bluuebunny/crossref_metadata_2025_split huggingface dataset:
0831 Identifying Sleep-Related Breathing Disorders in Underserved Demographics Using Commercial Portable Monitoring Devices: A Case Report
Authors: Tchopev Zahari , Carrizales Alex , Cunico Jorey , Mysliwiec Vincent , Peterson Alan , Kim David , Hansen Shana , Powell Tyler , Brock Matthew 
Published: May 2022

Abstract

Introduction
An estimated twenty-five percent of American women are at high risk of having obstructive sleep apnea (OSA). However, male sex is the predominantly reported risk factor. Women are less likely to report “classic” symptoms such as snoring that prompt referral for sleep evaluation. This dichotomy potentially represents a disparity in clinical evaluation and treatment of OSA in women. Consumer digital health devices are frequently used to monitor sleep in people with and without sleep disturbances. They are generally highly sensitive yet have lower specificity when compared with formal actigraphy or polysomnography. They may be used in conjunction with physician evaluation to guide decision-making.
Report of Cases: A 33 year-old female with a pertinent past medical history of obesity (BMI 37.83 kg/m ), depression, chronic pain, and anxiety was referred to our sleep center with a multi-year history of excessive daytime fatigue and non-restorative sleep that persisted despite healthy habits counseling and unremarkable lab evaluation. She ultimately presented her primary care
physician with biometric data collected by her Garmin watch and Oura ring. This data, which
included a reported low SpO of 83%, motivated a referral to Sleep Medicine. Her presentation Epworth Sleepiness Scale (ESS) score and Insomnia Severity Index (ISI) were 14 and 17, respectively. Polysomnography revealed an AHI of 32.6/hr, oxygen nadir of 79%, ODI of 28.7/hr, and a 97.2% sleep efficiency. PLMS index was 23.2/hour but did not contribute
to sleep fragmentation and there was increased proportion of stage N3 sleep (28.2%). Severe
OSA was treated with APAP. The two month follow-up ESS and ISS improved to 9 and 4, respectively. Device data revealed greater than 6 hours of consistent nightly use with a residual AHI of 3.1/hr. She subjectively stated APAP “has been a life changer” personally and professionally, as well as spousal report of resolution of snoring. Her consumer devices similarly reported improved sleep measures.

Conclusion
Minorities and women may be underserved in evaluation, diagnosis, and treatment of OSA. Portable monitoring using readily available consumer biometric devices may be a viable strategy for patients to further identify high risk features and prompt referral by primary care.

Support (If Any)
This work was supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health (DM170708; Mysliwiec) and the Air Force Research Laboratory, Wright Patterson Air Force Base, Ohio (FA8650-18-2-6953; Peterson).
0832 Nocturnal Tachypnea with Non-Invasive Ventilation; A case report
Authors: Elballat Mohammad , Anderson William , Patel Kevin 
Published: May 2022

Abstract

Introduction
We present a case of nocturnal tachypnea secondary to suspected auto-triggering in a patient on Bilevel device. Auto-triggering is a patient-ventilator asynchrony in which a ventilator breath is triggered in the absence of inspiratory muscle activity. This phenomenon was mostly described in postcardiac surgery and in brain dead patients on mechanical ventilation. Detecting this asynchrony is important as it can lead to patient discomfort, poor compliance and hypocarbia that can lead to apneic events.
Report of Cases: An 82-year-old male with history of chronic atrial fibrillation, coronary artery disease (s/p bypass surgery) and Ischemic cardiomyopathy (EF 25-30%). He had moderate obstructive sleep apnea with central apnea. He was started on AutoPAP then was upgraded to BPAP (IPAP 16/EPAP 9 cmH2O). His wife reported episodes of nocturnal tachypnea and increased daytime somnolence. This was confirmed by the compliance reports from his BPAP device, and a portable sleep study obtained while using the BPAP (respiratory rate &gt; 40 breaths/minute).

Conclusion
Vignaux et al estimated the incidence of auto-triggering with NIV to be 13%. This phenomenon can be caused by a major circuit leak or secondary to cardiogenic oscillations. Effect of cardiogenic oscillation on the pulmonary air flow was described by West and Hugh-Jones in 1961. Our patient had dilated cardiomyopathy with hyperdynamic circulation which we believe was the major cause of his auto-triggering asynchrony. Changes in intracardiac volume and cardiac movements during systole resulted in intrapulmonary flow oscillations exceeding the set flow-trigger threshold leading to the tachypnea. In our patient, the events resolved after cardiac resynchronization procedure that improved the overall cardiac function and adjusting the trigger sensitivity.

Support (If Any)
[1]Kondili E, Prinianakis G, Georgopoulos D.; Patient ventilator interaction, Br J Anaesth. 2003; 91: 106-119 [2] Richard Arbour; Cardiogenic Oscillation and Ventilator Autotriggering in Brain-Dead Patients: A Case Series. Am J Crit Care 1 September 2009; 18 (5): 496–488. doi: https://doi.org/10.4037/ajcc2009690 [3] Imanaka, Hideaki MD; Nishimura, Masaji MD; Takeuchi, Muneyuki MD; Kimball, William R. MD, PhD; Yahagi, Naoki MD; Kumon, Keiji MD Auto-triggering caused by cardiogenic oscillation during flow-triggered mechanical ventilation, Critical Care Medicine: February 2000 - Volume 28 - Issue 2 - p 402-407 [4]Vignaux L, Vargas F, Roeseler J, Tassaux D, Thille AW, Kossowsky MP, et al. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 2009;35(5):840–846
0837 Average Volume-Assured Pressure Support (AVAPS) after CPAP Failure in A Pediatric Patient with Severe Obstructive Sleep Apnea and Sleep-Related Hypoventilation
Authors: Tu Xinhang , Peng Victor , Lasso-Pirot Anayansi , Diaz-Abad Montserrat 
Published: May 2022

Abstract

Introduction
Obstructive sleep apnea (OSA) has become an increasingly pervasive sleep disorder in the pediatric population. Current mainstream treatments include adenotonsillectomy and positive airway pressure therapy. Average volume-assured pressure support (AVAPS) is a relatively new mode of non-invasive ventilation, which has been increasingly used in the treatment of respiratory failure and hypoventilation syndromes. Here we present a case of a pediatric patient with severe OSA and sleep-related hypoventilation who was successfully treated with AVAPS after failure of CPAP therapy.
Report of Cases: A four year old boy with history of severe OSA, severe obesity, asthma, and allergic rhinitis underwent polysomnography one year after adenotonsillectomy and nasal turbinate reduction due to continued symptoms of sleep-disordered breathing. Results showed elevated residual apnea-hypopnea index (AHI = 30.4 events/hour), sleep-related hypoventilation (T ETCO2≥50 = 228.3 minutes), and sleep-related hypoxemia (T≤90% = 7 minutes). Therefore the patient underwent repeated adenotonsillectomy and turbinate reduction, with post-operative course complicated by pulmonary edema requiring intubation. He was extubated and weaned to
nocturnal CPAP. Following discharge, CPAP titration failed to control AHI at maximal pressure
(AHI 54.5 on 20 cm H2O, T≤90% = 15.3 minutes). The patient was then started on AVAPS
with auto-titrating EPAP (AVAPS-AE, settings Pmax 20 cm H2O, PS 2-10 cm H2O, EPAP 5-10
cm H2O, RR auto, room air) with subsequent improvement of snoring and witnessed apneas, as
well as reduction of daytime sleepiness. Afterwards, AVAPS-AE titration confirmed resolution of obstructive sleep apnea, sleep-related hypoxemia, and sleep-related hypoventilation (AHI =
2.5, T≤90% = 1.2 minutes, T ETCO2 ≥50 = 6.5 minutes.) The patient has since remained stable on AVAPS-AE until age ten, with the most recent AVAPS titration demonstrating continued resolution of sleep-disordered breathing.

Conclusion
AVAPS was an effective treatment for a pediatric patient with severe OSA and sleep-related hypoventilation who had failed CPAP therapy.

Support (If Any)
None.
0861 Sleepy in the Mountains
Authors: Moshtagh-Sisan Mahtab , Zeidler Michelle , De Cruz Sharon 
Published: May 2022

Abstract

Introduction
Central sleep apnea (CSA) is a rare disorder caused by a reduction of airflow and ventilatory effort during sleep. CSA is rarely idiopathic and associated with medical conditions including heart failure, opioid medications, treatment emergent and high-altitude periodic breathing. At higher altitudes, hypoxemia induces periodic breathing with periods of deep and rapid breathing alternating with central apnea. Patients with high-altitude periodic breathing experience fragmented sleep, poor sleep quality, excessive daytime sleepiness, morning headaches and witnessed apnea. We discuss a patient with obstructive sleep apnea (OSA) who developed new-onset central sleep apnea after relocating to a higher altitude location.
Report of Cases: A 75-year-old male with a history of moderate obstructive sleep apnea well controlled on CPAP for eight years, with no known cardiovascular or pulmonary disease, presented with new-onset excessive daytime sleepiness. He had recently relocated to an area in the Colorado mountains (7000 ft elevation) from his previous home in Los Angeles (sea level). His residual apneahypopnea index (r-AHI) displayed on his CPAP machine increased to 7-14/hr from his normal of 1-2/hr after his relocation. Review of his compliance data revealed his central apnea index was elevated, contributing to his high r-AHI. A one-night nocturnal oximeter was mailed to the patient to use while on CPAP. Data revealed oxygen desaturation to less than 88% for about 2 hours of the night, worse during the early morning hours. The patient was advised to undergo a polysomnography and adaptive servo-ventilation titration if significant central sleep apnea was present. The patient declined due to concern about the COVID-19 pandemic. Supplemental nocturnal oxygen was initiated at 2L/min with normalization of the r-AHI.

Conclusion
Patients with OSA who experience worsening symptoms or increased r-AHI despite excellent compliance with PAP therapy should be considered for repeat polysomnography or titration study. While it is expected that high-altitude central sleep apnea will improve with acclimatization, nocturnal supplemental oxygen in addition to PAP therapy is indicated for patients with high-altitude central sleep apnea to diminish hypoxemia and improve residual AHI and sleep quality.

Support (If Any)
Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study
Authors: Goldstein Lizabeth A , Purcell Natalie , Sarmiento Kathleen F , Neylan Thomas C , Maguen Shira 
Published: May 2022

Abstract
Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient’s barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.
Inhibition of vascular endothelial growth factor alleviates neovascular retinopathy with regulated neurotrophic/proinflammatory cytokines through the modulation of DBI‐TSPO signaling
Authors: Gao Shuang , Li Na , Wang Yanuo , Lin Zhongjing , Zhu Yanji , Xu Jianmin , Zhang Qiong , Zhu Caihong , Zhou Yingming , Zhou Jia , Shen Xi 
Published: May 2022

AbstractDiazepam binding inhibitor (DBI)‐translocator protein (18kDa) (TSPO) signaling in the retina was reported to possess coordinated macroglia‐microglia interactions. We investigated DBI‐TSPO signaling and its correlation with vascular endothelial growth factor (VEGF), neurotrophic or inflammatory cytokines in neovascular retinopathy, and under hypoxic conditions. The vitreous expression of DBI, VEGF, nerve growth factor (NGF), and interleukin‐1beta (IL‐1β) were examined in proliferative diabetic retinopathy (PDR) patients with or without anti‐VEGF therapy and nondiabetic controls. Retinal DBI‐TSPO signaling and the effect of the anti‐VEGF agent were evaluated in a mouse model of oxygen‐induced retinopathy (OIR). Interactions between Müller cell‐derived VEGF and DBI, as well as cocultured microglial cells under hypoxic conditions, were studied, using Western blot, real‐time RT‐PCR, enzyme‐linked immunosorbent assay (ELISA), flow cytometry, and immunofluorescent labeling. Results showed that vitreous levels of DBI, VEGF, NGF, and IL‐1β were significantly higher in PDR patients compared with controls, which further changed after anti‐VEGF therapy. A statistical association was found between vitreous DBI and VEGF, NGF, IL‐1β, and age. The application of the anti‐VEGF agent in the OIR model induced retinal expression of DBI and NGF, and attenuated inflammation and microglial cell activation. Inhibition of Müller cell‐derived VEGF could increase its DBI expression under hypoxic conditions, while the DBI‐TSPO signaling pathway is essential for anti‐VEGF agents exerting anti‐inflammatory and neuroprotective effects, as well as limiting inflammatory magnitude, promoting its neurotrophin production and anti‐inflammatory (M2) polarization in microglial cells. These findings suggest the beneficial effect of anti‐VEGF therapy on inflammation and neurotrophy of retinal glial cells through modulation of the DBI‐TSPO signaling pathway.
A new preclinical model of western diet‐induced progression of non‐alcoholic steatohepatitis to hepatocellular carcinoma
Authors: Green Christopher D. , Weigel Cynthia , Brown Ryan D. R. , Bedossa Pierre , Dozmorov Mikhail , Sanyal Arun J. , Spiegel Sarah 
Published: May 2022

AbstractNon‐alcoholic steatohepatitis (NASH) results from the accumulation of excessive liver lipids leading to hepatocellular injury, inflammation, and fibrosis that greatly increase the risk for hepatocellular carcinoma (HCC). Despite the well‐characterized clinical and histological pathology for NASH‐driven HCC in humans, its etiology remains unclear and there is a deficiency in pre‐clinical models that recapitulate the progression of the human disease. Therefore, we developed a new mouse model amenable to genetic manipulations and gene targeting that mimics the gradual NASH to HCC progression observed in humans. C57BL/6NJ mice were fed a Western high‐fat diet and sugar water (HFD/SW) and monitored for effects on metabolism, liver histology, tumor development, and liver transcriptome for up to 54 weeks. Chronic HFD/SW feeding led to significantly increased weight gain, serum and liver lipid levels, liver injury, and glucose intolerance. Hepatic pathology progressed and mice developed hepatocellular ballooning, inflammation, and worse fibrosis was apparent at 16 weeks, greatly increased through 32 weeks, and remained elevated at 54 weeks. Importantly, hepatocellular cancer spontaneously developed in 75% of mice on HFD/SW, half of which were HCC, whereas none of the mice on the chow diet developed HCC. Chronic HFD/SW induced molecular markers of de novo lipogenesis, endoplasmic reticulum stress, inflammation, and accumulation of p62, all of which also participate in the human pathology. Moreover, transcriptome analysis revealed activation of HCC‐related genes and signatures associated with poor prognosis of human HCC. Overall, we have identified a new preclinical model that recapitulates known hallmarks of NASH‐driven HCC that can be utilized for future molecular mechanistic studies of this disease.
Calcium Channel Antagonists for Mood Disorders
Authors: Dubovsky Steven L. , Marshall Dori 
Published: May 2022

Abstract

Purpose
Development of new thymoleptic medications has primarily centered on anticonvulsants and antipsychotic drugs. Based on our studies of intracellular calcium ion signaling in mood disorders, we were interested in the use of novel medications that act on this mechanism of neuronal activation as potential mood stabilizers.

Method
We reviewed the dynamics of the calcium second messenger system and the international body of data demonstrating increased baseline and stimulated intracellular calcium levels in peripheral cells of patients with bipolar mood disorders. We then examined studies of the effect of established mood stabilizers on intracellular calcium ion levels and on mechanisms of mobilization of this second messenger. After summarizing studies of calcium channel blocking agents, whose primary action is to attenuate hyperactive intracellular calcium signaling, we considered clinical experience with this class of medications and the potential for further research.

Findings
Established mood stabilizers normalize increased intracellular calcium ion levels in bipolar disorder patients. Most case series and controlled studies suggest an antimanic and possibly mood stabilizing effect of the calcium channel blocking medications verapamil and nimodipine, with fewer data on isradipine. A relatively low risk of teratogenicity and lack of cognitive adverse effects or weight gain suggest possible applications in pregnancy and in patients for whom these are considerations.

Implications
Medications that antagonize hyperactive intracellular signaling warrant more interest than they have received in psychiatry. Further experience will clarify the applications of these medications alone and in combination with more established mood stabilizers.
Supporting a Learning System in Pediatric Emergency Pathways
Authors: Winters David Adam , Mehmi Ashley K. , Menzies-Wilson Richard , Folkard Samuel S. , Ryan Kate , Sevdalis Nick , Green James S.A. 
Published: May 2022

Background
Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion and increase the opportunity for testicular salvage. Using national data obtained from the NHS Improvement, we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to learning from these and improving outcomes.

Methods
A freedom of information request was made to all 134 hospital groups in England and Wales that manage testicular torsion. Serious incidents experienced by these hospitals were analyzed to see whether those with pediatric emergency departments fared better than those without. In addition, a qualitative thematic analysis of the NHS Improvement National Reporting and Learning System database over a 12-year period (2007–2019) was undertaken, to identify common themes associated with orchidectomies and “near-miss” events in the pediatric population.

Results
Three hundred four patient safety incidents were returned and divided into 62 orchidectomies and 242 near-miss events. The most common factor in the orchidectomy group was individual factors (83.9%). Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialist surgeons (odds ratio = 1.46, P = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED with specialists (odds ratio = 6, P = 0.0355). Near-miss events, not leading to orchidectomy, are often due to a wider variety of factors. A Mann-Whitney U test showed that there was no statistical significance in incidents when comparing general ED units caring for all ages with pediatric EDs in terms of incidents (U = 807.5, z = −1.124, P = 0.261).

Conclusions
There is a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It is also vital that specialist teams are cognizant of the standard operating procedures relevant to scrotal pain and testicular within the organization and the wider clinical network. Finally, there should be a drive for annual collation of data in urology and ED units with regards to testicular torsion as patient safety incidents may be underreported.
Anaphyl-Crisis
Authors: Patek Paul M. , Owda Dalia , Menoch Margaret J.A. 
Published: May 2022

Objectives
Anaphylaxis is a serious allergic reaction that has the potential to be life-threatening if not recognized and managed rapidly. Several regional studies have shown increased incidence of anaphylaxis over the past decade. The objectives of this study were to determine rates of pediatric anaphylaxis in southeast Michigan between January 1, 2010, and December 31, 2019, and to describe the epidemiology of pediatric patients presenting to emergency centers in southeast Michigan with anaphylaxis.

Methods
We performed a retrospective chart review of all pediatric patients aged 0 to 17 years presenting to 2 large emergency centers from 2010 to 2019 with a diagnosis of anaphylaxis using International Classification of Diseases, Ninth and Tenth Revision, Clinical Modification codes. Epidemiological and visit data, including length of stay, use of intravenous medication, and emergency severity index, were extracted and analyzed. Pediatric anaphylaxis rates were calculated based on detected anaphylaxis cases divided by total pediatric emergency department visits to the 2 emergency centers. A Poisson regression model was used to predict rates of anaphylaxis per 100,000 emergency department visits.

Results
One thousand three hundred ninety-one pediatric visits for anaphylaxis were identified during a period between January 1, 2010, and December 31, 2019. There was a significant rate of increase in pediatric anaphylaxis cases over the 10-year study period at both suburban emergency centers, with an annual increase of 21% and 13%. There was no significant change in trends in demographic factors. Most anaphylaxis cases were young, White males with private insurance. Most children did not receive intravenous medications (77%). The median length of stay increased by 1.5 hours over the study period and 92% of patients were discharged home.

Conclusions
Pediatric emergency center visits and length of stay for anaphylaxis in southeast Michigan have markedly increased over the past 10 years.