value of 0.0002. Additionally, we identified 18 patients between the ages of 13-18 years with obesity amongst which, 4 patients also had a baseline EtCO2 of &gt;45 torr (22%) with a potential diagnosis of OHS.

Conclusion
Patients diagnosed with OHS are reported to have a higher overall greater mortality. Our study suggests a higher diagnostic yield of OHS in adults and adolescents with the use of CO2 monitoring especially in the morbidly obese. This evidence would advocate for the routine use of CO2 monitoring in the obese patient population.

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0730 Validation studies for scoring polysomnograms and home sleep apnea tests with artificial intelligence: Sleep stage probabilities (hypnodensity) derived from neurological or cardiorespiratory signals
Authors: Anderer Peter , Ross Marco , Cerny Andreas , Fonseca Pedro , Shaw Edmund , Bakker Jessie 
Published: May 2022

Abstract

Introduction
There have been significant advances in machine learning in recent years. This means that powerful methods are now available for classification problems, such as scoring sleep stages from neurological or cardiorespiratory signals. In the present work, validation studies for both applications are presented.

Methods
To determine the 5 sleep stages from the neurological signals, 54 sleep-wake-related features were calculated and classified by a bidirectional long short-term memory (LSTM) network which had been trained on 1956 manual scorings of 588 PSGs from 294 subjects (supervised deep learning). To determine the 4 stages (wake, light sleep, deep sleep, REM) from cardiorespiratory signals, a convolutional neural network combined with LSTM layers was used for feature extraction and classification. This network had been trained on 685 PSGs from 391 subjects (Bakker et al. JCSM 2021). The networks obtained were validated in 428 PSGs with one and 10 PSGs with 12 manual scorings (neurological staging) as well as in 2 two datasets, each containing 296 ambulatory recordings (cardiorespiratory staging).

Results
Cohen’s kappa between autoscoring based on neurological signals and manual scoring was 0.74 (95%-confidence interval: 0.74-0.74) for the 428 PSGs. The intraclass correlation coefficient (ICC) for absolute agreement between autoscoring and manual scoring was for the AHI 0.97 (0.96-0.98), for the arousal index 0.79 (0.67-0.86) and for the PLMSI 0.91 (0.88-0.93). The ICC between the sleep stage probabilities derived from the 12 manual scorings and the artificial intelligence (AI) derived hypnodensity was 0.91 (0.91-0.91). Cohen’s kappa values for the cardiorespiratory sleep staging were 0.68 (0.68-0.68) and 0.64 (0.63-0.64) for the 2 datasets with 296 ambulatory recordings each.

Conclusion
All metrics from the PSG validation studies show substantial (Cohen’s kappa &gt; 0.6) as well as good to excellent agreement (ICC &gt; 0.75 or &gt; 0.90) compared to manual scorings. As an added value of the AI-supported PSG evaluation, the probabilities of the sleep stages per epoch are determined (hypnodensity graph). The valid estimation of the sleep stages from cardiorespiratory signals by means of AI may result in improved clinical interpretation of home sleep apnea tests, which are increasingly used in the sleep-disordered breathing diagnostic pathway.

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0732 Sonographic Phenotyping of the Upper Airway in OSA Using Backscattered Imaging Analyzed by Machine-Learning
Authors: Liu Stanley Yung Chuan , Abdelwahab Mohamed , Chao Peiyu , Lee Yili , Chen Argon , Kushida Clete 
Published: May 2022

Abstract

Introduction
Anatomic characterization of the upper airway remains important in directing and monitoring care of patients with obstructive sleep apnea (OSA). Nasopharyngoscopy is routine in clinical practice, but it is invasive, non-reproducible, and only allows subjective assessment. We used machine-learning enabled ultrasonography to correlate upper airway tissue characteristics with OSA severity.

Methods
Sixty-three subjects (14 female) with a mean age of 39.4±12.6 years, BMI of 26.4±4.6 kg/m2, and AHI of 19.0±16.1 were consented from Stanford Sleep Surgery (July 2020 to May 2021). Standardized ultrasound protocol was used to image the soft palate, oropharynx, and tongue-base. Via machine learning, an FDA-cleared backscattered ultrasound imaging (BUI) of the upper airway was performed. Combined with B-mode measurements of airway muscular cross-sections, a logistic regression model was built to correlate with OSA severity.

Results
BUI of subjects with mild OSA was different from moderate-severe (AHI≥15) OSA at the soft palate (p=0.0007). The axial-to-lateral ratio of upper airway length was reduced in the lower soft palate of the moderate-severe group (p =0.0207). The logistic regression model with BUI, axial-to-lateral ratio at the soft palate, and BMI showed an Area Under the Receiver Operating Characteristic (AUROC) curve of 0.84 (95% CI 0.726 to 0.920) in moderate-severe OSA.

Conclusion
A non-invasive yet replicable technique to visualize and phenotype the upper airway is critical in the management of patients with sleep-disordered breathing. Sonographic BUI combined with B-mode airway measurements analyzed by machine learning show promise in characterizing the upper airway in patients with moderate-severe OSA.

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0735 Sleep Disturbances in Post-Acute Sequelae of COVID-19 (PASC)
Authors: Orbea Cinthya Pena , Lapin Brittany , Katzan Irene , Englund Kristin , Foldvary-Schaefer Nancy , Mehra Reena 
Published: May 2022

Abstract

Introduction
Sleep difficulties and fatigue are highly prevalent, pervasive symptoms reported in patients with Post-Acute Sequelae of COVID-19 (PASC). As little is known of the predictors and severity of PASC-related sleep disturbance and intersection with fatigue, we leverage systematic data collected from the Cleveland Clinic ReCOVer Clinic for further elucidation

Methods
Analysis of data collected from Cleveland Clinic ReCOVer Clinic patients (February-November 2021) who completed the Patient-Reported Outcomes Measurement (PROMIS) Sleep Disturbance and PROMIS Fatigue questionnaires was performed. Data were extracted from the Cleveland Clinic COVID-19 registry and the electronic health record.PROMIS scores are standardized to the general U.S. adult population on a T-scale with mean 50±10. PROMIS sleep disturbance and fatigue T-scores ≥60 indicates at least moderate disturbance and ≥70 indicate severe disturbance. T-test and Chi-square tests were used to examine cross-group differences. Multivariable logistic regression adjusted for age, race, sex, and body mass index(kg/m2) was performed to investigate factors associated with sleep disturbance severity.

Results
Out of 1321, 682 patients completed the PROMIS Sleep Disturbance questionnaire with age 49.8±13.6, 75.2% female and 12.3% black race. Average T-scores were 57.7±8.3, 281 (41.2%) patients reported at least moderate sleep disturbance and 50 (7.3%) reported severe sleep disturbances. Average PROMIS Fatigue T-score was 63.0±9.2; 68.6% patients reported at least moderate fatigue, 22.6% reported severe fatigue. Patients with moderate-severe compared to normal-to-mild sleep disturbances respectively had higher BMI (32.3±8.7 vs 30.9±7.5, p=0.049), were more likely of black race (40.0±10.0 vs 41.0±15.7,p=0.010), had worse eneral Anxiety Disorder (GAD)-2 questionnaires scores (2.8±2.1 vs 1.6±1.7,p&lt;0.001), Patient Health Questionnaire (PHQ)-2 scores (2.8±2.0 vs 1.6±1.7,p&lt;0.001) and PROMIS fatigue scores (66.7±7.8 vs 60.4±9.1,p&lt;0.001) with no difference in age, sex, or hospitalization due to COVID-19. In the adjusted model, black race was associated with moderate-severe sleep disturbance (OR=3.42, 95%CI:1.64-7.13).

Conclusion
The prevalence of moderate to severe sleep disturbances reported by patients presenting for PASC was very high i.e.&gt;40% and associated with obesity, black race and mood symptoms. Notably, after adjustment for demographics, black race conferred a 3-fold higher odds of moderate-severe sleep disturbance emphasizing the need to characterize race-specific determinants and disparities in COVID-19 survivors.

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0743 Should We Use AHI or RDI to Diagnose Obstructive Sleep Apnea?
Authors: Palombini Luciana , Godoy Luciana , Poyares Dalva , Andersen Monica , Pires Gabriel , Tufik Sergio 
Published: May 2022

Abstract

Introduction
Sleep disordered breathing (SDB) is defined based on clinical complaints and polysomnography events. Obstructive sleep apnea (OSA) was initially diagnosed based on the apnea hypopnea index (AHI), but the ICSD-3 has defined the respiratory disturbance index (RDI) as the actual diagnostic criteria. This study aimed to evaluate and compare clinical outcomes related to daytime function in OSA patients defined by AHI and RDI.

Methods
This study was derived from the São Paulo Epidemiological Sleep Study (EPISONO), in its 3rd edition (2007) and follow up edition (2015). A total of 557 individuals had polysomnographies evaluated according to the 2012 American Academy of Sleep Medicine Scoring Manual in both editions. The scores of the Epworth Sleepiness Scale (ESS), Chalder Fatigue Scale (CFS), Pittsburgh Sleep Quality Index (PSQI), Beck Anxiety and Depression Inventories (BAI and BDI) and Insomnia Severity Index (ISI) were compared between individuals who sustained the same AHI level in both editions (either AHI&lt;15 or AHI≥15). We did the same comparison between individuals who had either RDI&lt;15 or RDI≥15.

Results
The grouping by AHI included 348 participants with AHI&lt;15 and 107 with AHI≥15; while the grouping by RDI was composed by 335 with RDI&lt;15 and 118 with RDI≥15. Considering the AHI grouping, there was no statistically significant differences in ESS, PSQI, BDI and ISI scores after 8 years of follow up (p=0.2, p=0.3, p=0.09 and p=0.7 respectively), but a significant increase in the CFS and BAI scores (p=0.05 and p=0.01, respectively) was observed. Considering the RDI grouping, there was no statistically significant difference on ESS, PSQI and ISI scores after 8 years of follow up (p=0.3, p=0.1 and p=0.4 respectively), but there was a significant increased on CFS, BAI and BDI.

Conclusion
OSA diagnosed by either AHI or RDI is associated with increase in fatigue levels. However, when OSA is diagnosed according to RDI, a worse depression score is observed. Depression complaints can significantly impair quality of life and should be consider an important SDB outcome.

Support (If Any)
AFIP, CNPq, CAPES.
0745 Sleep-Related Hypoxemia Association with Incident Atrial Fibrillation in a Clinic-Based Cohort
Authors: Heinzinger Catherine , Thompson Nicolas , Milinovich Alex , Foldvary-Schaefer Nancy , Van Wagoner David , Chung Mina , Mehra Reena 
Published: May 2022

Abstract

Introduction
Sleep disordered breathing (SDB) has been implicated in atrial fibrillation (AF) in population-based studies, however, its role remains unclear and inconsistent. We hypothesize greater risk of 5-year incident AF with SDB and sleep-related hypoxia in a clinic-based cohort.

Methods
Cleveland Clinic patients (age&gt;18) who underwent polysomnogram (PSG) or split studies 11/27/2004-12/30/2015 with &gt;3 hours diagnostic time were examined. Predictors include AHI, % sleep time oxygen saturation&lt;90% (T90), and minimum and mean oxygen saturation(minSaO2 and meanSaO2, respectively). Cox proportional hazard models were fit with time from sleep study to AF diagnosis as the dependent variable. Covariates included age, sex, race, body mass index(BMI), cardiovascular risk factors (hypertension, diabetes mellitus, hyperlipidemia), heart failure, coronary artery disease, myocardial infarction, history of coronary artery bypass grafting, chronic obstructive pulmonary disease, tobacco use, and use of anti-arrhythmic drugs. Data were censored at date of last follow up or at 5-years.

Results
The sample was comprised of 43,634 patients: age 51.7±14.5, 51.9% male, 74.5% White, and 7.1%(n=3,090) with AF. Of those without AF, 1,176(2.9%) developed 5-year incident AF. For each 10% increase in T90, incident AF increased by 7% (HR=1.07, 95%CI=1.05-1.10). Compared to reference, patients with 25.01-50%, 50.01-75%, and 75.01-100% time T90 had 22% (HR=1.22, 95%CI=1.01-1.46), 49% (HR=1.49, 95%CI=1.20-1.85), and 65% (HR=1.65, 95%CI=1.26-2.15) higher incident AF, respectively. For every 10-unit increase in minSaO2 and meanSaO2, incident AF decreased by 11%(HR=0.89, 95%CI=0.83-0.95) and 23% (HR=0.77, 95%CI=0.68-0.86), respectively. AHI did not demonstrate a statistically significant relationship with incident AF at a significance level of 0.05.

Conclusion
Sleep-related hypoxemia, defined by cumulative burden below 90% SaO2, demonstrated an association with incident AF in this large clinic-based cohort, even considering confounding factors. On the other hand, SDB severity as defined by AHI did not demonstrate this relationship. These findings are consistent with experimental models that identify intermittent hypoxia and oxidative stress leading to alterations of the cardiac substrate, thus implicating sleep-related hypoxemic mechanisms as a salient driver in the evolution of atrial arrhythmogenesis.

Support (If Any)
Cleveland Clinic Neurological Institute Center for Outcomes Research & Education Pilot Grant, Neuroscience Transformative Research Resource Development Award
0781 Neck circumference: A surrogate predictive variable of hypoglossal nerve stimulator therapy outcome
Authors: Plata Diana , McTabi Omar , Herdegen James , LoSavio Phillip , Hutz Michael 
Published: May 2022

Abstract

Introduction
Hypoglossal nerve stimulation therapy has strict eligibility requirements including a body mass index &lt; 32kg/m2 for non-Medicare patients and body mass index &lt; 35kg/m2 for Medicare patients. However, there is a wide variability in body fat distribution including variability between the sexes. We theorize that neck circumference may be a better surrogate predictive variable for hypoglossal nerve stimulation outcomes than body mass index.

Methods
A retrospective chart review was conducted at a single tertiary care center on adults who underwent hypoglossal nerve stimulator implantation by a single surgeon from March 2017 to October 2021. Baseline demographic data including neck circumference, diagnostic polysomnography and post-implantation polysomnography titration studies were collected. Patients without neck circumference measurements were excluded. Surgical success was defined by Sher criteria of apnea hypopnea index &lt; 20 and reduction of the apnea hypopnea index by 50%.

Results
75 patient charts were reviewed. 44 of these patients had neck circumference, body mass index, and AHI at effective voltage (AHI-v) data recorded. These were included in the analysis. Overall, AHI-v positively correlated with neck circumference (r2=0.20, p= 0.0025). Conversely, no significant association was apparent between AHI-v and BMI (r2=0.04, p=0.18). AHI-v appeared to worsen at a specific neck circumference of &gt; 15 inches. T-test analysis showed significant difference in AHI-v comparing the groups of neck circumference ≤15in. vs &gt; 15in. (x̄=27.58 vs 7.68, respectively, p=&lt;0.001). However, no significant difference was found in mean BMI, age or baseline AHI between the neck circumference groups (p=0.15, 0.26, 0.10, respectively).

Conclusion
Findings suggest that neck circumference correlates to AHI at effective voltage during the post-implantation titration study. Our data indicates that neck circumference may be a better outcome predictor than BMI, baseline AHI or age for hypoglossal nerve stimulator effectiveness.

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0796 The sleep instability in chronic rhinosinusitis patients with nasal polyps using CAP analyses during NREM sleep
Authors: Lopes Maria-Cecilia , Lacerda Glenda , Migueis Debora 
Published: May 2022

Abstract

Introduction
The sleep instability can increase the impact of several sleep disorders. The chronic rhinosinusitis leads to sleep fragmentation, and changes in systemic inflammatory biomarkers followed by upper airway flow limitation or nasal mucosa inflammation near the skull base. To evaluate the effect of sleep dysruption in chronic rhinosinusitis patients with nasal polyps using CAP analyses, this study aimed to analyse these patients before and after the anti-inflammatory effect of intranasal corticosteroids on nasal obstruction.

Methods
After two months of washout, thirty individuals with nasal polyps and sleep-disordered breathing used intranasal budesonide 400 mcg every day for one month. Before and after the treatment, they underwent the same exams: nasal endoscopy, subjective nasal resistance scores, fatigue severity scale, and Epworth sleepiness scale. Besides, T helper-two inflammation was measured by serum levels of eosinophils, interleukin-four and five. Intermittent hypoxia impact was documented using serum levels of IL-6 and tumor necrosis factor-alpha. Type 1 polysomnography was performed. It was scored according to the last manual of AASM and Terzano’s rules. The nonparametric Wilcoxon test was used to assess within-group differences before and after exposure to corticosteroids. Correlation between quantitative variables was analyzed by using the Spearman correlation coeficient, and p&lt; 0.05 was statistically significant.

Results
All the participants had sleep' fragmentation in non-REM sleep. The treatment decreased the subjective nasal obstruction (p&lt;0.005) and IL-5 levels (p&lt;0.05), without significant impact on other biomarkers, nasal endoscopy results, fatigue or somnolence scales, and sleep architecture. Interestingly, the subtypes of phase A of CAP weren′t statistically significant (p&gt;0.05) decreased compared two groups (before and after treatment).

Conclusion
The anti-inflammatory effects of intranasal corticosteroid decreased the nasal resistance and Th2 systemic inflammation without any changes in sleep fragmentation, highlighting. Terzano’s manual quantifies the sleep fragmentation using the cyclic alternating pattern, and it can be a sensitive electroencephalogram analysis of the non-NREM sleep described as a marker of sleep instability, however the analyse of phase A subtypes CAP did not show changes sleep disruption in patients with nasal polyps after their treatment of nasal mucosa inflammation. More studies are need to clarify the sleep complaints in these patients.

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0797 Reclaiming Her Life: Successful Treatment of Kleine-Levin Syndrome with Transdermal Flumazenil
Authors: Sajid Mehwish , Rupani Nawaz 
Published: May 2022

Abstract

Introduction
Kleine-Levin Syndrome (KLS) is a rare disorder of hypersomnolence with cognitive and behavioral disturbances. Currently, there are no definitive treatment recommendations although stimulants, mood stabilizers, and even electroconvulsive therapy have been utilized with inconsistent results.
Report of Cases: A 23-year-old female with a history of depression, anxiety, obsessive-compulsive disorder, Hashimoto's thyroiditis, lupus, and morbid obesity presented to our facility for management of debilitating episodes of sleepiness due to KLS, diagnosed at the age of 22.
She reported good health until a series of viral illnesses at the age of 20. She then began experiencing sleep episodes requiring 20-22 hours of sleep per day, only awakening to eat and use the bathroom.
These episodes typically lasted for two weeks and were preceded by periods of hyperphagia
and hypersexuality. When she presented to our facility, she was using lithium and modafinil daily along with amantadine and clarithromycin twice daily as needed for episodes of sleepiness.
At her initial visit, she was prescribed transdermal flumazenil, a GABA-A receptor/benzodiazepine antagonist, to be used as needed to supplement amantadine and clarithromycin. She was initially requiring flumazenil every other month. After seven months of flumazenil use, the frequency of episodes decreased to every 3-4 months. She would administer two clicks of flumazenil cream on each forearm with the prodrome symptom of fogginess, which would abort the episode. Rarely, she required a second dose 12 hours later.
With flumazenil and avoidance of triggers, such as alcohol and sleep deprivation, she reported completing her master’s degree and finally maintaining a job. Ultimately, she discontinued lithium, modafinil, amantadine, and clarithromycin use without reoccurrence of her symptoms.

Conclusion
This case demonstrates successful treatment of KLS with the use of a GABA-A receptor/benzodiazepine antagonist, flumazenil. Reduction in episodes of sleepiness with flumazenil ultimately led to discontinuing stimulant, mood stabilizer, and clarithromycin use. Early trials of transdermal flumazenil and continued research regarding the use of this medication for patients with KLS may prove to be a promising intervention.

Support (If Any)
None.