The interrelationships between sleep regularity, obstructive sleep apnea, and hypertension in a middle-aged community population

STUDY OBJECTIVES

Little is known about the interrelationships between sleep regularity, obstructive sleep apnea (OSA) and important health markers. This study examined whether irregular sleep is associated with OSA and hypertension, and if this modifies the known association between OSA and hypertension.

METHODS

Six hundred and two adults (age mean(SD) = 56.96(5.51) years, female = 60%) from the Raine Study who were not evening or night shift workers were assessed for OSA (in-laboratory polysomnography; apnea-hypopnea index ≥ 15 events/hour), hypertension (doctor diagnosed, or systolic blood pressure ≥140 mmHg and/or diastolic ≥90 mmHg) and sleep (wrist actigraphy for ≥5 days). A sleep regularity index (SRI) was determined from actigraphy. Participants were categorized by tertiles as severely irregular, mildly irregular, or regular sleepers. Logistic regression models examined the interrelationships between SRI, OSA and hypertension. Covariates included age, sex, body mass index, actigraphy sleep duration, insomnia, depression, activity, alcohol, smoking, and antihypertensive medication.

RESULTS

Compared to regular sleepers, participants with mildly irregular (OR 1.97, 95% confidence intervals [CI] 1.20 to 3.27) and severely irregular (OR 2.06, 95% CI: 1.25 to 3.42) sleep had greater odds of OSA. Compared to those with no OSA and regular sleep, OSA and severely irregular sleep combined had the highest odds of hypertension (OR 2.34 95% CI: 1.07 to 5.12; p for interaction = 0.02) while those with OSA and regular/mildly irregular sleep were not at increased risk (p for interaction = 0.20).

CONCLUSIONS

Sleep irregularity may be an important modifiable target for hypertension among those with OSA.

IMPROVING ACCESS TO CARE AND CONSENT FOR TRANSGENDER AND GENDER DIVERSE YOUTH IN THE UNITED STATES

Gender-affirming care (GAC) aims to benefit transgender and gender diverse (TGD) youth. GAC includes access to mental health, medical care, and surgical interventions. However, access to GAC and the youth's ability to consent to GAC is frequently contested. This editorial reviews access to care for TGD youth and discusses perspectives on youth consent for GAC. Pertinent challenges include the ability to provide informed consent within current medical and legal frameworks, mental health and parental concerns, and the long-term effects of GAC. Further research, advocacy, and patient education are warranted to ensure safe access to GAC for TGD youth.

The efficacy of intensive sleep retraining for insomnia: A systematic review and research agenda

Intensive sleep retraining (ISR) is a brief behavioural treatment for sleep onset insomnia, administered in just a single overnight treatment session. This systematic review evaluates existing trials about the efficacy of intensive sleep retraining for treating insomnia, to inform whether there is enough evidence to recommend its use for clinical practice. A systematic literature search was conducted across three databases, yielding 108 results. Of these studies, three were deemed suitable for inclusion in this review. The included studies consistently reported significant reductions in insomnia symptoms following intensive sleep retraining, particularly decreases in sleep diary-derived sleep latency and increases in total sleep time. Based on these inconclusive but promising findings, a research agenda is proffered to test intensive sleep retraining as a treatment for insomnia. Large randomised controlled trials are needed to elucidate the potential benefits of intensive sleep retraining for different populations with insomnia, as are mechanistic trials to test which components underlie its seemingly therapeutic effects. Since more practical modalities of intensive sleep retraining administration have been developed, such trials are more feasible to conduct now than ever before.

Does obstructive sleep apnea increase the risk of cancer and cancer mortality in combined community-based cohorts?

Obstructive sleep apnea (OSA) has been linked to cancer in several clinical and community-based cohorts. The effect in community-based studies free of clinical referral bias needs to be replicated. In this observational prospective cohort study, we pooled data from three community-based prospective cohorts (Uppsala Sleep and Health in Men cohort [UMEN]; Sleep and health in women [SHE]; Men Androgen Inflammation Lifestyle Environment and Stress Cohort [MAILES]; nTotal  = 1467). All cohorts had objective data on obstructive sleep apnea and registry linkage data on cancer and cancer mortality. Analyses for different obstructive sleep apnea measures (apnea-hypopnea index [AHI], oxygen desaturation index [ODI], and minimal saturation) as risk factors for cancer incidence (all cancers) were performed using Cox proportional hazards models (follow-up 5-16 years). We did not find an overall increased risk of cancer after adjustment for age, sex, and BMI (HRAHI [95% CI] = 1.00 [0.98; 1.01] and HRODI [95% CI] = 0.99 [0.97; 1.01]). Stratifying by daytime sleepiness did not influence the association. Cancer mortality was not significantly associated with obstructive sleep apnea. Taken together, we did not observe an overall increased risk of cancer or cancer mortality in relation to obstructive sleep apnea, however, our confidence limits remain wide for important diagnostic categories of sleep apnea severity. The relationship between obstructive sleep apnea and cancer needs further investigation in a comprehensive multi-cohort approach with greater statistical precision. For future studies we may need to find and then combine every community-based cohort study that can provide a definitive answer to the question on the risk of cancer from obstructive sleep apnea in the general population.

Joining forces to understand what matters most: qualitative insights into the patient experience of outpatient rheumatology care

Objective

People with rheumatic diseases are frequent, long-term attenders of health-care services. Their care experiences are central to improving services. The aim of this study was to explore real-world experiences and priorities of people attending outpatient rheumatology care and those of health-care professionals (HCPs) providing care.

Methods

This qualitative study consisted of five semi-structured focus groups. Participants included rheumatology outpatients (n = 16) of two tertiary teaching hospitals and HCPs (n = 14; rheumatologists, rheumatology trainees, physiotherapists, a specialty nurse and a pharmacist). Participants explored priorities when attending outpatient services, real experiences and aspirations for improving future care. Transcripts were coded using inductive and deductive thematic analysis.

Results

Seven key themes were identified: smooth flow of technical processes, care coordination, individualized care, information sharing, clinical excellence, patient empowerment and comprehensive care. The findings were aligned conceptually with quality standards in Australia and worldwide. Different sub-themes and prioritization of concerns emerged from patient and HCP subgroups. Highly prioritized themes for patients pertained to processes and technical aspects of care. HCPs focused on themes relating to non-technical aspects of service provision: information sharing, individualization of care, patient advocacy and empowerment.

Conclusion

This study captured valuable insights into the current experience of outpatient rheumatology care from the perspective of patients and HCPs. It informs a collective understanding of differing and shared priorities, positives of current care and areas requiring change. Themes derived from the study data can be conceptualized in terms of the process, content and impact of care. Such domains can be measured longitudinally by routine implementation of validated patient-reported experience measures in rheumatology.

Estimating sleep duration: performance of open-source processing of actigraphy compared to in-laboratory polysomnography in the community

Comparisons of actigraphy findings between studies are challenging given differences between brand-specific algorithms. This issue may be minimized by using open-source algorithms. However, the accuracy of actigraphy-derived sleep parameters processed in open-source software needs to be assessed against polysomnography (PSG). Middle-aged adults from the Raine Study (n = 835; F 58%; Age 56.7 ± 5.6 years) completed one night of in-laboratory PSG and concurrent actigraphy (GT3X+ ActiGraph). Actigraphic measures of total sleep time (TST) were analyzed and processed using the open-source R-package GENEActiv and GENEA data in R (GGIR) with and without a sleep diary and additionally processed using proprietary software, ActiLife, for comparison. Bias and agreement (intraclass correlation coefficient) between actigraphy and PSG were examined. Common PSG and sleep health variables associated with the discrepancy between actigraphy, and PSG TST were examined using linear regression. Actigraphy, assessed in GGIR, with and without a sleep diary overestimated PSG TST by (mean ± SD) 31.0 ± 50.0 and 26.4 ± 69.0 minutes, respectively. This overestimation was greater (46.8 ± 50.4 minutes) when actigraphy was analyzed in ActiLife. Agreement between actigraphy and PSG TST was poor (ICC = 0.27-0.44) across all three methods of actigraphy analysis. Longer sleep onset latency and longer wakefulness after sleep onset were associated with overestimation of PSG TST. Open-source processing of actigraphy in a middle-aged community population, agreed poorly with PSG and, on average, overestimated TST. TST overestimation increased with increasing wakefulness overnight. Processing of actigraphy without a diary in GGIR was comparable to when a sleep diary was used and comparable to actigraphy processed with proprietary algorithms in ActiLife.

Cross-sectional interrelationships between chronotype, obstructive sleep apnea and blood pressure in a middle-aged community cohort

Chronotype is linked to adverse health measures and may have important associations with obstructive sleep apnea and blood pressure, but data are limited. This study aimed to determine the separate and combined associations of chronotype with obstructive sleep apnea and blood pressure in a middle-aged community population. Adults (n = 811) from the Raine Study (female = 59.2%; age mean [range] = 56.6 [42.1-76.6] years) were assessed for chronotype (Morningness-Eveningness Questionnaire), blood pressure and hypertension (doctor diagnosed or systolic blood pressure ≥ 140 mmHg and/or diastolic ≥ 90 mmHg), and obstructive sleep apnea at different in-laboratory apnea-hypopnea index thresholds (5, 10, 15 events per hr). Linear and logistic regression models examined relationships between chronotype and the presence and severity of obstructive sleep apnea, blood pressure, hypertension, and blood pressure stratified by obstructive sleep apnea severity at above-mentioned apnea-hypopnea index thresholds. Covariates included age, sex, body mass index, alcohol consumption, smoking, physical activity, sleep duration, anti-hypertensive medication, insomnia, and depressive symptoms. Most participants were categorised as morning (40%) or intermediate (43%), with 17% meeting criteria for evening chronotypes. Participants with apnea-hypopnea index ≥ 15 events per hr and morning chronotype had higher systolic (9.9 mmHg, p < 0.001) and a trend for higher diastolic blood pressure (3.4 mmHg, p = 0.07) compared with those with an evening chronotype, and higher systolic blood pressure compared with those with an intermediate chronotype (4.8 mmHg, p = 0.03). Across chronotype categories, no differences in systolic or diastolic blood pressure or odds of hypertension were found at apnea-hypopnea index thresholds of ≥ 5 or ≥ 10 events per hr. Among participants with apnea-hypopnea index ≥ 15 events per hr, systolic blood pressure is higher in those with a morning chronotype than evening and intermediate chronotypes. Assessment for morning chronotype may improve risk stratification for hypertension in patients with obstructive sleep apnea.

Single-Night Diagnosis of Sleep Apnea Contributes to Inconsistent Cardiovascular Outcome Findings

BACKGROUND

Single-night disease misclassification of OSA due to night-to-night variability may contribute to inconsistent findings in OSA trials.

RESEARCH QUESTION

Does multinight quantification of OSA severity provide more precise estimates of associations with incident hypertension?

STUDY DESIGN AND METHODS

A total of 3,831 participants without hypertension at baseline were included in simulation analyses. Included participants had ≥ 28 days of nightly apnea-hypopnea index (AHI) recordings via an under-mattress sensor and ≥ 3 separate BP measurements over a 3-month baseline period followed by ≥ 3 separate BP measurements 6 to 9 months postbaseline. Incident hypertension was defined as a mean systolic BP ≥ 140 mm Hg or a mean diastolic BP ≥ 90 mm Hg. Simulated trials (1,000) were performed, using bootstrap methods to investigate the effect of variable numbers of nights (x = 1-56 per participant) to quantify AHI and the ability to detect associations between OSA and incident hypertension via logistic regression adjusted for age, sex, and BMI.

RESULTS

Participants were middle-aged (mean ± SD, 52 ± 12 y), mostly men (91%), and overweight (BMI, 28 ± 5 kg/m²). Single-night quantification of OSA failed to detect an association with hypertension risk in 42% of simulated trials (α = 0.05). Conversely, 100% of trials detected an association when AHI was quantified over ≥ 28 nights. Point estimates of hypertension risk were also 50% higher and uncertainty was 5 times lower during multinight vs single-night simulation trials.

INTERPRETATION

Multinight monitoring of OSA allows for better estimates of hypertension risk and potentially other adverse health outcomes associated with OSA. These findings have important implications for clinical care and OSA trial design.

7 LEARNING FROM THE FALLS ANALYSIS OF OLDER PEOPLE ADMITTED TO AN IRISH POST-ACUTE REHABILITATION SERVICE

Background

Thirty percent of community-dwelling older adults fall each year with 10% suffering a severe injury often resulting in hospital admission. To deliver effective falls prevention a thorough falls history is required. The objective of this study was to complete a SPLATT (symptoms before fall, previous falls, location of fall, activity at time of fall, time of day and trauma sustained) analysis of falls that resulted in an acute hospital admission reported by older people on admission to the post-acute rehabilitation unit.

Methods

Older people admitted to rehabilitation post fall that resulted in acute admission were included in this study. The SPLATT analysis was completed on OT initial assessment. Data was anonymized and recorded using Microsoft excel.

Results

A total of 61 falls were included in the analysis. Participants were all older people admitted to post-acute rehabilitation (female= 48, male= 13). 93% reported no symptoms before their fall. Almost half (43%) had experienced previous falls. Most falls (51%) happened at home with most of these (29%) occurring in the bedroom. A significant proportion (30%) happened in the community. The most common cause of fall was a loss of balance (32%) while completing a reaching or functional task. Most falls (87%) happened during the day but of those who fell at night, 62.5% occurred while trying to use the toilet. The majority (82%) of the falls lead to a significant trauma – hip fracture.

Conclusion

The results of this study supports that falls prevention interventions for rehabilitation service users should incorporate functional training both at home and in the community. The individual SPLATT analysis could support the design of a falls prevention intervention tailored to the person’s needs and history.

Nocturnal Wakefulness and Suicide Risk in the Australian Population

Objective: Temporal patterns for suicide over a 24-hour period have shown mixed results among prior studies. However, analyses of 24-hour temporal patterns for wakeful actions including suicidal behavior should adjust for expected sleep requirements that inherently skew such activities to conventional wakeful times. This study analyzed the time-of-day for suicide cases from the Australian population for the year 2017, adjusting for expected sleep patterns. Identification of time-of-day trends using this methodology may reveal risk factors for suicide and potentially modifiable contributors. Methods: The Australian National Coronial Information System database was accessed, and data for completed suicide were extracted for the most recent completed year (2017). Time of suicide was allocated to one of four 6-hourly time bins across 24 hours, determined from time last seen alive and time found subsequently. Prevalence of suicide for each time bin was adjusted for the likelihood of being awake for each bin according to sleep-wake norms published from a large Australian community survey. Observed prevalence of suicide was compared to expected values predicted from likelihood of being awake across each time bin calculated as a standardized incidence ratio (SIR). Results: For the year 2017, there were 2,808 suicides, of which 1,417 were able to be allocated into one of four 6-hourly time bins. When compared to expected values, suicides were significantly more likely to occur in the overnight bin (2301-0500; SIR = 3.93, P < .001). Conclusions: Higher-than-expected rates of suicide overnight associated with nocturnal wakefulness may represent a modifiable risk factor for triggering suicide events.

POS0180 THE EFFICACY AND SAFETY OF A FIXED-DOSE COMBINATION OF APOCYNIN AND PAEONOL IN SYMPTOMATIC KNEE OA: A DOUBLE-BLIND, RANDOMIZED, PLACEBO-CONTROLLED CLINICAL TRIAL

Background

There is a great unmet need for the development of effective treatments to treat the symptoms of OA. Nuclear-Factor Kappa-B (NF-κB) and Nrf2 play a key roles in OA pathogenesis and have been identified as potential targets. A fixed-dose combination of apocynin and paenol in a ratio of 2:7 (APPA) has been shown to inhibit activation of NF-κB and upregulate Nrf2. [1]

Objectives

We report the results of a phase 2a study evaluating the efficacy and safety of APPA in patients with symptomatic knee OA.

Methods

The trial was a 28-day randomized, placebo-controlled, double-blind study comparing 800 mg of APPA twice daily with matched placebo capsules. Patients with radiographic knee OA KL-grade 2-3, and a WOMAC pain score ≥40 and ≤90/100 of target knee at screening and baseline were randomized 1:1 to APPA or placebo. Main exclusion criteria included recent intraarticular surgery or injection therapy, hip pain greater than the target knee, and BMI ≥40 kg/m2. The primary endpoint was change from baseline to Day 28 in the WOMAC pain score. Safety outcomes included reported adverse events (AE), clinical laboratory parameters, ECG, and vital signs.

A pre-defined subgroup analysis in subjects with a baseline PainDETECT score >12 indicated a positive effect. Accordingly, post-hoc analyses were undertaken to further assess the effects of APPA in subgroups of participants with higher disease severity.

Results

152 participants were randomized, and 149 (98%) completed the trial. The mean (SD) WOMAC pain score at baseline was 55.3 (10.2). The two groups were comparable in terms of baseline pain score, gender, age, and BMI.

The primary endpoint was not met, mean difference (MD) between APPA and placebo was -0.89 (95 % CI: -5.62, 3.84, p=0.71, Figure 1A). Similarly, no significant differences were found on other key secondary endpoints (WOMAC Function and WOMAC total Figure 1B and C, respectively.) APPA was well tolerated and no differences in frequencies of reported AEs were noted, apart from a higher proportion of subjects reporting mild to moderate gastrointestinal discomfort reported with APPA compared to placebo (12% vs. 6.5 %).

In the pre-defined subgroup of participants with baseline PainDETECT ≥ 13 (N=45), the difference in mean change in pain from baseline favored the APPA-group (MD: -11.20, 95 % CI: -20.29 to -2.11, p=0.02). Analysis of participants > 50 WOMAC pain at baseline (Group 1, N=95, Figure 1D), and a KL-grade of the non-target knee >2 (Group 2, N=105, Figure 1E), and a combination of these two criteria (Group 3, N=64, Figure 1F) found a positive effect of APPA compared to placebo (Group 1 MD: -2.61, 95 % CI: -8.98 to 3.76, p=0.42, Group 2 MD: -4.01, 95 % CI: -9.35 to 1.33, p=0.14, and Group 3 MD: -8.32, 95 % CI: -15.48 to -1.16, p=0.02).

Conclusion

Treatment with APPA 800 mg twice daily for 28 days in patients with symptomatic knee OA overall was not associated with significantly improved outcomes compared to placebo. The treatment was well-tolerated and safe. Subgroup analyses, however, showed a significant effect of APPA in patients with moderate to severe OA, indicating that further research in the effects of APPA in appropriate patients is warranted.

References

[1]Cross AL, Hawkes J, Wright HL, Moots RJ, Edwards SW. APPA (apocynin and paeonol) modulates pathological aspects of human neutrophil function, without supressing antimicrobial ability, and inhibits TNFα expression and signalling. Inflammopharmacology. 2020 Oct; 28(5):1223-1235.

Disclosure of Interests

Asger Reinstrup Bihlet Shareholder of: NBCD A/S, Employee of: NBCD A/S, Inger Byrjalsen Employee of: NBCD A/S, Jeppe Ragnar Andersen Shareholder of: NBCD A/S, Employee of: NBCD A/S, Anna Metnik Shareholder of: NBCD A/S, Employee of: NBCD A/S, Alan Reynolds Shareholder of: AKL R&D, Employee of: AKL R&D, Nicholas Larkins Shareholder of: AKL R&D, Employee of: AKL R&D, Peter Alexandersen: None declared, Helene Rovsing: None declared, Ulla Schmidt: None declared, Robert Moots Speakers bureau: Pfizer, Amgen, Novartis, Gilead, Grant/research support from: University of Liverpool received grant support from AKL on Phase 1 trial where Prof. Rob Moots was principal investigator. UoL also received grant support from AKL on basic neutrophil research., Philip G Conaghan Speakers bureau: AbbVie, BMS, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB, Consultant of: AbbVie, BMS, Eli Lilly, Galapagos, Gilead, Novartis, Pfizer and UCB

0204 Sleep Irregularity Is Associated with Increased Risk of Hypertension: Data From Over Two Million Nights

Introduction

Sleep irregularity has been associated with worse cardio-metabolic health compared to regular sleep, but prior studies have been limited in sample size and have assessed sleep irregularity by actigraphy or questionnaires over a relatively short duration (~ 14 days). The current study investigated associations between sleep regularity and hypertension in a large, global sample over multiple months.

Methods

Data from 12,300 participants (aged 18-90 years) who used an under-mattress sleep device and a portable blood pressure monitor between July 2020 and March 2021 were included in this study. Sleep duration regularity was assessed as the standard deviation via device-assessed total sleep time. Sleep timing regularity was assessed as the standard deviation in sleep onset time and in sleep midpoint. Logistic regressions controlling for age, sex, BMI, and mean total sleep time were conducted to investigate potential associations between sleep regularity and hypertension.

Results

Participants were typically middle-aged (Mean ± SD; 50 ± 12 years) and predominantly male (12% females). Each participant had ~180 nights of recordings and ~70 blood pressure entries. There were 2,499 cases of hypertension defined as SBP&gt;140 and/or DBP &gt;90mmHg (20% of the sample). Across total sleep time quartiles, high sleep duration irregularity was consistently associated with a 9 to 15% increase in hypertension risk. A 38-minute increase in sleep midpoint irregularity was associated with an 11% (1.11 [1.03, 1.20]) increase in hypertension risk, independent of mean total sleep time and mean sleep midpoint. Similarly, a ~31-minute increase in sleep onset time irregularity was associated with a 29% increased risk of hypertension (1.29 [1.18, 1.42]).

Conclusion

These novel findings provide insight into the potential important impact of sleep irregularity on cardiovascular health. Further assessment of day-to-day fluctuations in sleep duration and timing for potential effects on next-day blood pressure and other cardiovascular health outcomes are warranted.

Support (If Any)

This was an unfunded investigator-initiated study. De-identified data were provided by Withings for unrestricted investigator-led analysis. PE serves as a consultant for Withings.

0205 Sleep Need: More Influential on Health and Daytime Function than Sleep Duration?

Introduction

Most prior research into relationships between sleep and health and daytime functioning have focused on average sleep duration or efficiency and ignored individual differences in sleep need. This study tested if sleep need is more strongly correlated with self-rated health and daytime function than sleep duration.

Methods

Data were drawn from the 2019 Sleep Health Foundation online survey of adult Australians (N=2,044, aged 18-90 years). Hierarchical multiple regressions assessed variance explained (R2 and R2 change) by demographics (Model 1: age, sex, BMI), self-reported sleep duration (Model 2: Model 1 + weighted variable of typical weekday/weekend sleep duration), and individual sleep need (Model 3: Model 2+ rating on a 5-point scale to ‘how often you get enough sleep to feel your best the next day’) on daytime function items for fatigue, concentration, motivation, and overall self-rated health (visual-analog scale from 0-100).

Results

Sleep need explained an additional 17.5–18.7% of the variance in fatigue, concentration, motivation, and health rating (all p &lt; 0.001 for R2 change) in Model 3. In contrast, Model 2 showed that sleep duration alone only explained an additional 2.0–4.1% variance in these outcomes after accounting for demographic variables. Findings were similar when stratified by sex. Sleep need also explained greater variance for older adults than for younger and middle-aged adults, especially on health rating (Model 3: R2 change = 0.11 for ages 18-24y, 0.14 for 45-54y, 0.27 for 75y+).

Conclusion

Sleep need appears to explain considerably more variance in daytime function and self-rated health than sleep duration. The effect of sleep need on other daytime consequences, and in clinical populations, needs further exploration. Validated assessments of sleep need are also needed to elucidate its importance for understanding the effect of sleep on health and functioning.

Support (If Any)

The 2019 Sleep Health Foundation online survey was supported by the not-for-profit Sleep Health Foundation using an unrestricted grant from Merck Sharp & Dohme (Australia) which did not inform nor restrict study design, methodology, or presentation.

Sleeping together: understanding the association between relationship type, sexual activity, and sleep

Objective

Insufficient sleep, and particularly difficulties initiating sleep, are prevalent in the community. Treatment for poor sleep typically consists of pharmacological intervention, or cognitive behavioural therapies - which can be both costly and time-consuming. Evidence suggests that sexual activities may positively impact sleep. However, little is known about relationship types, sexual activities, and perceived sleep outcomes. The aim of this study was to explore the association between relationship type (e.g., having a regular, occasional, or casual partner), sexual activity and satisfaction, and perceived sleep outcomes, to identify potential strategies to improve sleep.

Methods

Seven-hundred and seventy-eight participants aged 18 years and over (442 females, 336 males; mean age 34.5 ± 11.4 years) responded to a cross-sectional online anonymous survey at their convenience. Participants were asked about their sleep, sexual activity and satisfaction, and relationship type.

Results

Results from multiple regression analyses with age and gender covariates revealed that shorter sleep latencies were associated with regular relationships (p = 0.030), greater emotional satisfaction with sexual activity (p = 0.029), and increased frequency of orgasm (p < 0.001). Men reported a greater frequency of orgasm than women (p < 0.001).

Discussion

Findings indicate that relationship type may be associated with improved sleep outcomes, including sleep latency. Relationship type should therefore be taken into consideration by clinicians when developing treatment plans for individuals with poor sleep.

All-Cause Mortality in People with Co-Occurring Insomnia Symptoms and Sleep Apnea: Analysis of the Wisconsin Sleep Cohort

PURPOSE

Insomnia symptoms and sleep apnea frequently co-occur and are associated with worse sleep, daytime function, mental health and quality of life, compared to either insomnia or obstructive sleep apnea (OSA) alone. This study aimed to investigate the association of symptoms of co-morbid insomnia and sleep apnea (COMISA) with all-cause mortality.

PATIENTS AND METHODS

Wisconsin Sleep Cohort data were analysed to assess potential associations between COMISA symptoms and all-cause mortality. Nocturnal insomnia symptoms were defined as difficulties initiating sleep, maintaining sleep, and/or early morning awakenings "often" or "almost always", and/or regular sedative-hypnotic medicine use. OSA was defined as an apnea-hypopnea index ≥5/hr sleep. Participants were classified as having neither insomnia symptoms nor OSA, insomnia symptoms alone, OSA alone, or COMISA symptoms. Associations between the four groups and all-cause mortality over 20 years of follow-up were examined via multivariable adjusted Cox regression models.

RESULTS

Among 1115 adult participants (mean ± SD age 55 ± 8 years, 53% males), 19.1% had COMISA symptoms. After controlling for sociodemographic and behavioral factors, COMISA symptoms were associated with an increased risk of all-cause mortality compared to no insomnia symptoms or OSA (HR [95% CI]; 1.71 [1.00-2.93]). OSA alone (0.91 [0.53, 1.57]) and insomnia symptoms alone (1.04 [0.55, 1.97]) were not associated with increased mortality risk.

CONCLUSION

Co-morbid insomnia symptoms and sleep apnea is associated with increased all-cause mortality risk. Future research should investigate mechanisms underpinning COMISA and the effectiveness of different treatment approaches to reduce mortality risk for this common condition.

Multi-night Prevalence, Variability, and Diagnostic Misclassification of Obstructive Sleep Apnea

Rationale Recent studies suggest that obstructive sleep apnea (OSA) severity can vary markedly from night to night which may have important implications for diagnosis and management. Objectives This study aimed to assess OSA prevalence from multi-night in-home recordings and the impact of night-to-night variability in OSA severity on diagnostic classification in a large, global, non-randomly selected community sample from a consumer database of people that purchased a novel, validated, under-mattress sleep analyzer. Methods 67,278 individuals aged between 18 and 90 years underwent in-home nightly monitoring over an average of ~170 nights per participant between July 2020 to March 2021. OSA was defined as a nightly mean apnea-hypopnea index (AHI) >15 events/h. Outcomes were multi-night global prevalence and likelihood of OSA misclassification from a single night AHI value. Measurements and Main Results Over 11.6 million nights of data were collected and analyzed. OSA global prevalence was 22.6% (95% CI: 20.9-24.3%). The likelihood of misdiagnosis in people with OSA based on a single night ranged between ~20% and 50%. Misdiagnosis error rates decreased with increased monitoring nights (e.g. 1-night F1-score=0.77 vs. 0.94 for 14-nights); and remained stable after 14-nights of monitoring. Conclusions Multi-night in-home monitoring using novel non-invasive under mattress sensor technology indicates a global prevalence of moderate to severe OSA of ~20%, and that ~20% of people diagnosed with a single night study may be misclassified. These findings highlight the need to consider night-to-night variation on OSA diagnosis and management. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The impact of a short burst of exercise on sleep inertia

STUDY OBJECTIVES

Determine whether 30 s (s) of exercise performed upon waking can reduce sleep inertia and accelerate an increase in the cortisol awakening response (CAR) and core body temperature (CBT), compared to when sedentary.

METHODS

Fifteen participants (mean age ± SD, 25.9 ± 5.9 years; six females) completed a counterbalanced, repeated measures, in-laboratory study involving three single experimental nights, each separated by a four-night recovery period. Participants were woken following a 2-h nap (2400-0200) and completed a cycling bout of high-intensity (30-s sprint), low-intensity (30 s at 60% maximum heart rate), or no exercise (sedentary). Sleep inertia testing (eight batteries, 15-min intervals) began immediately following and included measures of subjective sleepiness (Karolinska Sleepiness Scale) and cognitive performance tasks (psychomotor vigilance, serial addition and subtraction, and spatial configuration). CBT was measured continuously via an ingestible telemetric capsule. The CAR was determined using salivary cortisol samples collected at 0, 30 and 45 min post-waking. Data were analysed using mixed effects analysis of variance.

RESULTS

There was no difference in cognitive performance or CBT between conditions. Participants felt less sleepy in the high-intensity condition, followed by the low-intensity and sedentary conditions (p = .003). The CAR was greatest in the high-intensity condition, followed by the sedentary condition, and low-intensity condition (p < 0.001), with no differences between the low-intensity and sedentary conditions.

CONCLUSIONS

Those who exercise upon waking should be aware that while they may feel more alert, they may not be performing better than if they had not exercised. Future research should investigate whether exercise of different duration or timing may impact sleep inertia.

219 IMPROVING DELIRIUM SCREENING AND MANAGEMENT IN POST-ACUTE REHABILITATION: A MULTI-STAGE QUALITY IMPROVEMENT INITIATIVE

Background

There is risk of delirium among older patients on transition from acute care to post-acute rehabilitation (Marcantonio et al. 2003). The 4AT is the recommended delirium detection tool for clinical practice (Tieges et al. 2020). A multi-disciplinary led quality improvement project was undertaken to standardise and improve delirium screening and management in the older person’s rehabilitation service of a post-acute rehabilitation hospital.

Methods

A retrospective audit of medical charts was completed for all patients admitted to a post-acute older person’s rehabilitation service from October 2019 to December 2019. Following that audit, there was a staff education intervention focusing on delirium awareness, screening and management. Furthermore, a dedicated ‘Delirium Champions Group’ was formed with representatives from the multi-disciplinary team. A Delirium Screen pro-forma was developed and implemented by this group. It included an attached 4AT sticker for all new admission medical charts. A post intervention medical chart audit was completed for all admissions to the same ward from October to December 2020.

Results

The pre-intervention chart audit showed 0% compliance with any form of formal delirium screening tool. The majority of patients had at least 2 delirium risk factors at the time of admission. The post-intervention audit recorded 92% compliance with 4AT use at the time of admission as well as full completion of the Delirium Screen pro-forma which included the documentation of risk factors for delirium. The Delirium Champions Group provide ongoing staff education, resources and are now exploring hospital environmental design and its role in delirium prevention.

Conclusion

This initiative lead to a significant improvement in the completion of delirium screening in post-acute rehabilitation. This project had the secondary benefit of prompting the formation of a dedicated delirium improvement group focusing on delirium awareness, screening, documentation, management and ultimately prevention.

875Association between dietary inflammatory index and sleep duration

Background

Diet and sleep are strongly and bidirectionally linked. This study aims to assess the association between dietary inflammatory index (DII) and sleep duration using the National Health and Nutrition Survey (NHANS) of the United States.

Methods

A total of 27,999 (median age 47 years, 48.6% male) participants were included. Dietary data were collected using 24-hour recall method and DII was calculated using 27 nutrients. Quantiles of DII were constructed (quantile 1, least inflammatory; quantile 5, most inflammatory). Self-reported habitual sleep duration was categorized as ≤ 6 hr (short sleep), ≥7 hr (normal/long sleep). We used log-binomial and multinomial logistic regression, adjusted for potential confounders, to examine the association between DII and short sleep duration. Sensitivity analysis was performed by excluding common chronic diseases. The analyses were adjusted using NHANES sampling weights.

Results

In the fully adjusted model, higher DII score was associated with shorter sleep duration [odds ratio (OR)quartile2vs1=1.04; 95% confidence interval (CI): 0.84-1.29; ORquartile3vs1=1.27; 95% CI: 1.06, 1.52; ORquartile4vs1=95% CI: 1.47; 95 CI: 1.25, 1.74; ORquartile5vs1=1.62; 95% CI: 1.33, 1.97; P for trend&lt;0.0001]. A similar trend of association was observed with long sleep duration and in both male and female participants. Participants in the fifth quantile, compared to those in the first, on average had 6 minutes (95% CI: 1, 11) less sleep.

Conclusions

Pro-inflammatory diet was positively associated with increased odds of short sleep duration.

Key messages

Patients with short sleep duration may benefit from avoiding pro-inflammatory foods. The association between DII and sleep duration could be bidirectional.

879Sleep Duration and all-cause and cause-specific mortality in people with diabetes

Background

Evidence shows that habitual short and long sleep is associated with higher mortality risk in the general population. However, studies on the association between sleep duration and mortality in people with diabetes are scarce.

Methods

Data from the National Health Interview Survey (NHIS) of the United States (US) between 2004 and 2014 (N = 32,766) were used. Self-reported habitual sleep duration for those with self-reported doctor diagnosed diabetes was categorized as ≤ 6 hr (short sleep), 7-8 hr (adequate sleep), and ≥9 hr (long sleep). Mortality status and cause of death data were retrieved from the US National Death Index and linked. We used adjusted Cox proportional models to examine the association between sleep duration and mortality risk. Dose-response relationships were quantified. Sensitivity analysis was performed excluding cardiovascular and cancer cases.

Results

In the median follow-up time of 4.6 years (171,375.2 person-years), 5312 all-cause, 1129 cardiovascular, 1148 cancer and 494 diabetes deaths were recorded. Whereas short sleep duration (adjusted hazard ratio (aHR)=1.04; 95% confidence interval (CI): 0.97, 1.11) in diabetic patients was not associated with all-cause mortality, long sleep duration was positively (aHR=1.43; 95% CI: 1.30, 1.57) associated with increased mortality risk. A similar trend of association was found with cause-specific mortality and the dose-response analysis identified a “J” shape association. Similar results were found upon sensitivity analysis.

Conclusions

Long but not short sleep duration is associated with all-cause and cause-specific mortality in diabetic patients.

Key messages

Sleep should be part of behavioural intervention to prevent premature mortality in those with diabetics.

889Association of maternal smoking during pregnancy and early-childhood with adult insomnia symptoms

Background

Evidence regarding the association between perinatal smoking and insomnia symptoms in adulthood is limited. Using the UK 1970 Birth Cohort Study, we determined the association of maternal smoking during pregnancy and early-childhood with insomnia symptoms at 42 years.

Methods

Participants were followed from birth (1970; N = 9020; male, 48%) and age 5 (1975; N = 8050; male, 47.9%) to 42 years (2012). Data on maternal smoking was collected at birth and age 5; difficulties initiating or maintaining sleep (DIMS) and DIMS plus daytime symptoms (tiredness, irritability, depression and nervousness) [DIMS plus] at age 42. We used a direct acyclic graph to select confounders. A log-binomial logistic regression, adjusted for confounders, was used to estimate the association. Missing data were imputed via multiple imputation.

Results

The prevalence of DIMS and DIMS plus was 32% and 25%, respectively. There was a 25% [odds ratio (OR)=1.25; 95% confidence interval (CI): 1.12-1.38)] and 23% [OR = 1.23; 95% CI: 1.09-1.38] increase in odds of DIMS and DIMS plus among participants whose mothers smoked during pregnancy compared to those whose mother did not. A 24% [OR = 1.24; 95% CI: 1.12-1.37] and 18% [OR = 1.18; 95% CI: 1.05-1.33] increase in odds of DIMS and DIMS plus respectively, was observed among participants who had smoking mothers at age 5. Intensity and duration of smoking had a dose-response relationship with insomnia symptoms.

Conclusions

Maternal smoking during pregnancy and early-childhood is associated with increased risk of adult insomnia symptoms.

Key messages

This study suggests that reducing maternal smoking may reduce the risk of adult insomnia.

AB0036 APPA (APOCYNIN AND PAEONOL) REDUCES ROS PRODUCTION AND SENESCENCE IN HUMAN ARTICULAR CHONDROCYTES

Background:

Disease modification is not yet possible for osteoarthritis (OA). Mitochondrial ROS and pro-inflammatory cytokines are involved in the pathogenesis of OA and are potential therapeutic targets. APPA, a combination of apocynin (AP) and paeonol (PA), has the potential capacity to modulate synthesis of pro-inflammatory stimuli.

Objectives:

To investigate the anti-inflammatory effect of APPA in human articular chondrocytes and cartilage.

Methods:

Tissue and chondrocytes from human OA cartilage were isolated. The effect of APPA on chondrocyte viability was analyzed using MTT. IL-1β 10 ng/mL and LPS 10 ng/mL were used as pro-inflammatory stimuli. ROS production was evaluated by flow cytometry using DCFH-DA and MitoSoxRed. The percentage of senescent cells was evaluated through the quantification of Fluorescein di-β-D-galactopyranoside (FDG) by flow cytometry. The effect of APPA on gene expression of pro-inflammatory cytokines (IL-8 and TNF-α) and enzymes degrading cartilage (MMP-13 and MMP-3) were analyzed in chondrocyte and cartilage by RT-PCR. Quantification of Toluidine Blue (TB) staining in cartilage was performed to evaluate proteoglycans content using software ImageJ/Fiji. Release of Glycosaminoglycan (GAGs) into the supernatant was quantified using BlyscanTM Glycosaminoglycan assay. Statistical analyses were performed with GraphPad Prism v6.

Results:

Chondrocytes, incubated in presence of APPA 10 µg/mL for 24 h had viability >85%, reduced cytoplasmic ROS (p=0.028) and mitochondrial anion superoxide production induced by LPS 10 ng/mL (p=0.057). Chondrocytes incubated in presence of APPA 10 µg/mL for 2 hours contained significantly fewer senescent cells (p=0.0079). APPA significantly reduced the gene expression induced by IL-1β 10 ng/mL in chondrocytes of IL-8, TNF-α, MMP-13 and MMP-3. Cartilage incubated with APPA 60 and 100 µg/mL for 48 h showed decreased the MMP-3 gene expression induced by IL-1β (p=0.021 and p<0.0001 respectively). Quantification of TB showed that APPA 60 and 100 µg/mL during 48h increased the proteoglycans in intermedial layer, which had been decreased through the incubation with IL-1β (p=0.0018 and p=0.018 respectively). Quantification of release GAGs into the supernatant decreased significantly when the cartilage explants were incubated for 48h in presence of APPA 100 µg/mL (p=0.028).

Conclusion:

APPA has a clear anti-inflammatory effect on human articular chondrocytes, and could reduce extracellular matrix degradation of cartilage. This could be mediated by the capacity to modulate ROS production and reduce senescence.

Disclosure of Interests:

Mercedes Fernandez-Moreno: None declared, Nicholas Larkins Shareholder of: I am a shareholder in AKL Research and Development Ltd, Alan Reynolds Shareholder of: I have share options in AKL Research and Development Ltd, Speakers bureau: I have not been a paid speaker for a pharma company - at least not since 2008 whichI think is outside the scope of this, Consultant of: The last time I was a paid consultant was in 2017 when I acted as a consultant for Avillion and Norgine, Employee of: I am also an employee of AKL Research and Development Ltd, Tamara Hermida Gómez: None declared, Francisco J. Blanco Speakers bureau: Lilly

Pfizer

Sanofi

Galapagos, Consultant of: Lilly

Pfizer

Sanofi

Galapagos, Grant/research support from: Lilly

MSD

Merck Serono

Pfizer

Pierre-Fabra

Roche

Sanofi

Servier

UCB

Abbvie

Amgen

Bioiberica

Bristol Mayer

Celgene

Celltrion

Cellerix

Grunenthal

Gebro Pharma

AKL Research and Development Ltd

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Prevalence and associations of co-morbid insomnia and sleep apnoea in an Australian population-based sample

INTRODUCTION

Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders, and frequently co-occur (COMISA) in sleep clinic samples. However, few studies have investigated the prevalence or associations of COMISA in the general population.

METHODS

We used population-based online survey data from 2044 Australian adults. The prevalence and associations of insomnia, OSA and COMISA were investigated according to symptom-level, and disorder-level definitions. Insomnia was defined according to chronic difficulties initiating and/or maintaining sleep (DIMS; symptom-level), and ICSD-3 chronic insomnia disorder (disorder-level). OSA was defined according to self-reported frequent obstructive events, snoring or doctor-diagnosed OSA (symptom-level), and doctor-diagnosed OSA (disorder-level). COMISA was defined if both conditions were met (for symptom-level, and disorder-level threshold). Associations with other conditions, and general health were investigated with Poisson regression analyses.

RESULTS

Chronic insomnia occurred more frequently among participants with doctor-diagnosed OSA (22.3%), compared to those without (14.3%, p = 0.010). Doctor-diagnosed OSA was more common among participants with chronic insomnia (10.2%) compared to those without (6.2%; p = 0.010). DIMS also occurred more frequently among participants with OSA symptoms (66.6%), compared to those without (47.2%; p < 0.001). Participants with symptom-level COMISA reported increased co-morbid conditions, and worse general health compared to participants with symptoms of insomnia-alone, OSA-alone, or neither insomnia/OSA.

CONCLUSIONS

COMISA at symptom and disorder level were common and associated with increased medical and psychiatric co-morbidity, as well as poor general health. More investigation is required to understand bi-directional associations underpinning the high co-morbidity, and improve diagnostic and treatment approaches for COMISA to reduce associated morbidity.

Acute growth inhibition & toxicity analysis of nano-polystyrene spheres on Raphidocelis subcapitata

Micro/nano-plastics (MNPs) have been found within many environments and organisms including humans, making them a significant and growing concern. Initial research into the potential detrimental effects these MNPs both from acute and chronic exposure has been ongoing but still requires substantially more data to clarify. This research presents the response of nano-polystyrene (NPS) on Raphidocelis subcapitata, a freshwater alga, under an existing acute toxicity test along with additional analytical techniques to try identifying possible sources of toxicity. R. subcapitata cells were exposed for 72 h to a concentration range of 0-100 mg/l NPS. Growth Inhibition (GI) testing showed the R. subcapitata demonstrated statistically distinct reductions in growth over 72 h at all NPS exposure concentrations while not suffering culture collapse. By the 100 mg/l NPS exposure the R. subcapitata has suffered almost a 33.7% reduction in cell concentration after 72 h compared to control samples. Confocal imaging showed the NPS wasn't permeating into the algal plasma membrane or individual organelles but agglomerated onto the algal cell wall. The agglomeration was irregular but increased in total surface area covered as NPS concentration increases. UV-Vis fluorimetry testing produced a linear response of emission intensities to algae exposed to the 0-100 mg/l range of NPS. However, comparisons of emission intensity values of algae exposed to NPS to emission intensities of pure NPS at identical concentrations showed consistent intensity reduction. This response further indicated NPS agglomerating within the media and onto the alga cells seen from confocal imaging. Finally, Raman spectroscopy on R. subcapitata attempted to distinguish the key 1001 cm^-1 peak or other crucial identifier peaks of polystyrene from overall Raman spectra. This was not successful as emissions from algal component (e.g. phenylaniline) completely suppressed the signal region.

Acute growth inhibition & toxicity analysis of nano-polystyrene spheres on Raphidocelis subcapitata

Micro/nano-plastics (MNPs) have been found within many environments and organisms including humans, making them a significant and growing concern. Initial research into the potential detrimental effects these MNPs both from acute and chronic exposure has been ongoing but still requires substantially more data to clarify. This research presents the response of nano-polystyrene (NPS) on Raphidocelis subcapitata, a freshwater alga, under an existing acute toxicity test along with additional analytical techniques to try identifying possible sources of toxicity. R. subcapitata cells were exposed for 72 h to a concentration range of 0-100 mg/l NPS. Growth Inhibition (GI) testing showed the R. subcapitata demonstrated statistically distinct reductions in growth over 72 h at all NPS exposure concentrations while not suffering culture collapse. By the 100 mg/l NPS exposure the R. subcapitata has suffered almost a 33.7% reduction in cell concentration after 72 h compared to control samples. Confocal imaging showed the NPS wasn't permeating into the algal plasma membrane or individual organelles but agglomerated onto the algal cell wall. The agglomeration was irregular but increased in total surface area covered as NPS concentration increases. UV-Vis fluorimetry testing produced a linear response of emission intensities to algae exposed to the 0-100 mg/l range of NPS. However, comparisons of emission intensity values of algae exposed to NPS to emission intensities of pure NPS at identical concentrations showed consistent intensity reduction. This response further indicated NPS agglomerating within the media and onto the alga cells seen from confocal imaging. Finally, Raman spectroscopy on R. subcapitata attempted to distinguish the key 1001 cm^-1 peak or other crucial identifier peaks of polystyrene from overall Raman spectra. This was not successful as emissions from algal component (e.g. phenylaniline) completely suppressed the signal region.

The Association between Sleep Duration and Quality with Readmissions: An Exploratory Pilot-Study among Cardiology Inpatients

Background: Readmissions within 30 days of discharge are prominent among patients with cardiovascular disease. Post hospital syndrome hypothesizes that sleep disturbance during the index admission contributes to an acquired transient vulnerability, leading to increased risk of readmission. This study evaluated the association of in-hospital sleep (a) duration and (b) quality with 30-day all-cause unplanned readmission. Methods: This prospective observational cohort study included patients admitted to the coronary care unit of a South Australian hospital between 2016–2018. Study participants were invited to wear an ActiGraph GT3X+ for the duration of their admission and for two weeks post-discharge. Validated sleep and quality of life questionnaires, including the Pittsburgh Sleep Quality Index (PSQI), were administered. Readmission status and questionnaires were assessed at 30 days post-discharge via patient telephone interview and a review of hospital records. Results: The final cohort consisted of 75 patients (readmitted: n = 15, non-readmitted: n = 60), of which 72% were male with a mean age 66.9 ± 13.1 years. Total sleep time (TST), both in hospital (6.9 ± 1.3 vs. 6.8 ± 2.9 h, p = 0.96) and post-discharge (7.4 ± 1.3 h vs. 8.9 ± 12.6 h, p = 0.76), was similar in all patients. Patient’s perception of sleep, reflected by PSQI scores, was poorer in readmitted patients (9.13 ± 3.6 vs. 6.4 ± 4.1, p = 0.02). Conclusions: Although an association between total sleep time and 30-day readmission was not found, patients who reported poorer sleep quality were more likely to be readmitted within 30 days. This study also highlighted the importance of improving sleep, both in and out of the hospital, to improve the outcomes of cardiology inpatients.

The Relationship of Sleep Duration with Ethnicity and Chronic Disease in a Canadian General Population Cohort

STUDY OBJECTIVES

Sleep duration is an important marker of sleep quality and overall sleep health. Both too little and too much sleep are associated with poorer health outcomes. We hypothesized that ethnicity-specific differences in sleep duration exist.

METHODS

This cross-sectional study utilized questionnaire data from the Ontario Health Study (OHS), a multi-ethnic population-based cohort of Canadian adult residents aged 18 to 99 years, who provided medical, socio-demographic, and sleep information. Generalised linear models were used to investigate the association of sleep duration with ethnicity.

RESULTS

The study sample consisted of 143,307 adults (60.4% women). The sample was multi-ethnic, including self-identified Aboriginal, Arab, Black, Chinese, Filipino, Hispanic, Japanese, Korean, Mixed (>1 ethnicity), South Asian, South-East Asian, West Asian, and White ethnicities. Univariate analyses found that mean sleep duration compared to the White reference group (7.34 hours) was shorter in the Filipino (6.93 hours, 25 min less), Black (6.96 hours, 23 min less), Japanese (7.02 hours, 19 min less), Chinese (7.23 hours, 7 min less), and Mixed (7.27 hours, 4 min less) groups (all P<0.001). Mean sleep duration was shorter in men (7.25 hours) compared to women (7.37 hours) in the cohort as a whole (P<0.001), and in all ethnic groups (P<0.001). Multivariate analyses, adjusted for a wide range of potential risk factors, and analysis of sleep duration as a categorical variable ("short", "average", and "long" sleepers) confirmed these relationships. Both sleep duration and ethnicity were independent significant predictors of a range of physician-diagnosed morbidities including diabetes, stroke, and depression.

CONCLUSION

Important differences exist in sleep duration between ethnic groups and may contribute to observed health disparities. Our results highlight the need for ethnicity-specific targeted education on the importance of prioritizing sleep for good health, and the need to account appropriately for ethnicity in future epidemiological, clinical, and translational research into sleep and related conditions.

Adipose tissue dysfunction in obese horses with equine metabolic syndrome

BACKGROUND

Obesity is a common feature of equine metabolic syndrome (EMS). In other species, obese adipose tissue shows pathological features such as adipocyte hypertrophy, fibrosis, inflammation and impaired insulin signalling all of which contribute to whole body insulin dysregulation. Such adipose tissue dysfunction has not been investigated in horses.

OBJECTIVES

To determine if obese horses with EMS have adipose tissue dysfunction characterised by adipocyte hypertrophy, fibrosis, inflammation and altered insulin signalling.

STUDY DESIGN

Cross-sectional post-mortem study.

METHODS

Samples of peri-renal (visceral) and retroperitoneal adipose tissue were obtained at post-mortem from healthy horses (n = 9) and horses with EMS (n = 6). Samples were analysed to determine average adipocyte size, fibrotic content and expression of inflammatory and insulin signalling genes.

RESULTS

Horses with metabolic syndrome showed marked adipocyte hypertrophy and increased expression of adipokines (leptin) and inflammatory cytokines (TNFα, IL1β and CCL2) in both adipose tissue depots compared to healthy horses. There were no differences in fibrosis or expression of genes relating to insulin signalling between the groups.

MAIN LIMITATIONS

Cases used in this study had advanced EMS and may represent the end stage of the condition; the design of the study is such that we were unable to relate the identified adipose tissue dysfunction to whole body insulin dysregulation.

CONCLUSIONS

Horses with obesity and EMS have significant dysfunction of the peri-renal and retroperitoneal adipose tissue that may contribute to whole body insulin dysregulation.

SUN-LB040 Associations of Testosterone and Sex Hormone Binding Globulin with the Risk of Cardiovascular Disease and Type 2 Diabetes in Men

Objective: Contrasting findings exist regarding the associations between circulating sex hormone-binding globulin (SHBG) and total testosterone (TT) with type 2 diabetes (T2D) and cardiovascular diseases (CVD) in men. We examined prospective associations of SHBG and TT with incident T2D and CVD, in a cohort of community-dwelling men. Methods: Participants were aged 35 years and over at enrolment (n=2563) and followed for an average of 4.95 years. This analysis included men without T2D (1597) or CVD (1492) at baseline, and with fasted morning serum SHBG (chemiluminescent immunoassay) and TT (LCMSMS) at both time points, and without meds affecting TT or SHBG. T2D was identified by either self-report, fasting glucose (≥7.0 mmol/L), HbA1c (≥ 6.5%) and/or prescriptions for diabetes medications. CVD was ascertained by self-report and/or hospital data linkage. Logistic binomial regressions were used to assess associations between SHBG and incident T2D & CVD, adjusting for self-reported psycho-social, demographic and health status and related behavioural factors; measured waist circumference, HBA1c and plasma glucose, triglycerides, high-sensitivity C-reactive protein. Sensitivity analyses assessed mediation effects of anxiety, sleep duration, shift work ≥3years, and obstructive sleep apnoea (OSA). Results: During an average follow-up of 4.95 years, 14.5% (n=232) and 6.7% (n=101) of men developed T2D and CVD, respectively. Baseline TT was independently associated with incident T2D (odds ratio (OR) =0.72, 95%CI= [0.57, 0.92], P=0.01). An inverse association of baseline SHBG levels with incident T2D (OR=0.77 [0.62, 0.95], P=0.02), was insignificant after adjustment for TT (OR=0.91 [0.71, 1.17], P=0.48 for SHBG. Baseline TT (OR=0.71 [0.52, 0.98], P=0.04) and SHBG (OR=1.54 [1.15, 2.06], P=0.003) were independently associated with incident CVD. A decrease in TT between time points was associated with incident T2D (OR=0.81 [0.68, 0.97], P=0.02) and CVD (OR=0.72 [0.56,0.92], P=0.01). There was no association between ΔSHBG and incident T2D and CVD. In the sensitivity analyses there was evidence for mediation effects of shift-work on the association of TT, but not SHBG with CVD (both baseline &change models), and of longer sleep duration, OSA and shift work on the association of TT with T2D (change TT model only). Conclusions Shift-work mediates associations of TT with CVD. All sleep parameters had mediation effects on the association of decreasing TT with T2D. Funding: NH&MRC Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. Abstracts presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Cord blood NK cells engineered to express IL-15 and a CD19-targeted CAR show long-term persistence and potent antitumor activity

Chimeric antigen receptors (CARs) have been used to redirect the specificity of autologous T cells against leukemia and lymphoma with promising clinical results. Extending this approach to allogeneic T cells is problematic as they carry a significant risk of graft-versus-host disease (GVHD). Natural killer (NK) cells are highly cytotoxic effectors, killing their targets in a non-antigen-specific manner without causing GVHD. Cord blood (CB) offers an attractive, allogeneic, off-the-self source of NK cells for immunotherapy. We transduced CB-derived NK cells with a retroviral vector incorporating the genes for CAR-CD19, IL-15 and inducible caspase-9-based suicide gene (iC9), and demonstrated efficient killing of CD19-expressing cell lines and primary leukemia cells in vitro, with marked prolongation of survival in a xenograft Raji lymphoma murine model. Interleukin-15 (IL-15) production by the transduced CB-NK cells critically improved their function. Moreover, iC9/CAR.19/IL-15 CB-NK cells were readily eliminated upon pharmacologic activation of the iC9 suicide gene. In conclusion, we have developed a novel approach to immunotherapy using engineered CB-derived NK cells, which are easy to produce, exhibit striking efficacy and incorporate safety measures to limit toxicity. This approach should greatly improve the logistics of delivering this therapy to large numbers of patients, a major limitation to current CAR-T-cell therapies.

Developing and validating a new national remote health advice syndromic surveillance system in England

Background

Public Health England (PHE) coordinates a suite of real-time national syndromic surveillance systems monitoring general practice, emergency department and remote health advice data. We describe the development and informal evaluation of a new syndromic surveillance system using NHS 111 remote health advice data.

Methods

NHS 111 syndromic indicators were monitored daily at national and local level. Statistical models were applied to daily data to identify significant exceedances; statistical baselines were developed for each syndrome and area using a multi-level hierarchical mixed effects model.

Results

Between November 2013 and October 2014, there were on average 19 095 NHS 111 calls each weekday and 43 084 each weekend day in the PHE dataset. There was a predominance of females using the service (57%); highest percentage of calls received was in the age group 1-4 years (14%). This system was used to monitor respiratory and gastrointestinal infections over the winter of 2013-14, the potential public health impact of severe flooding across parts of southern England and poor air quality episodes across England in April 2014.

Conclusions

This new system complements and supplements the existing PHE syndromic surveillance systems and is now integrated into the routine daily processes that form this national syndromic surveillance service.

Cows Milk Allergy: A Cohort of Patients from a University Hospital

The study illustrates advantages of Fiberoptic Bronchoscopy, a new service started at St. Lukes General Hospital in patient care since April 2014. Retrospective review of Bronchoscopies and referrals to Tertiary care unit for Bronchoscopy, prior and after initiation of service at St. Lukes Hospital were studied. Total 106 procedures were performed out of which 103(98%) were for diagnostic purpose. Common Indications for bronchoscopy were functional airway assessment in 38 cases (35%) of chronic cough, 26 cases (24.8%) of suspected Malignancy. The average time taken for procedure was 15 + 1 minute with overall rate of complication recorded in 1 case (0.95%). 32(30%) inpatients were referred before Bronchoscopy services were started locally.15(14%) patients were referred for Endobronchial ultrasound (EBUS) after diagnostic procedure performed at St. Lukes Hospital. To conclude, Bronchoscopy is a safe procedure used for diagnosis of various Lung conditions. The services offered locally reduced the time and cost involved in referrals. The diagnostic Bronchoscopies performed for Malignancy at St. Lukes Hospital have rightly increased references for EBUS at Tertiary care Unit.

Infection and pathology in Queensland grouper, Epinephelus lanceolatus, (Bloch), caused by exposure to Streptococcus agalactiae via different routes

Since 2007, 96 wild Queensland groupers, Epinephelus lanceolatus, (Bloch), have been found dead in NE Australia. In some cases, Streptococcus agalactiae (Group B Streptococcus, GBS) was isolated. At present, a GBS isolate from a wild grouper case was employed in experimental challenge trials in hatchery-reared Queensland grouper by different routes of exposure. Injection resulted in rapid development of clinical signs including bilateral exophthalmia, hyperaemic skin or fins and abnormal swimming. Death occurred in, and GBS was re-isolated from, 98% fish injected and was detected by PCR in brain, head kidney and spleen from all fish, regardless of challenge dose. Challenge by immersion resulted in lower morbidity with a clear dose response. Whilst infection was established via oral challenge by admixture with feed, no mortality occurred. Histology showed pathology consistent with GBS infection in organs examined from all injected fish, from fish challenged with medium and high doses by immersion, and from high-dose oral challenge. These experimental challenges demonstrated that GBS isolated from wild Queensland grouper reproduced disease in experimentally challenged fish and resulted in pathology that was consistent with that seen in wild Queensland grouper infected with S. agalactiae.

Excess mortality among the elderly in European countries, December 2014 to February 2015

Since December 2014 and up to February 2015, the weekly number of excess deaths from all-causes among individuals?≥?65 years of age in 14 European countries have been significantly higher than in the four previous winter seasons. The rise in unspecified excess mortality coincides with increased proportion of influenza detection in the European influenza surveillance schemes with a main predominance of influenza A(H3N2) viruses seen throughout Europe in the current season, though cold snaps and other respiratory infections may also have had an effect.

Temporospatial fate of bacteria and immune effector expression in house flies fed GFP-Escherichia coli O157:H7

The house fly Musca domestica L. (Diptera: Muscidae) harbours and transmits a variety of human enteropathogens including Escherichia coli (Enterobacteriales: Enterobacteriaceae) O157:H7. Interactions between ingested bacteria and the fly gut directly impact bacterial persistence, survival and ultimately fly vector competence. We assessed the temporospatial fate of green fluorescent protein (GFP)-expressing E. coli O157:H7 (GFP-ECO157) in house flies along with fly antimicrobial responses up to 12 h post-ingestion. In flies fed GFP-ECO157, culture and microscopy revealed a steady decrease in bacterial load over 12 h, which is likely to be attributable to the combined effects of immobilization within the peritrophic matrix, lysis and peristaltic excretion. However, flies can putatively transmit this pathogen in excreta because intact bacteria were observed in the crop and rectum. Quantitative reverse-transcriptase polymerase chain reaction analysis of antimicrobial peptides (AMPs) and lysozyme gene expression showed minimal upregulation in both the gut and carcass of house flies fed GFP-ECO157. However, these genes were upregulated in fly heads and salivary glands, and effector proteins were detected in the gut in some flies. Collectively, these data indicate that house flies can serve as reservoirs of E. coli O157:H7 for up to 12 h, and factors in addition to AMPs and lysozyme may contribute to bacteria destruction in the gut.

Burden of influenza B virus infections in Scotland in 2012/13 and epidemiological investigations between 2000 and 2012

We describe the burden of influenza B infections in Scotland during a 13-year study period. Influenza A and B viruses cocirculated throughout the period, with numbers of influenza B cases approaching or exceeding those of influenza A during six influenza seasons. Influenza B viruses of both Victoria and Yamagata lineage were detected in two of six seasons investigated. For the 2012/13 season, influenza B accounted for 44.4% of all influenzas, with the highest incidence in those under the age of five years. Influenza B virus infections led to fewer admissions to an intensive care unit (ICU) and a lower mortality rate than influenza A (37 vs 81 ICU admissions and three vs 29 deaths) during the 2012/13 season. However, a quarter of those admitted to ICU with influenza B had not been immunised and 60% had not received specific influenza antiviral therapy. This highlights the need for consistent influenza vaccination and prompt usage of antiviral treatment for identified risk groups. Combining the newly introduced vaccination programme for children with the use of a tetravalent vaccine may provide the opportunity to improve the control of influenza B in those with the highest influenza B burden, children and young adolescents.

Canonical Wnt signals combined with suppressed TGFβ/BMP pathways promote renewal of the native human colonic epithelium

BACKGROUND

A defining characteristic of the human intestinal epithelium is that it is the most rapidly renewing tissue in the body. However, the processes underlying tissue renewal and the mechanisms that govern their coordination have proved difficult to study in the human gut.

OBJECTIVE

To investigate the regulation of stem cell-driven tissue renewal by canonical Wnt and TGFβ/bone morphogenetic protein (BMP) pathways in the native human colonic epithelium.

DESIGN

Intact human colonic crypts were isolated from mucosal tissue samples and placed into 3D culture conditions optimised for steady-state tissue renewal. High affinity mRNA in situ hybridisation and immunohistochemistry were complemented by functional genomic and bioimaging techniques. The effects of signalling pathway modulators on the status of intestinal stem cell biology, crypt cell proliferation, migration, differentiation and shedding were determined.

RESULTS

Native human colonic crypts exhibited distinct activation profiles for canonical Wnt, TGFβ and BMP pathways. A population of intestinal LGR5/OLFM4-positive stem/progenitor cells were interspersed between goblet-like cells within the crypt-base. Exogenous and crypt cell-autonomous canonical Wnt signals supported homeostatic intestinal stem/progenitor cell proliferation and were antagonised by TGFβ or BMP pathway activation. Reduced Wnt stimulation impeded crypt cell proliferation, but crypt cell migration and shedding from the crypt surface were unaffected and resulted in diminished crypts.

CONCLUSIONS

Steady-state tissue renewal in the native human colonic epithelium is dependent on canonical Wnt signals combined with suppressed TGFβ/BMP pathways. Stem/progenitor cell proliferation is uncoupled from crypt cell migration and shedding, and is required to constantly replenish the crypt cell population.

Increase in scarlet fever notifications in the United Kingdom, 2013/2014

Increases in scarlet fever above usual seasonal levels are currently being seen across the United Kingdom. Medical practitioners have been alerted to the exceptional increase in incidence. Given the potential for this to signal a population increase in invasive group A streptococcal disease, close monitoring of invasive disease is essential.

Abstract P2-09-16: Pre-clinical evaluation of novel anti-angiogenic agents as breast cancer therapeutics

Background

There is a need to develop novel drugs that will improve survival in breast cancer patients. Angiogenesis is essential for breast tumour progression. To date, the most promising approach to inhibit angiogenesis in breast cancer patients has been the drug bevacizumab which targets the pro-angiogenic factor Vascular Endothelial Growth Factor (VEGF). Recently, there has been controversy regarding the efficacy of bevacizumab for breast cancer treatment. In clinical trials, bevacizumab failed to establish an overall-survival benefit and was associated with serious toxicities. This resulted in the FDA revoking approval for the drug for the first line treatment of advanced breast cancer. Due to this uncertainty surrounding the efficacy of bevacizumab for the treatment of breast cancer it is clear that there is a clinical need for more effective novel anti-angiogenic drugs with better toxicity profiles for the treatment of breast cancer.

Aim

This study aimed to identify novel small-molecule anti-angiogenic agents with therapeutic potential in human breast cancer.

Methods

Compounds with physiochemical properties consistent with drug-like compounds were screened for anti-angiogenic activity by high-throughput screening involving zebrafish larvae. Human breast tumour explants were treated with the lead compound and secretion of angiogenic factors was assessed by ELISA.

Results

We have identified a novel small-molecule agent ‘SMG1’ that significantly inhibited inter-segmental blood-vessel development in zebrafish and showed no toxicity. Treatment of breast tumour explants with SMG1 significantly inhibited secretion of the potent pro-angiogenic cytokine VEGF (p = 0.01). Furthermore, SMG1 inhibited VEGF secretion more than the standard targeted breast cancer therapies tamoxifen and Herceptin® which have been reported to inhibit angiogenesis.

Conclusion

Continuing pre-clinical work will determine if SMG1 has potential as a therapeutic agent for human breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-09-16.

Automated mortality monitoring in Scotland from 2009

Mortality monitoring systems are important for gauging the effect of influenza and other wide ranging health threats. We present the daily all-cause mortality monitoring system routinely used in Scotland, which differs from others by using two different statistical models for calculating expected mortality. The first model is an extended Serfling model, which captures annual seasonality in mortality using sine and cosine terms, and is frequently seen in other systems. Serfling models fit to summer seasonality well, but not to the winter peak. Thus, during the winter, there are frequent 'excesses', higher than expected mortality, making it harder to directly judge if winter mortality is higher than in previous years. The second model, a Generalised Additive Model, resolves this by allowing a more flexible seasonal pattern that includes the winter peak. Thus, excesses under the second model directly indicate if winter mortality is higher than in previous years, useful, for example, in judging if a new strain of seasonal influenza is more likely to produce death than previous ones. As common in all-cause mortality monitoring systems, the Scottish system uses a reporting delay correction: we discuss the difficulties of interpretation when such a correction is used and possible avenues for future work that may address these difficulties.