Sleep Center Research Articles

Effect of mandibular advancement device in the treatment of obstructive sleep apnea

Abstract Background Obstructive sleep apnea (OSA) is a situation of repetitive and interrupted collapse of the upper airways (UAs) during sleep. The physiopathology of OSA is multifactorial. Provided that continuous positive airway pressure is the gold standard for treatment of OSA, the American Academy of Sleep Medicine in 2015 stated that mandibular advancement device (MAD) was indicated as a first-line therapy for mild OSA and a second-line therapy for moderate to severe OSA with lower BMI. Aim This study is aimed to evaluate the MAD success rate in patient with OSA and to assess improvement in sleep quality. Patients and methods This was a prospective one-group pretest–post-test quasiexperimental study carried out on 30 patients with OSA admitted to the sleep center at Chest Medicine Department of Mansoura University Hospitals through the period from February 2019 to January 2021. All patients had thorough clinical examination. The clinical assessment was scored according to the following questionnaires: the Epworth Sleepiness Scale, the Berlin questionnaire, the STOP-Bang questionnaire, and the Pittsburgh sleep quality index. Patients also had polysomnography, drug-induced sleep endoscopy, and dental volumetric computerized tomography (CT) scan. All patients were treated by MAD, and then patients began home adjustment as patients were instructed to advance the device 0.5 mm each night as tolerated. After two weeks, patients repeated PSG and CBCT to assess airway volume and airway area after treatment of OSA by the MAD. Results A total of 30 patients with OSA were included, comprising 14 males and 16 females, with a mean age of 42.9 ± 7.0 years. The types of UA obstruction were detected by both drug-induced sleep endoscopy (DISE) and dental volumetric cone-beam CT (CBCT). A total of 30 patients were studied and showed that multiple-level obstruction was the most frequent type of UA obstruction detected by both dental volumetric CBCT and DISE, representing 53.3 and 60%, respectively. Regarding polysomnographic data of the studied patients before and after treatment by MAD, there is very high significant improvement of apnea-hypopnea index among the studied patients whose were treated by MAD. Conclusion MAD has a high success rate in treatment of OSA and improves sleep quality. DISE and CBCT can be useful tools for assessing the success of MAD in the treatment of OSA.

Event-Related Potential Assessment of Visual Perception Abnormality in Patients With Obstructive Sleep Apnea: A Preliminary Study

This study investigated the effect of obstructive sleep apnea (OSA) on the neural mechanism of visual perception. A preliminary case-control study was conducted. Seventeen patients with moderate to severe OSA in the sleep center of Civil Aviation General Hospital and 20 healthy controls matched for age, sex, and education were recruited. The participants accepted the perceptual contour integration task, compared the differences in behavioral indicators between the two groups, and compared the differences in electroencephalography (EEG) data between the two groups through event-related potential (ERP) technology. The groups did not differ significantly in age and gender, but they differed significantly in body mass index (BMI) (OSA higher than healthy controls, p < 0.05). The groups were not statistically different in terms of sleep structure and total sleep time. AHI, sleep efficiency, and minimal SaO2 value in the OSA group were significantly different from those of the control group. The results showed that the average reaction time of the OSA group was significantly longer than that of the healthy control group in the contour integration task. There was no significant difference in the accuracy rate. The results of EEG showed that the amplitudes of N100 of the OSA group were significantly higher than those of the control group at O1, Oz, and O2 electrodes. There was no significant difference in latency between the two groups. At the FCz electrode, the amplitudes of N200 of the OSA group were significantly higher than those of the control group. Therefore, we concluded that in the early stage of the perceptual integration task, although the neural response activity of patients with moderate and severe OSA was not accelerated, they need to call on more psychological resources, activate more neurons in the contour global recognition processing stage, and the compensatory effect of frontal lobe appeared in the stage of visual perception.

Circadian programming of the ellipsoid body sleep homeostat in Drosophila.

Homeostatic and circadian processes collaborate to appropriately time and consolidate sleep and wake. To understand how these processes are integrated, we scheduled brief sleep deprivation at different times of day in Drosophila and find elevated morning rebound compared to evening. These effects depend on discrete morning and evening clock neurons, independent of their roles in circadian locomotor activity. In the R5 ellipsoid body sleep homeostat, we identified elevated morning expression of activity dependent and presynaptic gene expression as well as the presynaptic protein BRUCHPILOT consistent with regulation by clock circuits. These neurons also display elevated calcium levels in response to sleep loss in the morning, but not the evening consistent with the observed time-dependent sleep rebound. These studies reveal the circuit and molecular mechanisms by which discrete circadian clock neurons program a homeostatic sleep center.

Restless Sleep Disorder (RSD): a New Sleep Disorder in Children. A Rapid Review.

Restless sleep disorder (RSD) is a recently identified pediatric sleep disorder characterized by frequent movements during sleep associated with daytime symptoms. In this review we summarize the expanding evidence of the clinical presentation of RSD, potential pathophysiology, associated comorbidities, and current treatment options that will help the pediatrician identify children with RSD in a timely manner. RSD is diagnosed in 7.7% of children referred evaluated in a pediatric sleep center. Children with RSD present with frequent nightly movements during sleep for at least 3months, and have daytime symptoms related to poor sleep quality including excessive sleepiness, hyperactivity, irritability among other symptoms. Current evidence shows an increased sympathetic predominance, increased NREM sleep instability, and iron deficiency, as well as increased prevalence in parasomnias and attention deficit hyperactivity disorder. Consensus diagnostic criteria were recently published to diagnose RSD and emergent evidence suggests that iron supplementation improves its nighttime and daytime symptoms.

Outcome of CPAP Titration for Moderate-to-Severe OSA Under Drug-Induced Sleep Endoscopy: A Randomized Controlled Crossover Trial.

BackgroundThe titration pressure of continuous positive airway pressure (CPAP) is important in patients with obstructive sleep apnea (OSA). This study aimed to understand the difference between drug-induced sleep endoscopy (DISE)-guided CPAP titration and conventional sleep center (CSC) CPAP titration in patients with OSA.MethodsIn this randomized, controlled, and single-blind crossover trial, we compared the effects of 1-month CPAP treatment in patients with OSA with either DISE-guided CPAP titration or CSC CPAP titration. Twenty-four patients with OSA were recruited for the study. All patients underwent polysomnography, DISE-guided CPAP titration, and accommodation. Initially, patients were randomly assigned to receive either DISE-guided CPAP titration or CSC CPAP treatment for the first month. They were then switched to other treatments in the second month. The Epworth sleepiness scale (ESS) score was recorded at baseline, 1 and 2 months.ResultsThe upper limit of the pressure of DISE-guided titration and CSC CPAP titration was not significantly different (13.9 ± 0.7 vs. 13.5 ± 0.5 cm H2O; P = 0.92). The residual apnea-hypopnea index and compliance were also not significantly different between the groups. ESS score significantly improved from baseline to 1 month after CPAP treatment in both groups. Both epiglottis (anterior-posterior collapse) and tongue base collapse were significantly associated with 95% CPAP pressure (P = 0.031 and 0.038, respectively). After multivariate regression analyses, the epiglottis (anterior-posterior collapse) was an independent factor for 95% CPAP pressure. The incidence rate of bradycardia was 58.3%, which is a safety concern for DISE. Despite the high incidence of bradycardia, all patients with bradycardia recovered with proper management.ConclusionBoth modalities were comparable in terms of establishing the pressure settings required to treat patients. Further large-scale studies are required to confirm these results.Trial registrationhttps://clinicaltrials.gov/, NCT03523013.

10-year anniversary of the European Somnologist examination - A historic overview and critical appraisal.

SummaryThe European Somnologist certification programme was developed by the European Sleep Research Society to improve patient care in sleep medicine by providing an independent evaluation of theoretical and practical knowledge. The examination of eligible experts plays a key role in this procedure. A process was started more than 15 years ago to create the European sleep medicine curriculum, eligibility criteria for certification, and sleep centre accreditation criteria. The process was characterised by interdisciplinary collaboration, consensus, and achieving new solutions. During the past 10 years, experience has been gained by the examination and certification of more than 1000 sleep medicine experts from more than 50 countries. The process has continuously been improved. However, as the programme was designed and administered mainly by medical experts in the field, systematic influence from teaching and pedagogic experts was partially underrepresented. The current critical appraisal pinpoints several missing links in the process – mainly as a missing constructive alignment between learning objectives, learning and teaching activities, and the final assessment. A series of suggestions has been made to further improve the ESRS certification programme.

Management of obstructive sleep apnea in Europe – A 10-year follow-up

ObjectiveIn 2010, a questionnaire-based study on obstructive sleep apnea (OSA) management in Europe identified differences regarding reimbursement, sleep specialist qualification, and titration procedures. Now, 10 years later, a follow-up study was conducted as part of the ESADA (European Sleep Apnea Database) network to explore the development of OSA management over time. MethodsThe 2010 questionnaire including questions on sleep diagnostic, reimbursement, treatment, and certification was updated with questions on telemedicine and distributed to European Sleep Centers to reflect European OSA management practice. Results26 countries (36 sleep centers) participated, representing 20 ESADA and 6 non-ESADA countries. All 21 countries from the 2010 survey participated. In 2010, OSA diagnostic procedures were performed mainly by specialized physicians (86%), whereas now mainly by certified sleep specialists and specialized physicians (69%). Treatment and titration procedures are currently quite homogenous, with a strong trend towards more Autotitrating Positive Airway Pressure treatment (in hospital 73%, at home 62%). From 2010 to 2020, home sleep apnea testing use increased (76%–89%) and polysomnography as sole diagnostic procedure decreased (24%–12%). Availability of a sleep specialist qualification increased (52%–65%) as well as the number of certified polysomnography scorers (certified physicians: 36%–79%; certified technicians: 20%–62%). Telemedicine, not surveyed in 2010, is now in 2020 used in diagnostics (8%), treatment (50%), and follow-up (73%). ConclusionIn the past decade, formal qualification of sleep center personnel increased, OSA diagnostic and treatment procedures shifted towards a more automatic approach, and telemedicine became more prominent.

Telehealth delivered Tai Chi intervention for managing aromatase inhibitor-induced arthralgia in breast cancer patients: TaiChi4Joint during the COVID-19 pandemic a Pilot study.

e12523 Background: Estrogen receptor positive breast cancer (BC) is the most common type of breast cancer in postmenopausal women and aromatase inhibitors (AI) are the endocrine therapy of choice recommended for these patients. Up to 50% of those treated with an AI develop Arthralgia often resulting in poor adherence and decreased quality of life. Methods: This is a single arm longitudinal pilot study aiming to evaluate the safety, feasibility, acceptability and potential efficacy of TaiChi4Joint, a remotely-delivered 12-week Tai Chi intervention designed for the relief of AI-induced joint pain. Women diagnosed with stage 0-III BC who have been receiving an AI for at least 2 months and reporting arthralgia with a ≥ 4 score on a 0-10 scale for joint pain were eligible for study enrollment. Participants were encouraged to join Tai Chi classes delivered over ZOOM three times a week for 12 weeks. Program engagement strategies include the use of a private Facebook study group and box.com cloud for archiving live class recordings. The program utilizes Text messaging and emails with periodic positive quotes and evidence based information on Tai Chi for facilitating community bonding and class attendance. Participants were invited to complete the following assessments online at baseline, 1, 2 and 3 months intervals from study enrollment: Brief Pain Inventory (BPI), Western Ontario and McMaster University Osteoarthritis index (WOMAC), The Australian Canadian Osteoarthritis Hand Index (AUSCAN), Fatigue Symptom Inventory (FSI), Hot Flash Related Daily Interference Scale (HFRDIS), Pittsburg Sleep Quality Index (PSQI) and Center for Epidemiological Studies Depression (CES-D). Results: 55 eligible patients were invited to participate and 39 consented and completed the baseline assessments. 61% (median) Participants attended the classes, with no Tai Chi related adverse events reported. 22 of the 39 participants completed the 3-month follow up assessments with a 56% retention rate. Study participants reported improvement from baseline compared to 3 month as follows: For BPI ( P = .000), AUSCAN pain subscale ( P =.000), AUSCAN function subscale for 35 patients ( P = .000), WOMAC ( P = .000), CES-D ( P = 0.001), FSI ( P = 0.00) and PSQI ( P = .000). However HFRDIS improved in 11 patients ( P = 0.00) for the other 22 patients (P = 0.154). Conclusions: The COVID-19 global pandemic has resulted in the need to rethink how mind-body therapies can be delivered. This study demonstrated the feasibility, acceptability, and potential efficacy of a Telehealth based Tai Chi intervention for reducing AI-induced arthralgia. The intervention decreased patient reported pain, stiffness and improved sleep quality and depressive symptoms. With our promising findings, larger telehealth based trials of Tai Chi for AI-associated arthralgia are needed. Clinical trial information: NCT04716920.

0360 PAP Adherence, Follow-Up, and Telehealth During the COVID-19 Pandemic

Abstract Introduction Positive airway pressure (PAP) is the gold standard therapy for OSA. However, patient follow-up and adherence to PAP therapy remains variable. With the onset of the COVID-19 pandemic, many sleep centers shifted towards telemedicine. In order to evaluate the impact of telehealth, we assessed the rates of follow-up and PAP adherence among patients newly diagnosed with OSA prior to and after the onset of the COVID-19 pandemic. Methods Patients aged 18-75 years enrolled in our military sleep center who met eligibility criteria were divided into a pre-pandemic group and a pandemic group. For the pre-pandemic group, initial and follow-up clinic appointments occurred via face-to-face encounters. For the pandemic group, these clinic appointments occurred via telephone encounters. PAP follow-up was defined as a clinic appointment occurring within 6 months of the initial OSA diagnosis and the onset of PAP therapy. Adequate PAP adherence was defined as usage of the device ≥ 4 hours per night on ≥ 70% of nights during a consecutive 30-day period. Differences among the two groups regarding PAP follow-up, PAP adherence, and demographic data were analyzed. Results Eligible patients (n=234) were divided into a pre-pandemic group (n=117) and a pandemic group (n=117). Demographic data for the pre-pandemic group vs. pandemic group included the following: mean age 42.2 vs. 40.3 years; 78.6% vs. 88.0% male; 60.7% vs. 76.9% active duty military, mean BMI 30.1 vs. 30.1; mean AHI 28.5/hr vs. 27.7/hr; mean Epworth Sleepiness Scale score 11.7 vs. 12.0; mean Insomnia Severity Index 16.9 vs. 16.8. The rates of PAP follow-up were 59.0% (pre-pandemic group) vs. 41.0% (pandemic group). The rates of adequate PAP adherence were 34.8% (pre-pandemic group) vs. 25.0% (pandemic group). Conclusion There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence. Support (If Any) There were higher rates of PAP follow-up and PAP adherence among patients seen via face-to-face encounters occurring prior to the onset of the COVID-19 pandemic. While utilization of telehealth in our center did not result in improved outcomes, there may still be utility in offering telehealth to the sleep patient population. Additional studies are needed to identify effective interventions that can be implemented to improve rates of PAP follow-up and PAP adherence.

0803 Extreme upper extremity movements in patient with narcolepsy type 1 and REM sleep behavior disorder affecting actigraphy results

Abstract Introduction Narcolepsy with Cataplexy is a central disorder of hypersomnia that is characterized by excessive daytime sleepiness and Rapid eye movement (REM) dissociation phenomena. A common manifestation of narcolepsy is REM behavioral disorder (RBD), a parasomnia characterized by loss of muscle atonia during REM sleep (RSWA). While RBD is relatively common in patients with narcolepsy, very extreme movements are considered rare. Report of Cases: A 20-year-old male with no significant past medical history presented with 8 months of new onset daytime sleepiness, sleep paralysis, and auditory hallucinations at sleep onset. After initial evaluation at our sleep center, he was scheduled for actigraphy testing and sleep logs, followed by video polysomnogram and mean sleep latency testing (MSLT). Initial PSG results were notable for a total sleep time of 498 minutes, a normal apnea-hypopnea index of 0.7/hr., sleep onset latency of 0 minutes, and REM latency of 0 minutes. Based upon military medical standards, the MSLT scheduled for the following morning was cancelled due to limited sleep during the preceding 2 weeks as measured via actigraphy. However, the patient’s sleep logs reported over 7.5 hours of sleep per night. The patient’s video PSG was reviewed, which showed evidence of frank RSWA, as well as episodes of dream enactment behavior during REM sleep, all including very violent movement in his upper extremities. Repeat trial of MSLT 2 weeks later showed mean sleep latency of 1.7 minutes, with 5 sleep onset REM periods (SOREMPS), and evidence of dream enactment involving the upper extremities during 3 of these SOREMPS. Conclusion We present the case of a patient with narcolepsy and RBD with significant upper extremity movements to the point of affecting the actigraphy sleep/wake detection algorithm. Actigraphy has been validated as a diagnostic tool in assessing sleep and wake patterns in individuals without significant REM sleep dissociation phenomena; however, our case highlights the necessity of further research of the validity of actigraphy in patients with Narcolepsy and/or REM behavioral disorder. Support (If Any)

0831 Identifying Sleep-Related Breathing Disorders in Underserved Demographics Using Commercial Portable Monitoring Devices: A Case Report

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).

0696 The Application of a QTc Risk Score in Patients with Obstructive Sleep Apnea

Abstract Introduction Evidence suggests that patients with obstructive sleep apnea (OSA) are at risk for QTc prolongation which, is a known risk factor for arrhythmias, sudden cardiac death and all cause mortality. QTc risk scores have been implemented widely to help physicians identify patients at risk for mortality however, these risk scores have not been routinely implemented in patients undergoing sleep studies or those diagnosed with OSA. The goal of this study was to evaluate the distribution of pro-QTc risk scores for patients with and without OSA diagnosed at our facility and its relationship to mortality. Methods Medical records of all patients undergoing a sleep study at our sleep center from 2/2012 through 8/2020 were analyzed. Patients were identified with or without OSA based on polysomnography or Type III home sleep study. The pro-QTc risk score was calculated with 1 point assigned for: female sex, QT-prolonging diagnoses and conditions, QT-prolonging electrolyte abnormalities, and QT-prolonging medications defined as medications with known and possible risk of torsades de Pointes based on the CredibleMeds website. Mortality was determined if a death date was noted in the electronic medical record. Results A total of 2,834 patient records (54% male, age 58 ± 16 years, n=106 dead) were evaluated. A total of 2,265 patients (age 58 ±15, 54% male, 89 dead) were identified as having OSA and 428 patients (age 54 ± 18, 41% male, 17 dead) did not have OSA. The remaining patients (n=141) had either central sleep apnea or a combination of both obstructive and central sleep apnea. A higher pro-QTc score was associated with greater mortality regardless of presence of OSA (HR 1.3, p&amp;lt;0.0001, 95% CI 1.12 -1.46) after adjusting for age. The association of pro-QTc with mortality was not increased in the moderate or severe OSA groups compared to those without OSA or mild OSA (p=0.36). Conclusion Increased pro-QTc scores were associated with greater mortality in all patients undergoing sleep studies. OSA status did not affect this association. Support (If Any) American Academy of Sleep Medicine Foundation (203-JF-18), National Institutes of Health (HL126140, 2L30HL154400-023), University of Arizona Health Sciences Career Development Award (5299903), and University of Arizona Faculty Seed Grant (5833261)

0410 Utility of the Urine Drug Screen in Maintenance of Wakefulness Testing Interpretation - A Single-Center, Retrospective Analysis in Pediatric Patients

Abstract Introduction Accurate assessment of hypersomnia depends upon consideration of several factors, including use of medications that affect alertness and sleep organization. Urine drug screens (UDS) are recommended when assessing hypersomnia, but there is little standardization with respect to screening methods, types of substances detected, and use in maintenance of wakefulness test (MWT) interpretation, in part because there is scant literature relating UDS results to patients’ characteristics, MWT findings and implications. Methods A retrospective analysis was performed in adolescents evaluated at Cincinnati Children's Sleep Center between 2008 and 2021 who underwent MWT with concurrent UDS to determine the adequacy of hypersomnia treatment. UDS in our laboratory were performed by Qualitative Immunoassay/Gas Chromatography-Mass Spectrometry/Liquid Chromatography-Tandem Mass Spectrometry. Results A total of 109 MWTs were accompanied by UDS in 79 patients. Patients were 17.7 [16.6, 18.6] years old (median, [IQ range]), 41.3% female, 68.8% White, 25.7% Black, 5.5% Other, with a BMI of 25.8 [22.1, 31.8] kg/m2. 85.3% had narcolepsy. In addition to prescribed medications, caffeine was positive in 54.1% of UDS, and diphenhydramine was positive in 58.7%. No patients reported use of caffeine or diphenhydramine on the day of MWT. There were no significant demographic differences between those who tested positive and negative for caffeine. The median sleep latency in those with caffeine-positive UDS was longer than those with caffeine-negative UDS, although it did not reach statistical significance (27.3 [14.7, 38.3] vs 19.1 [9.8, 36.1] minutes; P=0.15). Patients with a positive UDS for diphenhydramine all took modafinil/armodafinil. In addition, 80% of patients taking modafinil/armodafinil had diphenhydramine-positive results. Nicotine and cannabinoids were detected in 2 UDS. Conclusion Two unexpected substances (caffeine and diphenhydramine) were found on UDS during MWTs in a significant proportion of our cohort. Caffeine may influence the results of MWTs, although further investigations are warranted. The unexpected presence of diphenhydramine is a false positive for those patients on modafinil/armodafinil (supported by literature and confirmed by our laboratory director). Sleep clinicians should be aware of these findings and the implications of unexpected substances when interpreting MWTs. Support (If Any) Cincinnati Children's Hospital Research Fund

0791 Perceived racial discrimination predicts poor PAP adherence: a pilot study

Abstract Introduction Although racial and ethnic differences in continuous positive airway pressure (CPAP) adherence for people with obstructive sleep apnea (OSA) are well known, no studies have examined the influence of racial discrimination on CPAP use. The aim of this study was to determine if racial discrimination influenced CPAP use trajectories. Methods Participants with OSA initiating CPAP were enrolled from two sleep centers in New York City. Participants completed questionnaires including sociodemographics, perceived discrimination, daytime sleepiness, and depressive symptoms. Racial discrimination was measured via the validated Everyday Discrimination scale (EDS) , Participants endorsed at least one discriminatory experience “at least once a year” and race was the main reason for this treatment. Sociodemographic and questionnaire comparison were performed between participants reporting the presence and absence of racial discrimination. To examine differences in the trajectory of CPAP use based on racial discrimination status (between-subjects factor), we performed a two-factor repeated measures ANOVA with mean hours of daily use at 7, 30 and 90 days serving as the time dependent variable (within-subjects factor). Analyses were adjusted for depressive symptoms. Results The sample consisted of 88 participants (40% female; 40% Non-Hispanic Black; mean age of 57 ± 14 yrs). Twenty-two individuals (25% of the cohort) reported racial discrimination. In unadjusted two-factor repeated measures ANOVA, the test statistic for equality of racial discrimination CPAP adherence means over time was highly significant [ F = 9.71 (1, 68); p = 0.003] while the test for interaction between racial discrimination and time was marginally significant [F = 3.19 (1.53, 103.8); p = 0.059). Main effects for time were significant for participants reporting discrimination (p=0.04) but not for those without racial discrimination experiences (p=0.25). Thus, people reporting racial discrimination experienced greater decrement in CPAP use over time while a more stable CPAP use pattern was observed in those not perceiving racial discrimination. Conclusion Racial discrimination status may determine future poor CPAP adherence. Larger studies examining mechanisms of how perceived racial discrimination mediates worse CPAP adherence may assist in mitigating CPAP adherence disparities. Support (If Any) Natasha Williams was supported by grant from the National Institutes of Health: K23125939

0381 High levels of patient engagement with a novel sleep telehealth platform in the US military

Abstract Introduction Despite very high prevalence and documented adverse consequences of insufficient and disturbed sleep in the US military, there are well-recognized barriers limiting access to evidence-based sleep interventions within the military health system (MHS). Chief among these is an insufficient number of trained sleep specialists and sleep centers. As part of a larger implementation effort, the purpose of this pilot study was to evaluate patient engagement with a novel sleep telehealth platform at a busy military treatment facility. Methods The sleep telehealth platform consists of an online web portal for patients and providers, a secure mobile app, and integrated wearable sensors using an off the shelf commercial solution (COTS; in this study, Fitbit). The purposes of this platform are to 1) help primary care managers (PCMs) assess sleep complaints, 2) empower patients and PCMs to make evidence-based sleep treatment decisions, 3) deliver evidence-based behavioral sleep treatments via mobile devices, and 4) connect patients with sleep specialists in virtual or physical sleep centers. Participants were recruited from the Internal Medicine clinic and the Sleep Disorders Center at Walter Reed National Military Medical Center (WRNMMC). Inclusion criteria included ages of 18-75 years and self or provider referral for sleep problems, including insufficient sleep duration. In addition to wearing the COTS sleep tracker, participants completed a baseline assessment and 2x/daily diaries for ten days, and a brief satisfaction survey. Results Participants included 35 patients (57% female, mean age=44.7 years). One hundred percent of participants wore the COTS sleep tracker and completed the post-monitoring assessment. Satisfaction survey results indicated that 96.7% of participants found completing the 10-day continuous sleep monitoring assessments to be “easy” or “very easy,” and 96.7% of those who completed the monitoring expressed a preference for app-based sleep treatment either alone or in conjunction with virtual or in person care. Finally, participants offered suggestions to optimize the app and platform for pending clinical implementation. Conclusion Results of this pilot study demonstrate high levels of patient engagement with the sleep telehealth platform. Given the large number of patients seeking treatment and the shortage of trained specialist providers, sleep telehealth is a promising pathway to increase access to evidence-based care. Support (If Any) This research was supported by an investigator-initiated research award from the Department of Defense (via the Medical Technology Enterprise Consortium) to the University of Maryland, Baltimore (PI: EMW).

0356 Does Unconscious Socioeconomic Bias Influence Tele-evaluation of Obstructive Sleep Apnea? A Tele-Equity Exploratory Analysis

Abstract Introduction Telemedicine, once of limited scope, has become common and widespread due to the present and ongoing SARS-CoV-2 pandemic. Center to home delivery, the most common model, allows for convenient and efficient care. Concurrent with this groundshift, there is increasing attention to disparities in medical services, and how these disparities may impact patient outcomes. Telemedicine could be used to help bridge barriers to timely quality care, however, patient access and longstanding institutional biases may limit the potential. Healthcare providers must actively develop systems to ensure that telemedicine is optimized for people across the income spectrum. This exploratory analysis examined how economic disparities in patients being evaluated for obstructive sleep apnea may be associated with providers’ clinical impressions. The objective was to study the inter-method reliability of pre-test probability of obstructive sleep apnea assessed via telemedicine and in-person evaluations, and to compare that reliability between income classes. Methods This is a secondary analysis of a pre-pandemic interrater reliability study, conducted between March 2017 and January 2019. Our researchers completed a randomized, blinded study comparing the pre-test probability of obstructive sleep apnea between an in-person physician and a separate physician seeing the same patient via televideo conferencing. Patients referred to the University of Rochester (UR) Sleep Center were eligible for the study. Women and men 30-70 years old were invited to participate. The patients were not necessarily referred to the center for evaluation of sleep disordered breathing. Patients with dementia, hearing or visual loss, severe psychiatric or developmental illness, or not fluent in English were excluded. Patients had adequate computer literacy, access to high speed internet, and a computing device with appropriate video camera and microphone.The primary objective of the original study was to assess the interrater reliability between the in-person and telemedicine raters for pre-test probability of sleep apnea (high, moderate, or low). Providers used clinical judgement from the history and examination to determine pre-test probabilityFor this present analysis, we assessed the inter-method reliability separately for strata defined by reported annual income level: low income (&amp;lt; $50,000), middle income ($50,000-$100,000), and high income (&amp;gt; $100,000). Reliability was quantified for each stratum using weighted kappa statistics given the ordinal nature of the outcome variable, pre-test probability of obstructive sleep apnea (high, moderate, or low). Weighted kappa statistics were compared between the income strata (high vs. middle, high vs. low, middle vs. low). The operant statistic assumed an approximate standard normal distribution under the null hypothesis of equal kappa values in the two income strata. The Bonferroni method was used to adjust the p-values for the three pairwise comparisons performed among the three income strata. Results Data from 53 patients were avaiable for this analysis. 11 of these patients were in the low income group, 22 in the middle income, and 16 were in the high income group. 9 patients did not include their income bracket, and were not included in the analysis. Inter-method reliabilities, assessed using weighted kappa, were 0.83 (low income), 0.24 (middle income), and 0.66 (high income). When comparing between the strata, the kappa statistics were significantly different (p=0.005) between the low and moderate income groups. There was a trend between the high and moderate income groups that did not meet statistical significance (p=0.07). Conclusion The intermethod reliability was substantial in the low income stratum, moderate in the high income stratum, and slight in the middle income group based on the kappa statistic. There was a significant difference in the reliability values of telemedicine versus in-person assessments between the low and middle income brackets, and there was a trend between the high and moderate groups. Since the raters were unaware of the patients’ income levels, this association might suggest possible unconscious bias in evaluating for OSA. It may also suggest that beyond access to telemedicine technology, the quality of the care may also be influenced by socioeconomic factors. With telemedicine in its early stages, it is important to develop this technology that will minimize biases that could result from patients’ economic fortunes. Support (If Any) The study was funded by a grant from the American Academy of Sleep Foundation (AASM Foundation grant #163-FP-17).

0716 Risk for Heart Failure with preserved Ejection Fraction in patients with or without Obstructive Sleep Apnea

Abstract Introduction Approximately two out of three patients with Heart Failure with preserved Ejection Fraction (HFpEF) have co-morbid sleep apnea, but the risk of HFpEF in patients who test positive for obstructive sleep apnea (OSA) is unknown. Methods Referred subjects (n=228) over the age of 18 underwent a diagnostic in-lab polysomnogram at the University of Michigan Sleep Laboratories between 1/8/2019-3/11/2020 and an echocardiogram within 12 months of their sleep study. Individuals with a known history of HFpEF were excluded (n=44). OSA was defined as an apnea-hypopnea-index (AHI) ≥ 5/hour. Clinical and echocardiogram variables were abstracted from the electronic medical record and used to determine H2FPEF scores (ordinal scale, range 0-9). The H2FPEF score is a validated predictor of HFpEF risk in patients with dyspnea. In the presence of dyspnea, a H2FPEF score ≥ 3 indicates a &amp;gt;50% risk of HFpEF, though dyspnea was not assessed in this study. HFpEF probability (continuous variable) was determined using the corresponding online calculator. Linear regression was used to predict HFpEF probability based on AHI. Results The 184 subjects without a known diagnosis of HFpEF had a median age of 65 years (interquartile range (IQR) 51, 71). Seventy subjects (38%) were male, 150 (82%) had OSA, and the median AHI was 15 (7, 35). The median H2FPEF score was 3 (2, 5). Among 34 participants without OSA, 10 (29%) had an H2FPEF score ≥ 3, whereas among 150 participants with OSA, 59 (39%) had an H2FPEF score ≥ 3. Linear regression indicated that higher AHI is associated with a higher probability of HFpEF (β = 0.39, p=0.0001). Conclusion Many patients referred for polysomnography may be at high risk for HFpEF. Sleep-study-referred subjects without clinically-indicated echocardiograms were not assessed, but patients at sleep disorders centers who test positive for OSA may have a particularly high rate of undiagnosed HFpEF. Sleep physicians should consider a cardiology referral in appropriately screened patients. Support (If Any)

0325 A Comprehensive Evaluation of Sleep Disorders in Male and Female U.S. Military Personnel

Abstract Introduction Sleep disorders are increasingly recognized in military personnel. However, no study has comprehensively evaluated male and female service members with clinically significant sleep disturbances. While, insomnia and obstructive sleep apnea (OSA) are the two most recognized sleep disorders, some studies have suggested that comorbid insomnia and OSA, also known as COMISA, potentially is the most frequent sleep disorder. Further little is known regarding the co-occurrence of nightmares, shift work disorder, depression, anxiety, and posttraumatic stress disorder (PTSD) in this population. Methods Participants were 309 active duty service members (females n = 113, male n = 196) in all branches of the military who underwent a clinically indicated sleep evaluation in a military sleep disorders center. All underwent an attended in-lab polysomnogram, were diagnosed with insomnia, OSA, or COMISA and completed self-report measures. Participants completed the Nightmare Disorder Index and Shift Work Disorder Index, and non-sleep questionnaires using the PCL-5 for post-traumatic stress disorder (PTSD), the PHQ-9 for depression, the GAD-7 for anxiety, and History of Head Injuries for traumatic brain injury (TBI). Results COMISA was diagnosed in 36.8% of the sample, insomnia in 32.7%, and OSA in 30.4%. Males were significantly more likely to have COMISA or OSA and females were more likely to have insomnia. Polysomnographic variables were consistent with the respective sleep diagnoses. Forty service members (12.9%) met criteria for nightmare disorder; those with OSA were significantly less likely to have nightmares. Shift work disorder was present in 49 (15.9%) and did not differ between sleep diagnoses. PTSD was present in 57 (18%) and those with COMISA were significantly more likely to have PTSD. A history of head injuries was reported by 38.2% and there was no difference in rates between the sleep disorder groups. Conclusion The most frequent sleep disorder profile in service members with sleep disturbances was COMISA, which was associated with significantly higher rates of PTSD and anxiety. Conversely, OSA alone was not associated with higher rates of any comorbid disorders. Nightmare disorder and shift work are relatively prevalent in military personnel with sleep disorders. 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). The views expressed herein are solely those of the authors and do not represent an endorsement by or the official policy or position of the U.S. Air Force, the U.S. Army, the Defense Health Agency, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government.

0706 Older Age Is a Strong Risk Factor for Supine-position Dependent Obstructive Sleep Apnea

Abstract Introduction Positional obstructive sleep apnea (p-OSA) is commonly defined as a supine-position dependent OSA with the ratio of apnea hypopnea index while supine (s-AHI) to AHI while non-supine (ns-AHI) being greater than 2. Prevalence of p-OSA amongst OSA patients varies from 20 to 75% depending on the study. Previous studies using this definition showed p-OSA being more likely to be in subjects with lower BMI, smaller neck circumference, and milder OSA compared to patients with non-positional OSA (np-OSA). The primary aim of this study is to assess the prevalence of p-OSA using different cutoffs of s-AHI/ ns-AHI ratio and to evaluate the correlation of p-OSA with age, gender, neck circumference (NC), and medical comorbidities of OSA. Methods 846 participants aged 18 year or older who underwent diagnostic polysomnography at an academic sleep disorders center from July 2011 to June 2012 were recruited for this study. Inclusion criteria were total sleep time greater than 120 minutes, diagnosis of OSA, sleep time in supine position more than 10 minutes, and sleep time in non-supine position more than 10 minutes. We tested supine position dependency using the ratio of supine AHI to non-supine AHI (s-AHI/ns-AHI) and classified the subjects into p-OSA and np-OSA based on the ratio of s-AHI/ns-AHI at 2, 3, 5, and 10 respectively to assess the prevalence of p-OSA using each cut-off. For the multivariable logistic analysis of p-OSA and its association with independent variables, s-AHI/ns-AHI of 10 and ns-AHI of being less than 5 was used to define p-OSA. Multivariate analysis was conducted to explore correlation with age, gender, neck circumference, and OSA comorbidities (COPD, hypertension, diabetes). Age of 60 was used to define older age group. Results Of 356 eligible participants, p-OSA was highly prevalent when conventional s-AHI/ns-AHI ration of 2 was used resulting in p-OSA in 274 subjects (prevalence of 77%). The mean value of s-AHI/ns-AHI in this aggregate group of all 356 subjects was 11.7 (much higher than conventional ratio of 2). Thus, using s-AHI/ns-AHI ratio of 10 as the cut-off for supine-position dependency, 114 subjects were classified to have p-OSA. Logarithmic multivariate analysis demonstrated that there was a statistically significant, correlation between age and s-AHI/ns-AHI after adjusting for gender, NC, diabetes, hypertension, and COPD (p-value &amp;lt; 0.05). In the older group, 44.3% of older patient had s-AHI/ns-AHI &amp;gt; 10 compared to 30% of young patients (p-value &amp;lt; 0.05). 41.8% of the older group met criteria for p-OSA compared to 29.2% of younger group (p-value &amp;lt; 0.05). Being of older age was strong risk factor for p-OSA with odds ratio (OR) of 1.76 (confidence interval 1.01 – 3.09; p&amp;lt; 0.05). This effect of age on p-OSA was further modified by gender and diabetes. Older men had significantly higher OR of 3.23 (CI 1.51-6.89) for p-OSA whereas olde women was with OR of 0.79 (CI 0.33-2.42). Older persons with diabetes showed significantly higher OR than non-diabetic older persons (OR of 6.81 [CI 1.7-26.8] vs OR 1.22 [CI 0.65-2.29] respectively). Conclusion Supine-position dependency of obstructive events is much stronger than the conventional ratio of two. Thus, stricter definition is positional OSA is desired for more clinically meaningful use of this subgroup of OSA. Using stricter definition with higher supine-position dependency, an older age is significantly associated with positional OSA, especially in men or in diabetic patients. Support (If Any)

0753 Predictors of Residual sleep apnea in OSA patients on PAP

Abstract Introduction Positive airway pressure (PAP) is the first line therapy for patients with obstructive sleep apnea (OSA). However, clinical OSA may have multiple disease drivers beyond upper airway collapse, such as high loop gain and a low arousal threshold. The burden of residual sleep apnea in patients treated with PAP and it’s predictors remained to be fully defined. Methods Adult patients who were diagnosed with OSA through a split-night polysomnography (PSG) in the AASM accredited sleep center at the Beth Israel Deaconess Medical Center, Harvard Medical School and followed using the EncoreAnywhereTM system were prospectively included. Monthly visual/manual scoring of residual events was done. The ratio of patients with residual sleep apnea (defined as a manually-scored respiratory event index (REI) ≥ 15 times/hour in the 3rd month and 12th month were calculated. A linear regression model was used to explore the predictors of residual sleep apnea on PAP. Results One hundred and ninety five patients were included. In the 3rd month, there were 166 patients still on PAP. There were 74 (44.58%) with a residual AHI ≥ 15 times/h. In the 12th month, there were 93 patients still on PAP and 41 (44.09%) had residual AHI ≥ 15. In the short term, treatment CAHI (β= 0.511, SE=0.123, p=0.001), age (β= 0.123, SE=0.054, p=0.025), and hypertension (β= 3.627, SE=1.536, p=0.019) were the predictors for residual sleep apnea. In the long term, treatment CAHI (β= 0.598, SE=0.163, p=0.001), male gender (β= -5.117, SE=2.005, p=0.013) and baseline mean arousal duration (β= -0.601, SE=0.184, p=0.002) were predictors for residual sleep apnea. Conclusion There was a high percentage of patients with OSA on PAP who have residual sleep apnea. Treatment CAHI is a strong predictor, and may reflect high loop gain effects. Support (If Any) Category-I Strategic Research Award from the AASM Foundation to R. J. Thomas