Reply to Singh, G.D. Comment on "Dao et al. Retrospective Analysis of Real-World Data for the Treatment of Obstructive Sleep Apnea with Slow Maxillary Expansion Using a Unique Expansion Dental Appliance (DNA). Pathophysiology 2023, 30, 199-208"

In response to the commentary "Response to 'Retrospective analysis of real-world data for the treatment of obstructive sleep apnea with slow maxillary expansion'" [...].

Retrospective Analysis of Real-World Data for the Treatment of Obstructive Sleep Apnea with Slow Maxillary Expansion Using a Unique Expansion Dental Appliance (DNA)

In addition to mandibular advancement devices, dental expansion appliances are an important clinical approach for achieving an increased intra-oral space that promotes airflow and lessens the frequency or severity of apneic events in patients diagnosed with obstructive sleep apnea (OSA). It has been thought that dental expansion in adults must be preceded by oral surgery; however, in this paper, we examine the results of a new technique for slow maxillary expansion without any surgical procedures. The palatal expansion device, DNA (Daytime-Nighttime Appliance), was reviewed in this retrospective study, particularly regarding its effects on measurements of transpalatal width, airway volume, and apnea-hypopnea indices (AHI) as well as its common modalities and complications. The DNA effectively reduced AHI by 46% (p = 0.00001) and significantly increased both airway volume and transpalatal width (p < 0.00001). After DNA treatment, 80% of patients showed some improvement in AHI scores with 28% of patients having their OSA symptoms completely resolved. Compared to the use of mandibular appliances, this approach is intended to create a sustained improvement in airway management that can reduce or eliminate dependence on continuous positive airway pressure (CPAP) or other OSA treatment devices.

0836 Atypical presentation of Biot’s breathing in a patient with Arnold Chiari Malformation II with complex sleep apnea/Sleep hypoventilation/hypoxemia not on opioid and with no history of meningitis

Introduction

Sleep disordered breathing is very common in Arnold Chiari malformation but Biots’s breathing has not been reported in these cases.

Report of Cases: 3-year-old with history of Arnold Chiari II malformation with hydrocephalus (s/p VP shunt and surgical decompression), spina bifida myelomeningocele (s/p in utero repair), subglottic stenosis with prior tracheostomy and eventual decannulation presented for evaluation of sleep disordered breathing. Presenting symptoms included witnessed apneas, cyanosis, daytime sleepiness and frequent awakenings. Physical examination was largely unremarkable.

Initial PSG demonstrated complex sleep apnea, with an AHI 20.6, REM AHI 57.8 per hour of

sleep, ETCO2 peak of 69 cm H20 and an O2 saturation nadir of 34%, with sleep related

hypoventilation/hypoxemia and Biot's breathing in the absence of opioid use and CNS infection.

During titration study, Biot’s breathing, complex apnea and sleep related hypoventilation/hypoxemia responded well to BiPAP ST of IPAP 18 cm H20 and EPAP 14 cm H20 BUR of 12 and oxygen of 1 L/min. She later developed intolerance to BiPAP due to high

pressures and was decreased to BIPAP 13/11 cm H2O. Later the patient discontinued the use of

BIPAP due to intolerance and was switched to night time O2 at 3-4 L/min. Per the parents, the

patient has been maintaining her oxygen saturation in the absence of BIPAP therapy with

oxygen use. Due to COVID, patient was unable to follow up but will be scheduled for a repeat

PSG in the near future. She followed with Neurosurgery for Arnold Chiari II and they

recommended no surgical intervention at this time due to functional VP shunt.

Conclusion

This is an atypical presentation of Biot’s breathing in the absence of CNS infections and opioid use in a patient with Arnold Chiari malformation II. Patient has complex sleep apnea, initially well controlled with BiPAP ST, but developed BiPAP intolerance. She is on oxygen with good control of hypoxemia in the absence of BiPAP therapy.

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0851 Longitudinal Management of Narcolepsy with Atypical presentation of Cataplexy (unilateral with symptoms only on the right side for the past 13 years)

Introduction

Narcolepsy with atypical unilateral cataplexy is a rare phenotype. We would like to share single center, single patient experience over the last 13 years of managing this patient.

Report of Cases: 64-year-old female diagnosed with narcolepsy with unilateral cataplexy in 2008 with MSLT. Her cataplexy syndrome has been atypical, in that it has a strictly unilateral presentation for the past 13 years, with right face, arm, and leg weakness with strong emotions(anger/laughter). Her right-side extremities go limp for a few seconds to a minute.

Her cataplexy syndrome has never evolved to become bilateral or unilaterally on her left side.

Her physical examination has been largely unremarkable. For Narcolepsy, was on Modafinil (2008) which was up titrated to 600 mg with no side effects, eventually switched to Armodafinil 250 mg (2013). Eventually did not control EDS fully, methylphenidate (2014) was added. The patient reported cognitive impairment with gradual memory loss on stimulants (starting in 2012) and nocturnal insomnia on methylphenidate SR. Due to worsening cognition and memory, stimulants were discontinued in 2014 and patient referred to neurology and had neuropsychiatric evaluation for memory loss. Dementia lab workup and MRI with spectroscopy were unremarkable. Due to continuation of EDS was restarted on Modafinil until May 2021. In May 2021, she reported no longer fully controlled daytime sleepiness and Pitolisant was added with improvement in ESS from 17/24 to 9/24. For the management of unilateral cataplexy, patient was well controlled initially on venlafaxine (2008), eventually up titrated with an additional dose a few times. After cognitive impairment, patient stopped refilling it in 2014 and subsequently slept better without the venlafaxine. She reported that she would fall when she got very upset/mad so learnt not to get mad at people. She had many episodes of unilateral cataplexy mainly with laughing or excitement so was started on Fluoxetine 20 mg and eventually up titrated to 40 mg. Her unilateral cataplexy symptoms have been well controlled with the addition of Pitolisant.

Conclusion

Management of Narcolepsy with atypical unilateral cataplexy is challenging and requires use of multiple medications with different sites of action.

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The Role of the ACE2/MasR Axis in Ischemic Stroke: New Insights for Therapy

Ischemic stroke remains the leading cause of neurologically based morbidity and mortality. Current stroke treatment is limited to two classes of FDA-approved drugs: thrombolytic agents (tissue plasminogen activator (tPA)) and antithrombotic agents (aspirin and heparin), which have a narrow time-window (<4.5 h) for administration after onset of stroke symptoms. While thrombolytic agents restore perfusion, they carry serious risks for hemorrhage, and do not influence damage responses during reperfusion. Consequently, stroke therapies that can suppress deleterious effects of ischemic injury are desperately needed. Angiotensin converting enzyme-2 (ACE2) has been recently suggested to beneficially influence experimental stroke outcomes by converting the vasoconstrictor Ang II into the vasodilator Ang 1-7. In this review, we extensively discuss the protective functions of ACE2-Ang (1-7)-MasR axis of renin angiotensin system (RAS) in ischemic stroke.

Human placenta mesenchymal stem cell protection in ischemic stroke is angiotensin converting enzyme-2 and masR receptor-dependent

Thromboembolic stroke remains a major cause of neurological disability and death. Current stroke treatments (aspirin, tissue plasminogen activator) are significantly limited by timing and risks for hemorrhage which have driven researchers to explore other approaches. Stem cell‐based therapy appears to be an effective option for ischemic stroke. Besides trans‐differentiation into neural cells, stem cells also provide acute protection via paracrine signaling pathways through which releasing neuroprotective factors. We previously reported that intraperitoneal administration of human placenta mesenchymal stem cell (hPMSC) therapy upon reperfusion significantly protected the brain against middle cerebral artery occlusion (MCAO)‐induced injury. In the present study, we specifically investigated the role of hPMSC‐derived angiotensin converting enzyme‐2 (ACE‐2) in protection of MCAO‐induced brain injury by measurement of brain tissue viability, cerebral blood flow, and neurological score. Here, we report for the first time that hPMSC expressing substantial amount of ACE‐2, which mediates hPMSC protection in the MCAO model. Strikingly, we found that the protective effects of hPMSC in MCAO‐induced brain injury could be attenuated by pretreatment of hPMSCs with MLN‐4760, a specific inhibitor of ACE‐2 activity, or by transfection of hPMSCs with ACE‐2‐shRNA‐lentivirus. The hPMSC‐derived ACE‐2 specific protective mechanism was further demonstrated by administration of PD123319, an Angiotensin type‐2 receptor antagonist, or A779, a MasR antagonist. Importantly, our study demonstrated that the protective effects of hPMSC in experimental stroke are ACE‐2/MasR dependent and this signaling pathway represents an innovative and highly promising approach for targeted stroke therapy.

833 Evolution of sleep disordered breathing types in heart failure

Introduction

Central sleep apnea is commonly seen in patients with heart failure. Here we present a case demonstrating shifting of predominant apneic events from central to obstructive type after placement of left ventricular assist device (LVAD) in end stage heart failure patient.

Report of case(s)

Case Presentation: 66 year-old African American male has past medical history of chronic congestive heart failure diabetes, hypertension, paroxysmal atrial fibrillation, anemia, hypothyroidism, chronic kidney disease and sleep apnea. Prior to his LVAD placement, his left ventricular ejection fraction (EF) was &lt;10%. Patient was diagnosed with central sleep apnea with AHI of 58 (with 92% of apneic events being central events), oxygen nadir of 74%. Subsequently, patient had LVAD placed for symptomatic heart failure and repeat polysomnogram repeated at six month demonstrated an improved AHI of 45.8 with predominantly obstructive and mixed apneic events, with only 12.5% being central events.

Conclusion

This case report highlights not only the improvement of the sleep apnea in CHF treated with LVAD but also shows the shift of apneic events from predominantly central to obstructive type post LVAD.

Support (if any)

1. Henein MY, Westaby S, Poole-Wilson PA, Cowie MR, Simonds AK. Resolution of central sleep apnoea following implantation of a left ventricular assist device. Int J Cardiol. 2010 Feb 4;138(3):317–9. PMID: 18752859. 2. Köhnlein T, Welte T, Tan LB, Elliott MW. Central sleep apnoea syndrome in patients with chronic heart disease: a critical review of the current literature. Thorax. 2002 Jun;57(6):547–54. PMID: 12037232 3. Monda C, Scala O, Paolillo S, Savarese G, Cecere M, D’Amore C, Parente A, Musella F, Mosca S, Filardi PP. Apnee notturne e scompenso cardiaco: fisiopatologia, diagnosi e terapia [Sleep apnea and heart failure: pathophysiology, diagnosis and therapy]. G Ital Cardiol (Rome). 2010 Nov;11(11):815–22. Italian. PMID: 21348318.

842 PAP Therapy in a Pandemic: Management of Severe Mixed Apnea Predominant OSA & CSA during the COVID-19 Pandemic

Introduction

Introduction/Background: A new protocol and standard of care was created amidst the COVID-19 Pandemic that began in 2020. Traditional split night studies fell out of favor and were replaced by solely diagnostic studies with placement on Auto-PAP therapy if treatment of sleep disordered breathing was required. Some patients, however, required a more tailored approach if diagnostic polysomnogram (PSG) was particularly concerning. Our case report describes the treatment of a patient with severe Mixed Apnea Predominant Obstructive Sleep Apnea (OSA) with accompanying Central Sleep Apnea (CSA) using COVID-19 Precautions.

Report of case(s)

Case Description: A 48 year old AAM patient with a PMH of HTN, pre-diabetes, GERD, obesity and tobacco abuse initially presented to Sleep Medicine in late January 2020 with complaints of snoring, witnessed apneas, waking up gasping, excessive daytime sleepiness, fatigue, and non-restorative sleep for many years with ESS 24 and FSS 48 on initial evaluation. Diagnostic PSG showed AHI 76.9 with O2 desaturation to 59% and demonstrated the presence of severe Mixed Apnea predominant OSA and CSA with worsening during REM sleep. Because of the severity, he underwent a PAP titration in August 2020 using the AASM COVID-19 sleep study precautions which included use of a negative pressure room. Optimal control of snoring, apneic respiratory events and oxygen desaturations was achieved at 14 cm H2O in the supine body position during REM sleep. Follow up with Sleep Medicine in October and December 2020 showed objective compliance over a 30 day period not completely at goal due to issues with mask desensitization and sleep hygiene, however the patient subjectively reported that he noticed great improvement in snoring, excessive daytime sleepiness and fatigue.

Conclusion: Discussion/Conclusion

With a diagnosis of Severe Mixed Apnea Predominant OSA as well as CSA noted during the study, the differential diagnosis included CHF, Chiari malformation, opioid abuse and idiopathic CSA as the cause. Despite a dangerous pandemic, appropriate therapy for certain patients must still be attained. Special protocols developed during the COVID-19 Pandemic allowed for our patient to receive adequate treatment, while ensuring the safety of all involved.

Support (if any)

References COVID 19: FAQs for Sleep Clinicians. AASM official website. https://aasm.org/covid-19-resources/covid-19-faq/

733 PTSD and Sleep Disorders in Medical Learners and Healthcare Providers

Introduction

Medical student mental health and wellness has been an increasingly hot topic over the past decade. Much of the research, however, has remained focused more on anxiety and depression and less on other less common but just as detrimental mental health disorders such as PTSD, bipolar disorder, OCD and others. In addition to the more traditional psychological stresses medical students experience, they also experience physical consequences of their training, often with sleep patterns suffering most initially.

Methods

The questionnaire consists of thirty-five questions, compromising of demographic questions, questions relating to USMLE exams and education, the STOP-Bang Questionnaire, Epworth Sleepiness Scale, Fatigue Severity Scale and PTSD DSM-V Questionnaire. This survey was sent out between March and April of 2020 and was distributed to all medical students and residents with an LSU Health Shreveport email address via RedCAP, an encrypted electronic survey tool.

Results

A total of 78 participants responded to our survey, with 91.1% identifying as medical students and the rest as residents. 64.1%, identified as female, 34.6% identified as male and 1.3% declined to answer. While 43% of our participants found their educational experience emotionally traumatizing, 75% of them felt that preparing and/or taking USMLE exams was emotionally traumatizing. In regards the portions of our questionnaire that served as sleep disorder screening questions, the average score for the STOP-Bang was 1.48 (SD +/- 1.15) the average score for the ESS was 6.85 (SD +/- 4.72) and the average score for the FSS was 32.04 (SD +/- 11.99). It should be noted that, while the average score of the PTSD screening portion was 20.34 (SD +/- 17.47), 18 participants scored above 38, the minimum score needed to qualify for a PTSD diagnosis.

Conclusion

These results suggest some correlations that warrant further future study. It is worrisome that while less than half of our participants stated their educational experience as harrowing, 75% stated preparing for and/or taking these required exams was emotionally traumatizing. The possible connections suggested here between USMLE exams and an increase in fatigue, lack of motivation and PTSD symptoms urge us to look more closely at the impact of the USMLE.

Support (if any):

845 Progressive external ophthalmoplegia in sleep apnea presenting as floppy eyelid syndrome

Introduction

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

Report of case(s)

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

Conclusion

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

Support (if any)

1. McNab AA. Floppy eyelid syndrome and obstructive sleep apnea. Ophthalmic Plast Reconstr Surg. 1997 Jun;13(2):98–114. doi: 10.1097/00002341-199706000-00005. PMID: 9185193.

856 Sleep-writing, sleep-talking in uncontrolled REM-predominant obstructive sleep apnea

Introduction

Abnormal movements and behaviors during sleep are part of a larger group of nocturnal events that may occur during the sleep-wake cycle and/or the transitions into and out of sleep. We are presenting the case of OSA-related confusional arousals associated with sleep-writing and sleep-talking during REM-sleep.

Report of case(s)

46 year old female with history of CAD, HTN, RLS, Anxiety, Depression, and REM predominant OSA (AHI of 2.9 per hour of sleep, REM AHI of 40 per hour of sleep, and oxygen saturation nadir of 91%), noncompliant with PAP therapy, returned to reestablish sleep medicine care and restart PAP therapy. The patient reported worsening of her OSA symptoms while being without PAP therapy. In addition to traditional OSA symptoms (snoring, frequent nighttime awakenings, restless legs, daytime sleepiness/fatigue), she reported episodes of sleep-talking, sleep-writing with demonstrated evidence of these events in her personal diary. She maintains a collective diary that incorporates her blood pressure readings, her weight loss accounts with records of meals in a day, as well as a separate log of letters that she will write and mail. In this diary, she has noticed sleep writing instances in each field, with no recollections subsequently on the act of writing them. The patient reported that these episodes of sleep writing would occur 3–4 times in a week, during this period of PAP noncompliance. Last reported instance of her sleep writing was October 2020. After re-initiation of PAP therapy, the patient has not reported further episodes of sleep-writing or sleep-talking.

Conclusion

The sleep-writing is a very rare clinical symptom in the presentation of REM-predominant OSA as well as in REM/NREM parasomnias. We were not able to come across a case of it in the sleep literature review. Sleep-talking is a well-documented phenomenon. Confusional arousals may be responsible for symptoms of sleep-writing and sleep-talking in this case. We may repeat a sleep study with split protocol and parasomnia montage using AutoBipap if needed to investigate further. Further research should be done to explore the nature and correlation of sleep-writing in clinical practice.

Support (if any)

N/A

828 Challenges of artifact in Polysomnography-An LVAD Story

Introduction

Congestive heart failure and sleep-disordered breathing frequently coexist. Many of these patients are referred for polysomnography(PSG). Left ventricular assist device (LVAD) is increasingly used as a destination therapy or as a bridge to transplant. This can lead to artifacts in EEG and EKG. The artifact can mask pathological waves or over-reading of pathology. We present a case report of a patient who underwent a PSG on LVAD.

Report of case(s)

Sixty-six-year old male with severe heart failure with reduced ejection fraction (EF) of 15 % presented with snoring and witnessed apnea. The patient was diagnosed with predominant central sleep apnea (92%) but never initiated BPAP/ST due to an unstable heart. He was placed on LVAD (HeartMate III LVAD, oscillatory speed of 5300 rpm/83.3Hz) as the heart status deteriorated. Repeat polysomnography was done for persistent snoring but improved witnessed apneas revealed a newly appearing artifact. EEG showed a diffuse low amplitude,6–7 Hz frequency waves, and a regularly appearing high voltage sharp-peaked wave. The morphology of alpha wave, K wave, spindles, and delta waves could not be appreciated and hence was unable to perform sleep staging. EKG had electrical artifacts. All troubleshooting maneuvers were unsuccessful in eliminating artifacts. The artifact is generated by the impeller rotational speed of LVAD that ranges from 2400 rpm to 10,00 rpm(oscillation frequencies of 40 Hz to 166.7 Hertz,1Hz == 60 rpm). The device’s artificial pulse causes additional minor peaks. EEG artifact can be improved by moving the amplifier away from the heart and repositioning the patient. Adjusting the low-frequency filter can affect the nasal pressure tracing, delta waves, and stage 3 recognition. Reducing the high-frequency filter frequency by 10 from the LVAD oscillation frequency improves the EKG signal. But this may cut off the frequency component of pathologies like left ventricular hypertrophy.

Conclusion

The LVAD has been increasingly used in the United States. It is important to improve awareness regarding the artifacts among sleep techs and physicians. Unresolved artifacts may lead to missing serious pathologies in EEG and EKG and also can lead to misreading the waves as pathological leading to unnecessary treatment.

Support (if any)

An image of EEG and EKG

849 REM Behavioral Disorder as a Predictor of Lewy body Dementia- A Case Report

Introduction

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

Report of case(s)

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

Conclusion

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

Support (if any)

NOne

1233 Mitochondrial Myopathy Making It Hard To Sleep! OSA management in Mitochondrial Myopathy with a variant in SNAPC4 and PURA genes

Introduction

No standard of care exists for management of sleep disorders/sleep disordered breathing (SDB) and Mitochondrial myopathies. Our case report describes our experience with this condition in a pediatric patient.

Report of Case

A ten-year-old middle eastern male with PMH of Mitochondrial myopathy was referred to Sleep Medicine by ENT with reported snoring, witnessed apneic spells and daytime fatigue. Flexible Video Laryngoscopy did not reveal tonsillar or adenoid hypertrophy so it was postulated that his OSA was a result of his craniofacial abnormalities and global hypotonia.

Genetic workup showed Mitochondrial complex II & III deficiency from a variant in SNAPC4 gene and PURA gene leading to failure to thrive, severe developmental delay, generalized muscle weakness, bradycardia requiring pacemaker, global hypotonia requiring nocturnal oxygen for chronic respiratory failure and G-tube placement due to difficulty with feedings.

Diagnostic PSG showed severe OSA with AHI of 11.3, RDI 11.8, REM AHI 56.0, REM RDI 56, and minimum oxygen saturation 85%. Subsequent PAP titration led to initiation of BIPAP therapy with settings of Auto-BiPAP EPAP min 5, IPAP max 20; PSmin 4; PSmax 6 cm H2O and continuation of nocturnal home oxygen. Sleep fragmentation improved to an arousal index of 3.1 with BIPAP. The patient and caregiver presented to the Sleep Medicine clinic 1 month after the PAP titration study with objective report showing &gt;4 hours use &gt;70% of the time and subjective satisfaction with BIPAP therapy with improvement in snoring and apnea.

Conclusion

Mitochondrial disorders lead to a deficiency of ATP affecting all organ systems and is most recognizable in the form of neuromuscular impairments. Neuromuscular impairments can translate into SDB issues such as OSA. Patients with genetic conditions such as mitochondrial myopathy should be routinely screened and evaluated for SDB and treated if warranted to significantly improve morbidity, mortality and quality of life.

1240 Obstructive Sleep Apnea Management in Weill-Marchesani Syndrome: A Case Report

Introduction

Weill-Marchesani Syndrome (WMS) is a rare systemic genetic connective tissue disorder which usually presents with symptoms of short stature, limited joint movement, and eye problems such as glaucoma and microspherophakia. This genetic condition is associated with fibrous tissue hyperplasia. WMS is inherited as autosomal dominant or autosomal recessive patterns in families leading to a variability in presenting phenotype. Few papers have been written on airway management during anesthesia but as far as we know, this is the first case report on obstructive sleep apnea management in a patient with WMS.

Report of Case

A 9 year old boy with a past medical history of Methylene THF Reductase deficiency, von Willebrand’s Disease, seizure disorder, premature birth, developmental delays and Weill-Marchesani syndrome was referred to Sleep Medicine due to tonsillar hypertrophy (3+), snoring and witnessed apneas. Upon physical examination, patient had mid-facial hypoplasia, retropositioning of the mandible, high arched palate, Mallampti class IV, maxillary hypoplasia and mandibular hypoplasia. He had been evaluated by ENT which determined the patient to be too high risk due to his medical conditions for T&A. The patient had a polysomnogram in 2018 indicating OSA with an apnea-hypopnea index of 4.2 and a minimum oxygen saturation of 91%. After a CPAP titration study, the patient was started on Auto CPAP of 5-15 cmH2O and has shown improvement in symptoms based on subjective and objective compliance report. Patient has been able to tolerate PAP therapy well with 100% compliance greater than 4 hours per night.

Conclusion

This case is the first illustrating OSA in a patient with Weill-Marchesani Syndrome. In WMS, the causes of OSA are not only due to tonsillar hypertrophy, but multifactorial, including craniofacial abnormalities. Given the high risk of surgical complications in WMS patients, PAP therapy appears to be a reasonable option for OSA management.

Abstract TP142: Inpatient Mortality Rates in Endovascular Stenting and Angioplasty of Intracranial Vertebral and Basilar Arteries

Objective: To compare inpatient mortality rates in patients who underwent intracranial endovascular stenting and/or angioplasty of the vertebral artery or basilar artery by analyzing data from the National inpatient sample database (2012-2015).

Methods: We extracted data utilizing ICD-9 diagnosis codes for occlusion and stenosis of vertebral artery with or without stroke (433.20, 433.21) and occlusion and stenosis of basilar artery with or without stroke (433.00, 433.01). The cohort included total of 201 patients. Binary logistic regression and Chi-square tests were utilized for data analysis.

Results: A total number of 201 patients underwent either intracranial angioplasty alone or stenting with or without angioplasty for either vertebral or basilar artery stenosis. Male patients were predominant (74%). The majority were 51 to 75 years of age (76.1%). 55% of the patients had stenosis of the basilar artery, 45% had vertebral artery stenosis. The majority of patients underwent stenting with or without angioplasty (69%); 47% had basilar stenting and 53% had vertebral stenting. The common co-morbidities observed were hypertension (84%), diabetes mellitus (37%), peripheral vascular disease (20%) and obesity (14%). The overall mortality rate in this cohort was 17.4%. The mortality rate was significantly higher in patients with basilar artery stenosis when compared with vertebral artery stenosis regardless of type of procedure performed (24% vs 9%, P = 0.004). The mortality during hospitalization was not significantly affected by the type of procedure (angioplasty vs stenting with or without angioplasty), or by the aforementioned comorbidities. The significant predictor of mortality was basilar artery stenosis (OR 2.87, 95% CI 1.18-6.98, P =0.02).

Conclusion: The overall mortality in this cohort of patients who underwent angioplasty vs stenting with or without angioplasty for basilar or vertebral intracranial artery stenosis was 17.4%. Mortality rate was significantly higher in patients with basilar artery stenosis (24%) compared to those with vertebral artery stenosis (9%). The type of procedure performed (angioplasty vs stenting with or without angioplasty) had no significant statistical impact.

Abstract TP102: Human Placental Mesenchymal Stem Cells Derived Exosome-Angiotensin Converting Enzyme-2 Dependent Protection in Ischemic Stroke Injury

Following thrombolytic therapy for stroke, ischemia/reperfusion (I/R) mediated inflammation often disrupts the blood brain barrier (BBB). This can enhance expression of endothelial adhesion markers and perturb normal blood flow regulation. Proposed benefits of stem cell therapy (SCT) in stroke, besides long-term trans-differentiation into neural cells, include secretion of protective factors, which partly depends on exosomes released by stem cells. We evaluated human placenta mesenchymal stem cells (hPMSC) as potential ameliorative SCT in an acute ischemic stroke model. We hypothesize that hPMSC would achieve site-specific suppression of post-ischemic immune cell transmigration, preservation of the BBB and maintenance of blood flow via ‘paracrine’ signaling pathways in acute stroke injury.We found that intraperitoneal (IP) administration of hPMSC at the time of reperfusion, using the middle cerebral artery occlusion (MCAO)/reperfusion model, produced significant protection ( p =0.0001) of the ipsilateral hemisphere. We also demonstrated that hPMSC-treated MCAO mice exhibited significantly greater neurological recovery ( p <0.0001) compared to untreated MCAO, an effect which was accompanied by significant restoration of blood flow ( p <0.01) to the MCAO-stressed brains. Using Evans Blue dye assay, we also observed significant ( p =0.004) improvement of BBB integrity in ipsilateral hemispheres of hPMSC-treated mice vs MCAO controls. Furthermore, we determined that hPMSC-derived exosomes contribute to paracrine based protection of hPMSC in MCAO model. Importantly, we found that hPMSC/exosome protection is mediated partly by the function of angiotensin converting enzyme 2 (ACE2). To evaluate the contribution of ACE2 in protection of the brain after ischemic stroke, we first demonstrated that hPMSC and their exosomes express ACE2. Second, mice injected with hPMSC which had been pre-treated with the specific ACE2 inhibitor (10μM) MLN-4760, showed tissue injury and neurological behavior similar to that seen in untreated MCAO.We conclude that pleiotropic factors associated with hPMSC administration can have a favorable impact on blood flow, BBB integrity potentially alleviating the detrimental effects of ischemic stroke.

Evaluation of Clinical Tools to Screen and Assess for Obstructive Sleep Apnea

ABSTRACT

Obstructive sleep apnea (OSA) is a globally recognized medical condition, associated with development of long-term adverse health consequences, including cardiovascular disease, cerebrovascular disease, neurocognitive deficiencies, and vehicular and occupational accidents. OSA can be screened effectively, because it can be identified well before the manifestation of the aforementioned poor health and public safety consequences. Additionally, appropriate management of OSA includes an assessment of outcomes before and after therapeutic intervention initiation. OSA clinical screening and outcome assessment tools exist; however, a key existing knowledge gap is identifying which tools are most clinically relevant and efficient to use in clinical practice models. The American Academy of Sleep Medicine (AASM) commissioned a task force (TF) of sleep medicine experts to identify and evaluate current OSA screening and assessment tools for adult patients and determine if they are reliable, effective, and feasible for use in clinical settings. No single tool met all the TF's objective criteria and subjective evaluation for clinical validity and feasibility to be recommended by the AASM. The TF provides several suggestions for the development of new tools or modifications to existing tools that would enhance their functionality in adults.

Restoration of sleep using a novel biomimetic protocol for adult OSA: Clinical case report

BACKGROUND

A sleep study of a 56-year old male with excessive daytime sleepiness demonstrated an AHI of 16.4hr^-1 with 13% of total sleep time in REM sleep and a mean oxygen desaturation (SpO₂) of 86%.

CLINICAL PRESENTATION

On intra-oral examination, it was found that the patient had maxillary hypoplasia and bilateral torus mandibularis. A 3D cone-beam CT (CBCT) scan was taken, and 28 craniofacial parameters were measured. Surgical reduction of the mandibular tori followed by biomimetic oral appliance therapy (BOAT) was initiated. After 14 months, a post-treatment CBCT scan revealed that 70% of parameters measured had improved. Therefore, another sleep study was performed with no device in the mouth. This follow-up home sleep test demonstrated that the AHI fell to 5.3hr^-1hr; with 27% REM sleep, and a mean SpO₂ of 93% without any device in the mouth.

CONCLUSION

These findings suggest that BOAT might be able to restore sleep in certain adult cases.

Abstract TP268: Distribution of Acute Ischemic Strokes After Implementation of Endovascular Guidelines in Louisiana

Objective: To highlight the distribution of acute ischemic strokes (AIS) after implementation of endovascular guidelines.

Background: Louisiana Emergency Response Network (LERN) is an organization with a mission to build comprehensive statewide systems of care for time-sensitive conditions including stroke. Four levels of stroke centers were recognized in 2013. Level 1: Comprehensive stroke center; Level 2: Primary stroke center; Level 3: Acute stroke ready hospital and Level 4: Non-stroke hospitals. As of 2017, there are 2 comprehensive stroke centers in Louisiana and 15 primary stroke centers. Statewide education was provided regarding mechanical endovascular recanalization (MER) for large vessel occlusion (LVO) in AIS as AHA/ASA guidelines were updated in 2015.

Design/Methods: Louisiana hospital inpatient discharge database for year 2014 and 2015 was retrospectively analyzed. Distribution of AIS and MER based on hospital level were explored.

Results: A total of 9396 patients with AIS were identified in dataset for year 2014 and 10409 for the year 2015. Proportion of AIS treated in Level 1, 2 and 3 hospitals increased in 2015 {Level 1: 2014 VS 2015: 1034 (11%) VS 1342 (13%); Level 2: 3946 (42%) VS 5035 (48%); level 3: 3195 (34%) VS 3610 (35%)}. Proportion of AIS patients in level 4 hospitals declined in 2015 {Level 4: 2014 VS 2015: 1221 (13%) VS 422 (4%)}. In 2014, 8.2% (770/9396) received any form of recanalization therapy compared to 9.5% in 2015 (989/10409), with higher proportions in Level 1 (22.2% VS 26.2%) and 2 centers (9.4% VS 10.2%) than Level 3 (4.1% VS 3.2%) and 4 (2.6% VS 1.4%). In 2015, 1.8% of patients with AIS had MER; this compares to 0.8% in 2014.

Conclusion: The reduction of patients treated in Level 4 hospitals in 2015 suggests our pre-hospital destination protocol facilitated transport to appropriate facilities. The proportion of patients with AIS receiving any form of recanalization increased in 2015, specifically in Level 1 and 2 centers. Improved destination of acute stroke patients likely contributed to increased recanalization rate and utility of MER. Statewide implementation of a revised initial destination protocol respecting the endovascular guidelines should lead to more LVO AIS patients receiving MER.

Neurological Respiratory Failure

West Nile virus infection in humans is mostly asymptomatic. Less than 1% of neuro-invasive cases show a fatality rate of around 10%. Acute flaccid paralysis of respiratory muscles leading to respiratory failure is the most common cause of death. Although the peripheral nervous system can be involved, isolated phrenic nerve palsy leading to respiratory failure is rare and described in only two cases in the English literature. We present another case of neurological respiratory failure due to West Nile virus-induced phrenic nerve palsy. Our case reiterates the rare, but lethal, consequences of West Nile virus infection, and the increase of its awareness among physicians.

Abstract WP84: Obstructive Sleep Apnea May Worsen the Overall Outcome of Intracranial Aneurysms

Introduction: Obstructive sleep apnea (OSA) is associated with the progression of abdominal and thoracic aortic aneurysms. However, the role of OSA in the overall outcome of intracranial aneurysms (IAs) has not yet been established. We have investigated the role of OSA in the progression and outcome of intracranial aneurysms.

Methods: Radiological and clinical data of 283 patients (from 2010 through 2015) were retrospectively reviewed. Significant differences between the OSA and non-OSA groups were determined by a chi-square test. Logistic regression analysis was performed to identify the predictors of unfavorable outcome.

Results: Among the 283 patients with IAs, 45 (16%) patients were positively screened for OSA, a proportion that was significantly higher than the prevalence of OSA in the general population (4%), p=0.008. Number of patients with hypertension (p=0.018), BMI ≥ 30 (p<0.0001), hyperlipidemia (p=0.034), diabetes mellitus (DM, p=0.005), chronic heart disease (CHD, p=0.024), cerebrovascular accident (CVA, p=0.03) was significantly higher in the OSA group compared to the non-OSA group. Similarly, the number of wide neck aneurysms (p=0.00001) and poor Hunt and Hess grade 4-5 (p=0.01) was significantly higher in the OSA group compared to the non-OSA group. In addition, the number of ruptured aneurysms (p=0.03) and vasospasms (p=0.02) was significantly higher in the OSA group. The number of the patients with poor modified Rankin scale (mRS) scores (3-6) was significantly higher in the OSA group (p=0.03). Both in univariate (p=0.01) and multivariate (p=0.04) regression analysis, OSA was identified as an individual predictor of unfavorable outcome. In addition, hypertension, smoking, CHD and CVA were revealed as positive predictors of poor outcome of IAs.

Conclusions: The complications of IAs such as rupture and vasospasms are influenced by presence of OSA. Overall outcome (mRS) of IAs is also affected by the concurrence of OSA. Therefore, coexistence of OSA in patients with IAs affects progression as well as outcome of IAs. Lastly, OSA serves as an individual risk factor for poor outcome in these patients.

Can We Assess Pulsus Paradoxus through Polysomnography in a Patient with Chronic Obstructive Pulmonary Disease and Sleep-Disordered Breathing?

ABSTRACT

Pulsus paradoxus (PP) is a decrease in systolic blood pressure greater than 10 mm Hg during inspiration that occurs in various medical conditions. Using polysomnography pulse oximetry signal, photoplethysmography variations of the amplitude of the pulse pressure within the respiratory cycle were observed. There is a proportional relationship between the changes of inspiratory waveform values and the generated PP. A 59-year-old male underwent polysomnography that showed sleep hypoxemia, obstructive sleep-disordered breathing (apnea hypopnea index [AHI] = 5.1and respiratory disturbance index [RDI] = 87.9), with variations of pulse pressure induced primarily by inspiration. The highest variations in the pulse wave were observed in NREM sleep during obstructive respiratory events and in biocalibration during nasal breathing. The lowest variations occurred after the correction of inspiratory obstructive events and during biocalibration when asked to hold his breath.

Abstract T P263: Screening Practices for Sleep-Disordered Breathing in Stroke Medical Community

Background: Frequency of sleep-disordered breathing (SDB) among stroke and TIA patients ranges from 50% to 94%, and is associated with poor neurological outcomes. Per current stroke prevention guidelines from American Stroke Association, SDB is included in the list of modifiable risk factors for stroke and TIA prevention. The goal of our study was to determine screening practices for SDB in stroke medical community.

Methods: A web-based survey was conducted between 12/2013 to 7/2014 among practitioners taking care of stroke patients across United States and Europe.

Results: Among 112 total responses (18%), 91 were stroke physicians (81.25%), 9 were general neurologist (8.04%), 3 were sleep medicine physicians (2.68%) and 9 were other specialty (8.04%). Majority of practitioners (72%, n= 81) do not use SDB screening questionnaires in their stroke patients. Epworth sleepiness scale is the most used among SDB questionnaires (24%), followed by Berlin sleep questionnaire (9.5%) and STOP-BANG questionnaire (7%). Only 12% of practitioners use screening questionnaires in both in-patients and out- patients, where as 20% use only in out- patients and 5% use only in acute stroke setting. Only 50% of practitioners would refer their stroke patients to a sleep medicine specialist when patients were screened positive for SDB on questionnaires.

Conclusion: Despite being an independent risk factor for stroke and TIA, majority of practitioners do not screen stroke and TIA patients for SDB. Further work is needed to improve screening practices for SDB in stroke medical community.

Treatment of nonresponders to oral sumatriptan with zolmitriptan and rizatriptan: a comparative open trial

In order to study the effect of zolmitriptan and rizatriptan in oral sumatriptan nonresponders (defined as lack of response in three or more of five attacks), 56 patients were studied in an open trial in a crossover fashion. Both zolmitriptan, 5 mg, and rizatriptan, 10 mg, were effective in the majority of sumatriptan nonresponders. The response to rizatriptan, 10 mg, appeared to be better than to zolmitriptan, 5 mg. Approximately 19% of sumatriptan nonresponders remained nonresponders to both zolmitriptan and rizatriptan.

Polyribonucleotides induce nitric oxide production by human monocyte-derived macrophages

Cytokine-mediated activation of inducible nitric oxide synthase (iNOS) in monocytes or macrophages is species specific. In contrast to rat or mouse, human macrophages do not produce measurable levels of nitric oxide (NO) when induced by inflammatory mediators. Exposure to noncytokine mediators such as tumor cells or viruses, however, has recently been shown to activate human iNOS. NO production in response to these mediators is much lower than that seen for rat or mouse cells and often requires several days of stimulation. We have found that the synthetic, doublestranded polyribonucleotide polyinosinic-polycytidilic acid (Poly I:C), commonly used to mimic viral exposure, activated iNOS in human monocyte-derived macrophages (MDM). The production of NO, measured by nitrite accumulation, was detected after 24 h of stimulation with Poly I:C. The single-stranded polyribonucleotide Poly I, but not Poly C, also increased NO production. Nitrite production was enhanced when the MDM were primed (pretreated) with gamma or alpha interferon or other immune mediators such as IL-4 and was reduced by the iNOS inhibitor, N-methyl-L-arginine (L-NMMA). The use of Poly I:C to initiate NO production in human macrophages provides a useful tool to study the differences between the commonly used animal models and human cells and may provide insight into the pathophysiological significance of these differences.

Biological activity of interleukin-10 in the central nervous system

Cytokines play a crucial role as mediators of inflammation. Astrocytes and microglia are the two major glial cells involved in the central nervous system immune responses. In this study we examined the effects of interleukin-10 (IL-10), one of the naturally occurring inhibitory cytokines, on different types of glial cells in culture such as rat astrocytes, hamster microglia and C6-2B glioma cells. Phosphorylation of signal transducers and activators of transcription (STAT) proteins was used as a marker for IL-10 activity. Within minutes, IL-10 elicited a strong and weak increase in STAT3 and STAT1 phosphorylation, respectively, in human T lymphocytes, suggesting that STAT3 is a main IL-10 signaling event in these cells. In contrast, IL-10 failed to induce STAT3 in glial cells, but elicited a weak increase in STAT1 phosphorylation in microglia and C6-2B glioma cells only, suggesting that in some glial cell population(s) IL-10 may produce cellular responses via activation of the STAT1 pathway. Moreover, in C6-2B cells, IL-10 elicited a decrease in the level of basic fibroblast growth factor mRNA. A similar decrease was observed in adult rat hypothalamus, indicating that this cytokine may regulate glial production of trophic factors. Our data suggest that IL-10 may play a role in glial cell differentiation and proliferation.

Species differences in the generation of reactive oxygen species by microglia

Although a variety of potential sources for reactive oxygen species (ROS) exist in the CNS, brain macrophages, i.e., the microglia, generate large quantities of these reactive species, particularly in response to injury or inflammatory signals. In order to understand how microglia contribute to changes in oxidative status of the CNS and how this might related to disease states, such as Alzheimer disease (AD), we have examined the regulation of superoxide anion and nitric oxide production from rodent and human microglia. Our results indicate that microglia from all species we have studied release superoxide anion, but produce significantly different amounts in response to the same activating agents. Species differences are also found in the ability to generate nitric oxide (NO). In particular, mouse microglia generate large quantities of NO when stimulated, but human and hamster microglia do not produce measurable amounts under the same stimulation conditions. These species differences are important to consider when modeling human disease processes from rodent studies.