The Ultra-Long-Term Sleep study: Design, rationale, data stability and user perspective

Sleep deprivation and poor sleep quality are significant societal challenges that negatively impact individuals' health. The interaction between subjective sleep quality, objective sleep measures, physical and cognitive performance, and their day-to-day variations remains poorly understood. Our year-long study of 20 healthy individuals, using subcutaneous electroencephalography, aimed to elucidate these interactions, assessing data stability and participant satisfaction, usability, well-being and adherence. In the study, 25 participants were fitted with a minimally invasive subcutaneous electroencephalography lead, with 20 completing the year of subcutaneous electroencephalography recording. Signal stability was measured using covariance of variation. Participant satisfaction, usability and well-being were measured with questionnaires: Perceived Ease of Use questionnaire, System Usability Scale, Headache questionnaire, Major Depression Inventory, World Health Organization 5-item Well-Being Index, and interviews. The subcutaneous electroencephalography signals remained stable for the entire year, with an average participant adherence rate of 91%. Participants rated their satisfaction with the subcutaneous electroencephalography device as easy to use with minimal or no discomfort. The System Usability Scale score was high at 86.3 ± 10.1, and interviews highlighted that participants understood how to use the subcutaneous electroencephalography device and described a period of acclimatization to sleeping with the device. This study provides compelling evidence for the feasibility of longitudinal sleep monitoring during everyday life utilizing subcutaneous electroencephalography in healthy subjects, showcasing excellent signal stability, adherence and user experience. The amassed subcutaneous electroencephalography data constitutes the largest dataset of its kind, and is poised to significantly advance our understanding of day-to-day variations in normal sleep and provide key insights into subjective and objective sleep quality.

CD11c+ B cells in relapsing-remitting multiple sclerosis and effects of anti-CD20 therapy

OBJECTIVES

B cells are important in the pathogenesis of multiple sclerosis. It is yet unknown which subsets may be involved, but atypical B cells have been proposed as mediators of autoimmunity. In this study, we investigated differences in B-cell subsets between controls and patients with untreated and anti-CD20-treated multiple sclerosis.

METHODS

We recruited 155 participants for an exploratory cohort comprising peripheral blood and cerebrospinal fluid, and a validation cohort comprising peripheral blood. Flow cytometry was used to characterize B-cell phenotypes and effector functions of CD11c+ atypical B cells.

RESULTS

There were no differences in circulating B cells between controls and untreated multiple sclerosis. As expected, anti-CD20-treated patients had a markedly lower B-cell count. Of B cells remaining after treatment, we observed higher proportions of CD11c+ B cells and plasmablasts. CD11c+ B cells were expanded in cerebrospinal fluid compared to peripheral blood in controls and untreated multiple sclerosis. Surprisingly, the proportion of CD11c+ cerebrospinal fluid B cells was higher in controls and after anti-CD20 therapy than in untreated multiple sclerosis. Apart from the presence of plasmablasts, the cerebrospinal fluid B-cell composition after anti-CD20 therapy resembled that of controls. CD11c+ B cells demonstrated a high potential for both proinflammatory and regulatory cytokine production.

INTERPRETATION

The study demonstrates that CD11c+ B cells and plasmablasts are less efficiently depleted by anti-CD20 therapy, and that CD11c+ B cells comprise a phenotypically and functionally distinct, albeit heterogenous, B-cell subset with the capacity of exerting both proinflammatory and regulatory functions.

Real-world impact of continuous positive airway pressure on sleepiness in patients with obstructive sleep apnea in a national registry

OBJECTIVE

Excessive daytime sleepiness (EDS) persists in some patients with obstructive sleep apnea (OSA) despite continuous positive airway pressure (CPAP) treatment. This study characterized response to CPAP and factors associated with residual EDS.

METHODS

Danish National Patient Registry data were analyzed. Patients with OSA diagnosis (1994-2016), Epworth Sleepiness Scale (ESS) scores and apnea-hypopnea index recorded before beginning CPAP (baseline) and after 1-13 months of CPAP use, and CPAP adherence were included. Odds ratios (OR) for residual EDS after CPAP treatment were estimated using multivariate logistic regression.

RESULTS

Of 1174 patients (mean age, 57 years; 75.5% male), 41.1% had baseline EDS (mild, 13.2%; moderate, 14.0%; severe, 13.9%); 58.9% did not. After CPAP treatment, follow-up mean ESS scores were normal (≤10) for all baseline EDS subgroups; however, 15.6% (n = 183) of patients had residual EDS (mild, 6.7%; moderate, 5.5%; severe, 3.4%). Odds of residual EDS were higher for patients with mild (OR, 5.2; 95% confidence interval [CI], 3.2-8.6), moderate (OR, 4.5; 95% CI, 2.7-7.4), and severe (OR, 13.0; 95% CI, 8.0-21.2) EDS at baseline compared with those with normal daytime sleepiness at baseline. Patients adherent with CPAP use were 38.2% less likely to have residual EDS compared with nonadherent patients (OR, 0.62; 95% CI, 0.43-0.88).

CONCLUSIONS

EDS was common in this cohort of Danish patients with OSA. Baseline EDS severity predicted higher odds of residual EDS. After CPAP treatment, adherence was associated with reduced odds of residual EDS, but EDS persisted in a subgroup of patients.

Lifestyle and demographic associations with 47 inflammatory and vascular stress biomarkers in 9876 blood donors

BACKGROUND

The emerging use of biomarkers in research and tailored care introduces a need for information about the association between biomarkers and basic demographics and lifestyle factors revealing expectable concentrations in healthy individuals while considering general demographic differences.

METHODS

A selection of 47 biomarkers, including markers of inflammation and vascular stress, were measured in plasma samples from 9876 Danish Blood Donor Study participants. Using regression models, we examined the association between biomarkers and sex, age, Body Mass Index (BMI), and smoking.

RESULTS

Here we show that concentrations of inflammation and vascular stress biomarkers generally increase with higher age, BMI, and smoking. Sex-specific effects are observed for multiple biomarkers.

CONCLUSION

This study provides comprehensive information on concentrations of 47 plasma biomarkers in healthy individuals. The study emphasizes that knowledge about biomarker concentrations in healthy individuals is critical for improved understanding of disease pathology and for tailored care and decision support tools.

Borderline personality disorder and the diagnostic co-occurrence of mental health disorders and somatic diseases: A controlled prospective national register-based study

OBJECTIVE

Information on borderline personality disorder (BPD) and its comorbidities is often limited to concentrate on a few diagnoses. The aim of the study was to use national register data to investigate all diagnostic co-occurring mental health disorders and somatic diseases 3 years before and after initial BPD diagnosis compared with a matched control group.

METHOD

The study was a register-based cohort of 2756 patients with incident BPD (ICD F60.3) and 11,024 matched controls, during 2002-2016. Comorbidity data were classified into main disease groups, in accordance with the World Health Organization ICD-10 criteria.

RESULTS

Almost half the patients had been diagnosed with mental and behavioral disorders before the BPD diagnosis as compared to 3% in the control group. Further, the co-occurrence of diseases due to external causes of morbidity, including injury, self-harm, and poisoning were more represented in the BPD group before diagnosis as compared to the control group. In addition, co-occurring morbidity related to diseases in the circulatory, the respiratory, the digestive, the musculoskeletal, and the genitourinary system was more represented in the BPD group. After diagnosis, the proportion of patients with co-occurring morbidity increased further in all main disease groups in the BPD group. As many as 87% of patients had mental and behavioral co-occurring morbidity and 15% nervous diseases as compared with 3% and 4%, respectively, in the control group. Also, comorbidities related to external causes of morbidity, including for example, injury and self-harm were more represented in the BPD group. The BPD group had more somatic co-occurring morbidity, especially digestive, respiratory, circulatory, and endocrine diseases. Finally, the mortality over 12 years was statistically significantly higher in people with BPD than in the control group.

CONCLUSION

Patients with BPD have higher odds for multiple physical health conditions and co-occurrence of mental health disorders.

Fractional exhaled nitric oxide-a possible biomarker for risk of obstructive sleep apnea in snorers

STUDY OBJECTIVES

Airway inflammation in patients with obstructive sleep apnea (OSA) has been described and can be assessed by measuring the biomarker fractional exhaled nitric oxide (FeNO). In this pilot study, we investigated FeNO measurements in identification of OSA among persons with snoring.

METHODS

In this study we aimed to investigate (1) if FeNO could be used in screening for OSA, (2) if daytime sleepiness correlated to FeNO levels, and (3) whether asthma affected FeNO levels. Persons with snoring were prospectively included in three primary care ear, nose, and throat clinics. Patients underwent spirometry, FeNO tests, and partial polygraphy. They filled out questionnaires on sinonasal and asthma symptoms, daytime sleepiness, and quality of life. Current smokers, patients with upper airway inflammatory conditions, and patients treated with steroids were excluded.

RESULTS

Forty-nine individuals were included. Median apnea-hypopnea index was 11.4, mean age was 50.9 years, and 29% were females. OSA was diagnosed in 73% of the patients of whom 53% had moderate-severe disease. Patients with moderate-severe OSA had significantly higher FeNO counts than patients with no or mild OSA (P = .024). Patients younger than 50 years with a FeNO below 15 had the lowest prevalence of moderate-severe OSA. No correlation was found between FeNO measurements and daytime sleepiness, and asthma did not affect FeNO levels.

CONCLUSIONS

We found a low prevalence of moderate-severe OSA in persons with snoring when FeNO and age were low. This might be considered in a future screening model, though further studies testing the FeNO cutoff level and the diagnostic accuracy are warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: NO Measurements in Screening for Asthma and OSA, in Patients With Severe Snoring; URL: https://clinicaltrials.gov/study/NCT03964324; Identifier: NCT03964324.

CITATION

Kiaer E, Ravn A, Jennum P, et al. Fractional exhaled nitric oxide-a possible biomarker for risk of obstructive sleep apnea in snorers. J Clin Sleep Med. 2024;20(1):85-92.

Transient intracranial pressure elevations (B waves) are associated with sleep apnea

BACKGROUND

Repetitive transient intracranial pressure waveform elevations up to 50 mmHg (ICP B-waves) are often used to define pathological conditions and determine indications for ICP-reducing treatment. We recently showed that nocturnal transient ICP elevations are present in patients without structural brain lesions or hydrocephalus in whom they are associated with sleep apnea. However, whether this signifies a general association between ICP macropatterns and sleep apnea remains unknown.

METHODS

We included 34 patients with hydrocephalus, or idiopathic intracranial hypertension (IIH), who were referred to the Neurosurgical Department, Copenhagen, Denmark, from 2017 to 2021. Every patient underwent diagnostic overnight ICP monitoring for clinical indications, with simultaneous polysomnography (PSG) sleep studies. All transient ICP elevations were objectively quantified in all patients. Three patients were monitored with continuous positive airway pressure (CPAP) treatment for an additional night.

RESULTS

All patients had transient ICP elevations associated with sleep apnea. The mean temporal delay from sleep apnea to transient ICP elevations for all patients was 3.6 s (SEM 0.2 s). Ramp-type transient ICP elevations with a large increase in ICP were associated with rapid eye movement (REM) sleep and sinusoidal-type elevations with non-REM (NREM) sleep. In three patients treated with CPAP, the treatment reduced the number of transient ICP elevations with a mean of 37%. CPAP treatment resulted in insignificant changes in the average ICP in two patients but elevated the average ICP during sleep in one patient by 5.6 mmHg.

CONCLUSION

The findings suggest that sleep apnea causes a significant proportion of transient ICP elevations, such as B-waves, and sleep apnea should be considered in ICP evaluation. Treatment of sleep apnea with CPAP can reduce the occurrence of transient ICP elevations. More research is needed on the impact of slow oscillating mechanisms on transient ICP elevations during high ICP and REM sleep.

SViT: A Spectral Vision Transformer for the Detection of REM Sleep Behavior Disorder

REM sleep behavior disorder (RBD) is a parasomnia with dream enactment and presence of REM sleep without atonia (RSWA). RBD diagnosed manually via polysomnography (PSG) scoring, which is time intensive. Isolated RBD (iRBD) is also associated with a high probability of conversion to Parkinson's disease. Diagnosis of iRBD is largely based on clinical evaluation and subjective PSG ratings of REM sleep without atonia. Here we show the first application of a novel spectral vision transformer (SViT) to PSG signals for detection of RBD and compare the results to the more conventional convolutional neural network architecture. The vision-based deep learning models were applied to scalograms (30 or 300 s windows) of the PSG data (EEG, EMG and EOG) and the predictions interpreted. A total of 153 RBD (96 iRBD and 57 RBD with PD) and 190 controls were included in the study and 5-fold bagged ensemble was used. Model outputs were analyzed per-patient (averaged), with regards to sleep stage, and the SViT was interpreted using integrated gradients. Models had a similar per-epoch test F1 score. However, the vision transformer had the best per-patient performance, with an F1 score 0.87. Training the SViT on channel subsets, it achieved an F1 score of 0.93 on a combination of EEG and EOG. EMG is thought to have the highest diagnostic yield, but interpretation of our model showed that high relevance was placed on EEG and EOG, indicating these channels could be included for diagnosing RBD.

MSED: A Multi-Modal Sleep Event Detection Model for Clinical Sleep Analysis

Clinical sleep analysis require manual analysis of sleep patterns for correct diagnosis of sleep disorders. However, several studies have shown significant variability in manual scoring of clinically relevant discrete sleep events, such as arousals, leg movements, and sleep disordered breathing (apneas and hypopneas). We investigated whether an automatic method could be used for event detection and if a model trained on all events (joint model) performed better than corresponding event-specific models (single-event models). We trained a deep neural network event detection model on 1653 individual recordings and tested the optimized model on 1000 separate hold-out recordings. F1 scores for the optimized joint detection model were 0.70, 0.63, and 0.62 for arousals, leg movements, and sleep disordered breathing, respectively, compared to 0.65, 0.61, and 0.60 for the optimized single-event models. Index values computed from detected events correlated positively with manual annotations (r2 = 0.73, r2 = 0.77, r2 = 0.78, respectively). We furthermore quantified model accuracy based on temporal difference metrics, which improved overall by using the joint model compared to single-event models. Our automatic model jointly detects arousals, leg movements and sleep disordered breathing events with high correlation with human annotations. Finally, we benchmark against previous state-of-the-art multi-event detection models and found an overall increase in F1 score with our proposed model despite a 97.5% reduction in model size.

Prevalence of sleep apnea in unselected patients with atrial fibrillation by a home-monitoring device: The DAN-APNO study

Background

Sleep apnea (SA), a modifiable risk factor in - atrial fibrillation (AF), is associated with worse outcomes in AF. We aimed to assess the prevalence and severity of SA in patients with AF, and, subsequently, to assess the positive predictive value (PPV) of moderate to severe SA by a home-monitoring device in comparison to cardio-respiratory monitoring (CRM) in consecutive patients with AF.

Methods

This cross-sectional study recruited unselected patients with AF without known SA from an out-patient clinic at Department of Cardiology, Herlev-Gentofte University Hospital. Participants underwent four consecutive nights of sleep-recording with the home-monitoring device NightOwl™ (NO). Moderate SA was defined as an Apnea-Hypopnea Index (AHI) of 15-29 and severe SA as ≥ 30 AHI. Participants with moderate to severe SA was offered CRM for validation of the diagnosis.

Results

We included 126 patients with AF with a median age of 68 (interquartile range: 60-75) years, 42 (33 %) women, 70 (56 %) hypertension, 61 (48 %) hyperlipidemia and 49 (39 %) heart failure. NO detected severe SA in 36 (29 %) of patients with AF, moderate SA in 35 (28 %), mild SA in 45 (36 %) and no SA in 10 (8 %). Of 71 patients with moderate to severe SA by NO, 38 patients underwent CRM and the PPV of NO was 0.82 (31/38) to diagnose moderate SA and 0.92 (22/24) to diagnose severe SA by CRM.

Conclusion

Moderate to severe SA by NO was highly prevalent in patients with AF without known SA. A home-monitoring device such as NO could be an easy and feasible SA screening tool in patients with AF.

Use of melatonin for children and adolescents with chronic insomnia attributable to disorders beyond indication: a systematic review, meta-analysis and clinical recommendation

Background

Melatonin has become a widely used sleeping aid for young individuals currently not included in existing guidelines. The aim was to develop a recommendation on the use of melatonin in children and adolescents aged 2-20 years, with chronic insomnia due to disorders beyond indication.

Methods

We performed a systematic search for guidelines, systematic reviews, and randomised trials (RCTs) in Medline, Embase, Cochrane Library, PsycInfo, Cinahl, Guidelines International Network, Trip Database, Canadian Agency for Drugs and Technologies in Health, American Academy of Sleep Medicine, European Sleep Research Society and Scandinavian Health Authorities databases. A separate search for adverse events was also performed. The latest search for guidelines, systematic reviews, and adverse events was performed on March 17, 2023. The latest search for RCTs was performed on to February 6, 2023. The language was restricted to English, Danish, Norwegian, and Swedish. Eligible participants were children and adolescents (2-20 years of age) with chronic insomnia due to underlying disorders, in whom sleep hygiene practices have been inadequate and melatonin was tested. Studies exclusively on autism spectrum disorders or attention deficit hyperactive disorder were excluded. There were no restrictions on dosage, duration of treatment, time of consumption or release formula. Primary outcomes were quality of sleep, daytime functioning and serious adverse events, assessed at 2-4 weeks post-treatment. Secondary outcomes included total sleep time, sleep latency, awakenings, drowsiness, quality of life, non-serious adverse events, and all-cause dropouts (assessed at 2-4 weeks post-treatment), plus quality of sleep and daytime functioning (assessed at 3-6 months post-treatment). Pooled estimates were calculated using inverse variance random effects model. Statistical heterogeneity was calculated using I² statistics. Risk of bias was assessed using Cochrane risk of bias tool. Publication bias was assessed using funnel plots. A multidisciplinary guideline panel constructed the recommendation using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). The certainty of evidence was considered either high, moderate, low or very low depending on the extent of risk of bias, inconsistency, imprecision, indirectness, or publication bias. The evidence-to-decision framework was used to discuss the feasibility and acceptance of the constructed recommendation and its impact on resources and equity. The protocol is registered with the Danish Health Authority.

Findings

We identified 13 RCTs, including 403 patients with a wide range of conditions. Melatonin reduced sleep latency by 14.88 min (95% CI 23.42-6.34, 9 studies, I² = 60%) and increased total sleep time by 18.97 min (95% CI 0.37-37.57, 10 studies, I² = 57%). The funnel plot for total sleep time showed no apparent indication of publication bias. No other clinical benefits were found. The number of patients experiencing adverse events was not statistically increased however, safety data was scarce. Certainty of evidence was low.

Interpretation

Low certainty evidence supports a moderate effect of melatonin in treating sleep continuity parameters in children and adolescents with chronic insomnia due to primarily medical disorders beyond indication. The off-label use of melatonin for these patients should never be the first choice of treatment, but may be considered by medical specialists with knowledge of the underlying disorder and if non-pharmacological interventions are inadequate. If treatment with melatonin is initiated, adequate follow-up to evaluate treatment effect and adverse events is essential.

Funding

The Danish Health Authority. The Parker Institute, Bispebjerg and Frederiksberg Hospital, supported by the Oak Foundation.

Use of melatonin in children and adolescents with idiopathic chronic insomnia: a systematic review, meta-analysis, and clinical recommendation

Background

Melatonin prescriptions for children and adolescents have increased substantially during the last decade. Existing clinical recommendations focus on melatonin as a treatment for insomnia related to neurodevelopmental disorders. To help guide clinical decision-making, we aimed to construct a recommendation on the use of melatonin in children and adolescents aged 5-20 years with idiopathic chronic insomnia.

Methods

A systematic search for guidelines, systematic reviews and randomised controlled trials (RCT) were performed in Medline, Embase, Cochrane Library, PsycInfo, Cinahl, Guidelines International Network, Trip Database, Canadian Agency for Drugs and Technologies in Health, American Academy of Sleep Medicine, European Sleep Research Society and Scandinavian Health Authorities databases. A search for adverse events in otherwise healthy children and adolescents was also performed. The latest search for guidelines, systematic reviews, and adverse events was performed on March 18, 2023. The latest search for RCTs was performed on to February 6, 2023. The language was restricted to English, Danish, Norwegian, and Swedish. Eligible participants were children and adolescents (5-20 years of age) with idiopathic chronic insomnia, in whom sleep hygiene practices have been inadequate and melatonin was tested. There were no restrictions on dosage, duration of treatment, time of consumption, or release formula. Primary outcomes were quality of sleep, daytime functioning and serious adverse events. Secondary outcomes included total sleep time, sleep latency, awakenings, drowsiness, quality of life, all-cause dropouts, and non-serious adverse events. Outcomes were assessed at different time points to assess short-term and long-term effects. Meta-analysis was performed using inverse variance random-effects model and risk of bias was assessed using Cochrane risk of bias tool. If possible, funnel plots would be constructed to investigate publication bias. Heterogeneity was calculated via I² statistics. A multidisciplinary guideline panel formulated the recommendation according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The certainty of evidence was considered either high, moderate, low or very low depending on the extent of risk of bias, inconsistency, imprecision, indirectness, or publication bias. The evidence-to-decision framework was subsequently used to discuss the feasibility and acceptance of the constructed recommendation alongside the impact on resources and equity. The protocol is registered with the Danish Health Authority.

Findings

We included eight RCTs with 419 children and adolescents with idiopathic chronic insomnia. Melatonin led to a moderate increase in total sleep time by 30.33 min (95% confidence interval (CI) 18.96-41.70, 4 studies, I² = 0%) and a moderate reduction in sleep latency by 18.03 min (95% CI -26.61 to -9.44, 3 studies, I² = 0%), both as assessed by sleep diary. No other beneficial effects were found. None of the studies provided information on serious adverse events, yet the number of participants experiencing non-serious adverse events was increased (Relative risk 3.44, 95% CI 1.25-9.42, 4 studies, I² = 0%). Funnel plots were not constructed due to the low number of studies. The certainty of evidence was very low on the quality of sleep and low for daytime functioning.

Interpretation

Evidence of very low certainty shows that benefits are limited and unwanted events are likely when melatonin is used to treat otherwise healthy children and adolescents with chronic insomnia. Melatonin should never be the first choice of treatment for this particular population, yet carefully monitored short-term use may be considered if sleep hygiene practices and non-pharmacological interventions have proven inadequate, and only if daytime function is compromised.

Funding

The Danish Health Authority and the Parker Institute, Bispebjerg and Frederiksberg Hospital supported by the Oak Foundation.

The short-term and long-term adverse effects of melatonin treatment in children and adolescents: a systematic review and GRADE assessment

Background

Currently, melatonin is used to treat children and adolescents with insomnia without knowing the full extent of the short-term and long-term consequences. Our aim was to provide clinicians and guideline panels with a systematic assessment of serious-and non-serious adverse events seen in continuation of melatonin treatment and the impact on pubertal development and bone health following long-term administration in children and adolescents with chronic insomnia.

Methods

We searched PubMed, Embase, Cinahl and PsycINFO via Ovid, up to March 17, 2023, for studies on melatonin treatment among children and adolescents (aged 5-20 years) with chronic insomnia. The language was restricted to English, Danish, Norwegian, and Swedish. Outcomes were non-serious adverse events and serious adverse events assessed 2-4 weeks after initiating treatment and pubertal development and bone health, with no restriction on definition or time of measurement. Observational studies were included for the assessment of long-term outcomes, and serious and non-serious adverse events were assessed via randomised studies. The certainty of the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). The protocol is registered with the Danish Health Authority.

Findings

We identified 22 randomised studies with 1350 patients reporting on serious-and non-serious adverse events and four observational studies with a total of 105 patients reporting on pubertal development. Melatonin was not associated with serious adverse events, yet the number of patients experiencing non-serious adverse events was increased (Relative risk 1.56, 95% CI 1.01-2.43, 17 studies, I² = 47%). Three studies reported little or no influence on pubertal development following 2-4 years of treatment, whereas one study registered a potential delay following longer treatment durations (>7 years). These findings need further evaluation due to several methodological limitations.

Interpretation

Children who use melatonin are likely to experience non-serious adverse events, yet the actual extent to which melatonin leads to non-serious adverse events and the long-term consequences remain uncertain. This major gap of knowledge on safety calls for caution against complacent use of melatonin in children and adolescents with chronic insomnia and for more research to inform clinicians and guideline panels on this key issue.

Funding

The Danish Health Authority. The Parker Institute, Bispebjerg and Frederiksberg Hospital, supported by the Oak Foundation.

Fully Automated Detection of Isolated Rapid-Eye-Movement Sleep Behavior Disorder Using Actigraphy

Isolated rapid-eye-movement (REM) sleep behavior disorder (iRBD) is caused by motor disinhibition during REM sleep and is a strong early predictor of Parkinson's disease. However, screening questionnaires for iRBD lack specificity due to other sleep disorders that mimic the symptoms. Nocturnal wrist actigraphy has shown promise in detecting iRBD by measuring sleep-related motor activity, but it relies on sleep diary-defined sleep periods, which are not always available. Our aim was to precisely detect iRBD using actigraphy alone by combining two actigraphy-based markers of iRBD - abnormal nighttime activity and 24-hour rhythm disruption. In a sample of 42 iRBD patients and 42 controls (21 clinical controls with other sleep disorders and 21 community controls) from the Stanford Sleep Clinic, the nighttime actigraphy model was optimized using automated detection of sleep periods. Using a subset of 38 iRBD patients with daytime data and 110 age-, sex-, and body-mass-index-matched controls from the UK Biobank, the 24-hour rhythm actigraphy model was optimized. Both nighttime and 24-hour rhythm features were found to distinguish iRBD from controls. To improve the accuracy of iRBD detection, we fused the nighttime and 24-hour rhythm disruption classifiers using logistic regression, which achieved a sensitivity of 78.9%, a specificity of 96.4%, and an AUC of 0.954. This study preliminarily validates a fully automated method for detecting iRBD using actigraphy in a general population.Clinical relevance- Actigraphy-based iRBD detection has potential for large-scale screening of iRBD in the general population.

Narcolepsy risk loci outline role of T cell autoimmunity and infectious triggers in narcolepsy

Narcolepsy type 1 (NT1) is caused by a loss of hypocretin/orexin transmission. Risk factors include pandemic 2009 H1N1 influenza A infection and immunization with Pandemrix®. Here, we dissect disease mechanisms and interactions with environmental triggers in a multi-ethnic sample of 6,073 cases and 84,856 controls. We fine-mapped GWAS signals within HLA (DQ0602, DQB1*03:01 and DPB1*04:02) and discovered seven novel associations (CD207, NAB1, IKZF4-ERBB3, CTSC, DENND1B, SIRPG, PRF1). Significant signals at TRA and DQB1*06:02 loci were found in 245 vaccination-related cases, who also shared polygenic risk. T cell receptor associations in NT1 modulated TRAJ*24, TRAJ*28 and TRBV*4-2 chain-usage. Partitioned heritability and immune cell enrichment analyses found genetic signals to be driven by dendritic and helper T cells. Lastly comorbidity analysis using data from FinnGen, suggests shared effects between NT1 and other autoimmune diseases. NT1 genetic variants shape autoimmunity and response to environmental triggers, including influenza A infection and immunization with Pandemrix®.

Effects of Two Physical Activity Interventions on Sleep and Sedentary Time in Pregnant Women

Pregnancy is often associated with poor sleep and high sedentary time (SED). We investigated the effect of physical activity (PA) interventions on sleep and SED in pregnant women. A secondary analysis of a randomized controlled trial (n = 219) explored the effect of structured supervised exercise training (EXE) or motivational counseling on PA (MOT) compared to standard prenatal care (CON) on sleep and SED during pregnancy. Three times during pregnancy, sleep was determined by the Pittsburgh Sleep Quality Index (PSQI) and SED by the Pregnancy Physical Activity Questionnaire (PPAQ). Also, a wrist-worn consumer activity tracker measured sleep and SED continuously. Data from the activity tracker confirmed that sleep time decreases, and SED increases by approx. 30 and 24 min/day, respectively, from baseline (maximum gestational age (GA) week 15) to delivery. Compared to CON, the global PSQI score was better for EXE in GA week 28 (-0.8 [-1.5; -0.1], p = 0.031) and for both EXE and MOT in GA week 34 (-1 [-2; -0.5], p = 0.002; -1 [-2; -0.1], p = 0.026). In GA week 28, SED (h/day) from PPAQ was lower in EXE compared to both CON and MOT (-0.69 [-1; -0.0], p = 0.049; -0.6 [-1.0; -0.02], p = 0.042). In conclusion, PA interventions during pregnancy improved sleep quality and reduced SED.

Automatic scoring of drug-induced sleep endoscopy for obstructive sleep apnea using deep learning

BACKGROUND

Treatment of obstructive sleep apnea is crucial for long term health and reduced economic burden. For those considered for surgery, drug-induced sleep endoscopy (DISE) is a method to characterize location and pattern of sleep-related upper airway collapse. According to the VOTE classification system, four upper airway sites of collapse are characterized: velum (V), oropharynx (O), tongue (T), and epiglottis (E). The degree of obstruction per site is classified as 0 (no obstruction), 1 (partial obstruction), or 2 (complete obstruction). Here we propose a deep learning approach for automatic scoring of VOTE obstruction degrees from DISE videos.

METHODS

We included 281 DISE videos with varying durations (6 s-16 min) from two sleep clinics: Copenhagen University Hospital and Stanford University Hospital. Examinations were split into 5-s clips, each receiving annotations of 0, 1, 2, or X (site not visible) for each site (V, O, T, and E), which was used to train a deep learning model. Predicted VOTE obstruction degrees per examination was obtained by taking the highest predicted degree per site across 5-s clips, which was evaluated against VOTE degrees annotated by surgeons.

RESULTS

Mean F1 score of 70% was obtained across all DISE examinations (V: 85%, O: 72%, T: 57%, E: 65%). For each site, sensitivity was highest for degree 2 and lowest for degree 0. No bias in performance was observed between videos from different clinicians/hospitals.

CONCLUSIONS

This study demonstrates that automating scoring of DISE examinations show high validity and feasibility in degree of upper airway collapse.

Autonomic dysfunction after mild acute ischemic stroke and six months after: a prospective observational cohort study

INTRODUCTION

Autonomic dysfunction is prevalent in ischemic stroke patients and associated with a worse clinical outcome. We aimed to evaluate autonomic dysfunction over time and the tolerability of the head-up tilt table test in an acute stroke setting to optimize patient care.

PATIENTS AND METHOD

In a prospective observational cohort study, patients were consecutively recruited from an acute stroke unit. The patients underwent heart rate and blood pressure analysis during the Valsalva maneuver, deep breathing, active standing, and head-up tilt table test if active standing was tolerated. In addition, heart rate variability and catecholamines were measured. All tests were performed within seven days after index ischemic stroke and repeated at six months follow-up.

RESULTS

The cohort was comprised of 91 acute stroke patients, mean (SD) age 66 (11) years, median (IQR) initial National Institute of Health Stroke Scale 2 (1-4) and modified Ranking Scale 2 (1-3). The head-up tilt table test revealed 7 patients (10%) with orthostatic hypotension. The examination was terminated before it was completed in 15%, but none developed neurological symptoms. In the acute state the prevalence of autonomic dysfunction varied between 10-100% depending on the test. No changes were found in presence and severity of autonomic dysfunction over time.

CONCLUSION

In this cohort study of patients with mild stroke, autonomic dysfunction was highly prevalent and persisted six months after index stroke. Head-up tilt table test may be used in patients who tolerate active standing. Autonomic dysfunction should be recognized and handled in the early phase after stroke.

Experiences of group-based cognitive behavioural therapy for insomnia among patients with rheumatoid arthritis: a qualitative study

OBJECTIVE

Rheumatoid arthritis (RA) is a chronic autoimmune disease, with a prevalence of insomnia disorders in up to 70%. Patients' experiences of participating in group-based cognitive behavioural therapy for insomnia (CBT-I) are sparsely explored, and CBT-I has not been evaluated in patients with RA until now. Therefore, the aim was to explore patients' experiences of CBT-I and how the components of CBT-I were incorporated in sleep management.

DESIGN

We conducted a qualitative study with semi-structured interviews. The interview guide was developed based on CBT-I, with questions that explicitly explored the participants' experiences of sleep education and the behavioural components of CBT-I.

SETTING

Interviews were conducted one-to-one at Center for Rheumatology and Spine Diseases, Copenhagen.

PARTICIPANTS

Patients with RA who had received CBT-I as intervention in a randomised controlled trial (N=11). The analysis was based on a reflexive thematic method.

RESULTS

Five themes were identified (1) When knowledge contributes to an altered perception of sleep, referring to the reduced misperception and increased motivation that followed sleep education, (2) Overcoming habits and perceptions to accelerate sleep onset, referring to barriers related to sleep behaviour and how stimulus control enabled them to find meaningful behaviour, (3) The sleep window of challenges in learning how to sleep right referring to that payoff from sleep restriction did not come easily or by magic, and commitment gave them confidence to continue, (4) Relaxation becomes a behavioural habit and goes beyond sleep, referring to a means to achieve a relaxed body and mind and how they thereby coped better with RA-related symptoms and (5) Break the cycle and regain control referring to how trust in one's own accomplishment was crucial to reducing worrying.

CONCLUSION

The process towards eliminating insomnia was a bodily experience and involved a changed mindset that resulted in an alteration of behaviour and cognitions.

Ambulatory Detection of Isolated Rapid-Eye-Movement Sleep Behavior Disorder Combining Actigraphy and Questionnaire

BACKGROUND

Isolated rapid-eye-movement sleep behavior disorder (iRBD) is in most cases a prodrome of neurodegenerative synucleinopathies, affecting 1% to 2% of middle-aged and older adults; however, accurate ambulatory diagnostic methods are not available. Questionnaires lack specificity in nonclinical populations. Wrist actigraphy can detect characteristic features in individuals with RBD; however, high-frequency actigraphy has been rarely used.

OBJECTIVE

The aim was to develop a machine learning classifier using high-frequency (1-second resolution) actigraphy and a short patient survey for detecting iRBD with high accuracy and precision.

METHODS

The method involved analysis of home actigraphy data (for seven nights and more) and a nine-item questionnaire (RBD Innsbruck inventory and three synucleinopathy prodromes of subjective hyposmia, constipation, and orthostatic dizziness) in a data set comprising 42 patients with iRBD, 21 sleep clinic patients with other sleep disorders, and 21 community controls.

RESULTS

The actigraphy classifier achieved 95.2% (95% confidence interval [CI]: 88.3-98.7) sensitivity and 90.9% (95% CI: 82.1-95.8) precision. The questionnaire classifier achieved 90.6% accuracy and 92.7% precision, exceeding the performance of the Innsbruck RBD Inventory and prodromal questionnaire alone. Concordant predictions between actigraphy and questionnaire reached a specificity and precision of 100% (95% CI: 95.7-100.0) with 88.1% sensitivity (95% CI: 79.2-94.1) and outperformed any combination of actigraphy and a single question on RBD or prodromal symptoms.

CONCLUSIONS

Actigraphy detected iRBD with high accuracy in a mixed clinical and community cohort. This cost-effective fully remote procedure can be used to diagnose iRBD in specialty outpatient settings and has potential for large-scale screening of iRBD in the general population. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Sleep impairments in refugees diagnosed with post-traumatic stress disorder: a polysomnographic and self-report study

Background: Post-traumatic stress disorder (PTSD) is the clinical manifestation of traumatic events and is associated with sleep disturbances. Sleep disturbances, if left untreated, may perpetuate or even worsen symptoms of PTSD. Previous studies of other PTSD populations show a higher incidence of sleep impairments and sleep disorders compared to healthy controls (HCs); however, this has never been investigated in trauma-affected refugees diagnosed with PTSD.Objectives: To examine subjective sleep quality, measure sleep architecture, and identify latent sleep disorders in refugees diagnosed with PTSD compared to HCs.Method: This comparative study included 20 trauma-affected refugees diagnosed with PTSD and 20 HC matched on age, sex, and body mass index. All participants completed self-report questionnaires assessing sleep quality, insomnia severity, and disturbing nocturnal behaviour, and all took part in a one-night polysomnography (PSG) assessment.Results: Patients reported significantly poorer subjective sleep quality, sleep latency, sleep duration, and sleep efficiency compared to HCs. Subjective reports on hours spent in bed were not significantly different between patients and HCs. Patients reported significantly higher nightmare frequency and severity compared to HCs. PSG measures showed that patients had significantly reduced sleep efficiency, more awakenings, and longer REM sleep latency, and spent more time awake, whereas there was no significant differences regarding total time in bed, total sleep time, or sleep latency. The prevalence of sleep disorders was equal between groups.Conclusions: The study identified significant impairments in several sleep domains, with a preponderance of disturbed regulation of sleep resulting in awakenings. These results indicate a need for more focus on hyperarousal and nightmares as key elements of disturbed sleep in PTSD. Furthermore, the study identified a discrepancy between subjective and objective measures concerning total sleep time, raising questions regarding the causes of 'sleep state misperception'.Trial registration: ClinicalTrials.gov identifier: NCT03535636..Trial registration: Sleep Impairments in Refugees Diagnosed with PTSD (PSG-PTSD). URL: https://clinicaltrials.gov/ct2/show/NCT03535636. ClinicalTrials.gov NCT03535636. Date of registration: 24/05/2018.

Survival and long-term socioeconomic consequences of childhood and adolescent onset of brain tumours

AIM

To evaluate survival distributions, long-term socioeconomic consequences, and health care costs in patients with childhood and adolescent onset of brain tumours in a Danish nationwide prospective cohort study.

METHOD

A search of national registries identified 2283 patients (1198 males, 1085 females; mean age 9 years 6 months [SD 5 years 7 months]) diagnosed with a brain tumour between 1980 and 2015 and aged no older than 18 years at diagnosis. These were compared with sex-, age-, and residency-matched comparison individuals. Patients with malignant tumours were compared with those with benign tumours. Survival distributions were estimated by the Kaplan-Meier method and hazard ratio by the Cox proportional hazard model. Socioeconomic data at age 20 and 30 years were assessed.

RESULTS

The probability of mortality was highest during the first year after tumour diagnosis. In young adulthood, the patients were generally less likely to be married, had lower grade-point averages, educational levels, and income, were less likely to be in employment, and had higher health care costs than comparison individuals. Patients with malignant tumours had worse outcomes with respect to education, employment, and health care costs than those with benign tumours.

INTERPRETATION

A diagnosis of brain tumour in childhood and adolescence adversely affects survival and has negative long-term socioeconomic consequences, especially in patients with malignant tumours. These patients require continuous social support.

Associations between treatment with melatonin and suicidal behavior: a nationwide cohort study

STUDY OBJECTIVES

Melatonin is often prescribed to patients with sleep disorders who are known to have elevated suicide risks, yet melatonin's association with suicidal behavior remains to be examined. We investigated whether individuals prescribed melatonin had higher rates of suicide and suicide attempts when compared to individuals who were not prescribed this drug, including both those with and without known mental disorders.

METHODS

A cohort design was applied to longitudinal, register data on all persons aged ≥ 10 years in Denmark during 2007-2016. Based on data from the National Prescription Registry, periods of being in treatment with melatonin were defined using information on the number of tablets and the daily defined dose. We calculated incidence rate ratios for suicide and suicide attempts, as identified in register records, comparing those in treatment with melatonin to those not in treatment.

RESULTS

Among 5,798,923 individuals, 10,577 (0.2%) were treated with melatonin (mean treatment length, 50 days) during the study period. Of those, 22 died by suicide and 134 had at least 1 suicide attempt. People in treatment with melatonin had a 4-fold higher rate of suicide (incidence rate ratio, 4.8; 95% CI, 3.0-7.5) and a 5-fold higher rate of suicide attempt (incidence rate ratio, 5.9; 95% CI, 4.4-8.0) than those not in treatment and when adjusting for sex and age group.

CONCLUSIONS

Treatment with melatonin was associated with suicide and suicide attempt. Although there are several possible explanations, attention to suicide risk is particularly warranted for people with mental comorbidity who are in treatment with melatonin.

CITATION

Høier NK, Madsen T, Spira AP, et al. Associations between treatment with melatonin and suicidal behavior: a nationwide cohort study. J Clin Sleep Med. 2022;18(10):2451-2458.

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

OBJECTIVE

In 2010, a questionnaire-based study on obstructive sleep apnea (OSA) management in Europe identified differences regarding reimbursement, sleep specialist qualification, and titration procedures. Now, 10 years later, a follow-up study was conducted as part of the ESADA (European Sleep Apnea Database) network to explore the development of OSA management over time.

METHODS

The 2010 questionnaire including questions on sleep diagnostic, reimbursement, treatment, and certification was updated with questions on telemedicine and distributed to European Sleep Centers to reflect European OSA management practice.

RESULTS

26 countries (36 sleep centers) participated, representing 20 ESADA and 6 non-ESADA countries. All 21 countries from the 2010 survey participated. In 2010, OSA diagnostic procedures were performed mainly by specialized physicians (86%), whereas now mainly by certified sleep specialists and specialized physicians (69%). Treatment and titration procedures are currently quite homogenous, with a strong trend towards more Autotitrating Positive Airway Pressure treatment (in hospital 73%, at home 62%). From 2010 to 2020, home sleep apnea testing use increased (76%-89%) and polysomnography as sole diagnostic procedure decreased (24%-12%). Availability of a sleep specialist qualification increased (52%-65%) as well as the number of certified polysomnography scorers (certified physicians: 36%-79%; certified technicians: 20%-62%). Telemedicine, not surveyed in 2010, is now in 2020 used in diagnostics (8%), treatment (50%), and follow-up (73%).

CONCLUSION

In the past decade, formal qualification of sleep center personnel increased, OSA diagnostic and treatment procedures shifted towards a more automatic approach, and telemedicine became more prominent.

Listening to music for insomnia in adults

BACKGROUND

Insomnia is a common problem in modern society. It is associated with reduced quality of life and impairments in physical and mental health. Listening to music is widely used as a sleep aid, but it remains unclear if it can actually improve insomnia in adults. This Cochrane Review is an update of a review published in 2015.

OBJECTIVES

To assess the effects of listening to music on sleep in adults with insomnia and to assess the influence of specific variables that may moderate the effect.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE, Embase, nine other databases and two trials registers up to December 2021. In addition, we handsearched reference lists of included studies, and contacted authors of published studies to identify additional studies eligible for inclusion, including any unpublished or ongoing trials.

SELECTION CRITERIA

Randomised controlled trials comparing the effects of listening to music with no treatment or treatment as usual (TAU) in adults complaining of sleep difficulties.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened records for eligibility, selected studies for inclusion, extracted data and assessed risk of bias of the included studies. We assessed the certainty of the evidence using GRADE. The primary outcomes were sleep quality, insomnia severity, sleep-onset latency, total sleep time, sleep interruption, sleep efficiency and adverse events. Data on the predefined outcome measures were included in meta-analyses when consistently reported by at least two studies that were homogeneous in terms of participants, interventions and outcomes. We undertook meta-analyses using random-effects models.

MAIN RESULTS

We included 13 studies (eight studies new to this update) comprising 1007 participants. The studies examined the effect of listening to prerecorded music daily, for 25 to 60 minutes, for a period of three days to three months. The risk of bias within the studies varied, with all studies being at high risk of performance bias, because of limited possibilities to blind participants to the music intervention. Some studies were at high risk of detection bias or other bias. Four studies reported funding from national research councils, three studies reported financial support from university sources and one study reported a grant from a private foundation. Five studies did not report any financial support. At the end of the intervention, we found moderate-certainty evidence for improved sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI) in themusic groups compared to no intervention or TAU (mean difference (MD) -2.79, 95% confidence interval (CI) -3.86 to -1.72; 10 studies, 708 participants). The PSQI scale ranges from 0 to 21 with higher scores indicating poorer sleep. The size of the effect indicates an increase in sleep quality of the size of about one standard deviation in favour of the intervention. We found no clear evidence of a difference in the effects of listening to music compared to no treatment or TAU on insomnia severity (MD -6.96, 95% CI -15.21 to 1.28; 2 studies, 63 participants; very low-certainty evidence). We found low-certainty evidence that, compared to no treatment or TAU, listening to music may reduce problems with sleep-onset latency (MD -0.60, 95% CI -0.83 to -0.37; 3 studies, 197 participants), total sleep time (MD -0.69, 95% CI -1.16 to -0.23; 3 studies, 197 participants) and sleep efficiency (MD -0.96, 95% CI -1.38 to -0.54; 3 studies, 197 participants), but may have no effect on perceived sleep interruption (MD -0.53, 95% CI -1.47 to 0.40; 3 studies, 197 participants). In addition, three studies (136 participants) included objective measures of sleep-onset latency, total sleep time, sleep efficiency and sleep interruption and showed that listening to music may not improve these outcomes compared to no treatment or TAU. None of the included studies reported any adverse events.

AUTHORS' CONCLUSIONS

The findings of this review provide evidence that music may be effective for improving subjective sleep quality in adults with symptoms of insomnia. More research is needed to establish the effect of listening to music on other aspects of sleep as well as the daytime consequences of insomnia.

Age estimation from sleep studies using deep learning predicts life expectancy

Sleep disturbances increase with age and are predictors of mortality. Here, we present deep neural networks that estimate age and mortality risk through polysomnograms (PSGs). Aging was modeled using 2500 PSGs and tested in 10,699 PSGs from men and women in seven different cohorts aged between 20 and 90. Ages were estimated with a mean absolute error of 5.8 ± 1.6 years, while basic sleep scoring measures had an error of 14.9 ± 6.29 years. After controlling for demographics, sleep, and health covariates, each 10-year increment in age estimate error (AEE) was associated with increased all-cause mortality rate of 29% (95% confidence interval: 20-39%). An increase from -10 to +10 years in AEE translates to an estimated decreased life expectancy of 8.7 years (95% confidence interval: 6.1-11.4 years). Greater AEE was mostly reflected in increased sleep fragmentation, suggesting this is an important biomarker of future health independent of sleep apnea.

End-to-end Deep Learning of Polysomnograms for Classification of REM Sleep Behavior Disorder

Rapid eye movement (REM) sleep behavior disorder (RBD) is parasomnia and a prodromal manifestation of Parkinson's disease. The current diagnostic method relies on manual scoring of polysomnograms (PSGs), a procedure that is time and effort intensive, subject to interscorer variability, and requires high level of expertise. Here, we present an automatic and interpretable diagnostic tool for RBD that analyzes PSGs using end-to-end deep neural networks. We optimized hierarchical attention networks in a 5-fold cross validation directly to classify RBD from PSG data recorded in 143 participants with RBD and 147 age-and sex-matched controls. An ensemble model using logistic regression was implemented to fuse decisions from networks trained in various signal combinations. We interpreted the networks using gradient SHAP that attribute relevance of input signals to model decisions. The ensemble model achieved a sensitivity of 91.4 % and a specificity of 86.3 %. Interpretation showed that electroencephalography (EEG) and leg electromyography (EMG) exhibited most patterns with high relevance. This study validates a robust diagnostic tool for RBD and proposes an interpretable and fully automatic framework for end-to-end modeling of other sleep disorders from PSG data. Clinical relevance- This study presents a novel diagnostic tool for RBD that considers neurophysiologic biomarkers in multiple modalities.

Detection of Cheyne-Stokes Breathing using a transformer-based neural network

Annotation of sleep disordered breathing, including Cheyne-Stokes Breathing (CSB), is an expensive and time-consuming process for the clinician. To solve the problem, this paper presents a deep learning-based algorithm for automatic sample-wise detection of CSB in nocturnal polysomnographic (PSG) recordings. 523 PSG recordings were retrieved from four different sleep cohorts and subsequently scored for CSB by three certified sleep technicians. The data was pre-processed and 16 time domain features were extracted and passed into a neural network inspired by the transformer unit. Finally, the network output was post-processed to achieve physiologically meaningful predictions. The algorithm reached a F1-score of 0.76, close to the certified sleep technicians showing that it is possible to automatically detect CSB with the proposed model. The algorithm had difficulties distinguishing between severe obstructive sleep apnea and CSB but this was not dissimilar to technician performance. In conclusion, the proposed algorithm showed promising results and a confirmation of the performance could make it relevant as a screening tool in a clinical setting.

The Association between Sleep Problems and Neuropsychological Deficits in Medication-naïve Children with ADHD

BACKGROUND

Children with ADHD are reported to have sleep problems and neuropsychological deficits, but studies examining a potential association between the two are scarce and the use of varying methodology can complicate conclusions.

PARTICIPANTS

A clinical sample of 59 medication-naïve children with ADHD between the ages of 6 and 14 years (71% male).

METHODS

Children underwent polysomnography and multiple sleep latency test, and parent rated sleep habits on the Children's Sleep Habits Questionnaire. Children also completed an extensive neuropsychological battery of executive function and delay aversion tasks, and parents and teachers rated executive function behavior on the Behavior Rating Inventory of Executive Function. Linear regression analyses were conducted with each of the neuropsychological outcomes included as the outcome variable and the sleep parameters as the predictor variables.

RESULTS

The correlations between sleep and neuropsychological outcomes were generally modest, but some sleep parameters (primarily sleep stages and sleep latencies) were associated with objectively and subjectively measured executive function and delay aversion.

CONCLUSIONS

Using objective and subjective gold standard assessment procedures this study supports a (modest) association between sleep and neuropsychological function in children with ADHD.

Use of hypnotic drugs among Scandinavian children, adolescents, and young adults

Introduction

Hypnotic drug use in children and adolescents is widely debated.

Objectives

To describe use of hypnotic drugs (melatonin, z-drugs and sedating antihistamines) among 5-24-year-old Scandinavians during 2012 to 2018.

Methods

Aggregate-level data from public data sources in Sweden, Norway and Denmark. We calculated annual prevalence (users/1000 inhabitants) stratified by sex, age group and country. Quantity of use (Defined Daily Dose (DDD)/user/day) was estimated for Norway and Denmark.

Results

Melatonin was most frequently used, with an increase from 2012 to 2018 in all countries. Sweden presented the highest rise (7 to 25/1,000) compared to Denmark (6 to 12/1,000) and Norway (10 to 20/1,000). The increase was strongest for females and 15-24-year-olds. Melatonin use was twice as common for males under age 15 years, and slightly more common for females thereafter. The annual prevalence of sedating antihistamine use doubled from 7 to 13/1,000 in Sweden, whereas it was more stable in Norway and Denmark, reaching 8/1,000 and 3/1,000, respectively. Z-drug use decreased in all countries, lowering to 4/1,000 in Sweden and Norway in 2018 and 2/1,000 in Denmark. The quantity of hypnotic use in Norway and Denmark was 1 DDD/user/day for melatonin, as compared to 0.1-0.3 for z-drugs and antihistamines.

Conclusions

There is an increasing use of melatonin and sedating antihistamines among Scandinavian children, adolescents and young adults. The increase is more pronounced in Sweden compared to Norway and Denmark. This Scandinavian discrepancy could reflect variation in frequency of sleep problems or national variation in clinical practice or health care access.

Disclosure

No significant relationships.

OP0295-HPR THE EFFECT OF GROUP-BASED COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA IN PATIENTS WITH RHEUMATOID ARTHRITIS: A RANDOMISED CONTROLLED TRIAL

Background

Insomnia is highly prevalent in patients with rheumatoid arthritis (RA) and may exacerbate symptoms and burdens, such as fatigue, depressive symptoms, and pain1. Cognitive behavioural therapy for insomnia (CBT-I) has been shown to produce positive effects on sleep in other clinical populations2,3. However, CBT-I has not previously been investigated in patients with RA.

Objectives

The primary objective was to compare the effect of nurse-led group-based CBT-I to usual care on sleep efficiency, measured by polysomnography (PSG) immediately after the intervention (i.e. seven weeks after baseline) in patients with RA. Secondary objectives included comparing the longer-term effect of CBT-I on sleep and RA-related outcomes at 26 weeks’ follow-up.

Methods

In a randomised controlled trial, using a parallel group design, the experimental intervention was six weeks’ CBT-I; the control comparator was usual care. CBT-I was delivered face-to-face by a CBT-I trained nurse. The primary analyses were based on the intention-to-treat (ITT) population; missing data were statistically handled using repeated-measures linear mixed effects models adjusted for the level at baseline.

Results

The ITT population consisted of 62 patients (89% women), with an average age of 58 years (SD 10), DAS28-CRP of 3.4 (SD 1.0), Insomnia Severity Index (ISI) score of 18.9 (SD 4.4) and median Patient Global Assessment score of 55 (IQR 28;71).

When primary outcome was measured by PSG at week seven, sleep efficiency was 88.7% in the CBT-I group, compared to 83.7% in the control group (difference: 5.0 [95% CI -0.4 to 10.4]; p=0.068) (See Table 1). Secondary outcomes measured by PSG had not improved at week 26 either. However, for all secondary sleep and RA-related patient-reported outcomes, there were statistically highly significant differences between CBT-I and usual care e.g. insomnia (ISI: -9.8 [95% CI -11.8 to -7.9]), RA impact of disease (RAID: -1.4 [95% CI-1.9 to -0.80]) and Patient Global Assessment (-13.0 [95% CI -20.9 to -5.1]) at 26 weeks’ follow-up.

Table 1.

Primary and key secondary outcomes at week 7 and week 26, and differences between treatment groups (based on the ITT population)

CBT-I n=31Usual care n=31Difference between groups (95% CI)P-valueAt week 7Sleep efficiency (PSG, %)188.7 (1.8)83.7 (2.0)5.0 (-0.4 to 10.4)0.068At week 26Sleep efficiency (PSG, %)84.8 (1.9)86.3 (2.0)-1.5 (-7.0 to 3.9)0.577Total sleep time (PSG, minutes)376.5 (11.8)394.6 (12.8)-18.1 (-52.5 to 16.4)0.302Sleep onset latency (PSG, minutes)14.2 (2.2)10.0 (2.4)4.2 (-2.2 to 10.7)0.197Wake after sleep onset (PSG, minutes)52.1 (10.7)41.5 (11.6)10.6 (-20.7 to 41.9)0.505Insomnia severity (ISI 0-28)27.6 (0.7)17.4 (0.7)-9.8 (-11.8 to -7.9)<0.0001Sleep quality global (PSQI 0-21)35.9 (0.5)11.1 (0.5)-5.2 (-6.6 to -3.8)<0.0001Fatigue (BRAF-MDQ 0-70)424.0 (1.4)36.4 (1.5)-12.4 (-16.5 to -8.4)<0.0001RA impact of disease (RAID 0-10)54.2 (0.20)5.5 (0.20)-1.4 (-1.9 to -0.80)<0.0001Depressive symptoms (HADS-D 0-21)63.8 (0.5)6.5 (0.5)-2.7 (-4.1 to -1.3)<0.0001

Values are reported as least squares means (standard errors) by group, while the differences between groups are reported with 95% confidence intervals.

1Polysomnography, 2Insomnia Severity Index, 3Pittsburgh Sleep Quality Index, 4Bristol Rheumatoid Arthritis Fatigue - Multidimensional Questionnaire, 5Rheumatoid Arthritis Impact of Disease, 6Hospital Anxiety and Depression Scale - Depression.

Conclusion

Nurse-led, group-based CBT-I for two hours per week for six weeks, did not improve objectively measured sleep efficiency or any other outcomes measured by PSG. However, CBT-I showed long-term improvement on patient-reported outcomes such as fatigue, impact of disease, depression, pain, and Patient Global Assessment – a finding that could have important clinical implications.

References

[1]PMID: 25620673

[2]PMID: 16804151

[3]PMID: 26434673

Acknowledgements

We thank the participants for their time and commitment and the patient research partners for valuable insight into the process and content of the trial.

Disclosure of Interests

None declared

The association between melatonin and suicide: a nationwide cohort study

Introduction

Melatonin is often prescribed to patients experiencing sleep disturbances, which has been linked to elevated risks of suicide. However, it remains to be assessed whether melatonin is associated with suicide and suicide attempts.

Objectives

We aimed to investigate whether individuals in treatment with melatonin had higher rates of suicide and suicide attempt when compared to individuals not in treatment.

Methods

Using longitudinal data on all persons aged 10+ years living in Denmark between 2007-2016 were obtained. Data from the National Prescription Register was used to identify periods of being in treatment with melatonin based on number of tablets and daily defined dose. Suicide and suicide attempt were identified in hospital and cause of death registries.

Results

Among 5,798,923 included individuals, 10,577 (0.18%) were in treatment with melatonin (mean treatment length 50 days). Out of 5,952 individuals who died by suicide, 22 (0.37%) were in melatonin treatment, while 134 (0.53%) out of 25,136 had a first suicide attempt. After adjustment for sex and age-group, people in treatment with melatonin were found to have a higher rate of suicide (IRR: 4.2; 95% CI, 2.7-6.4) and suicide attempt (IRR: 6.7-fold (95% CI, 5.7-7.9) when compared to those not in treatment.

Conclusions

Treatment with melatonin was associated with higher rates of suicide and suicide attempt. The association might be explained through mediators, such as psychiatric comorbidity and sleep disorders. Our findings indicate that attention towards these issues might be warranted.

Disclosure

No significant relationships.

OP0116-HPR PATIENTS’ EXPERIENCES OF GROUP-BASED COGNITIVE BEHAVIOURAL THERAPY FOR INSOMNIA IN PATIENTS WITH RHEUMATOID ARTHRITIS: A QUALITATIVE STUDY

Background

Despite disease-modifying anti-rheumatic drugs, residual arthritis-related symptoms and burdens are still common in patients with rheumatoid arthritis (RA)1. In addition, insomnia – characterised by reduced sleep quantity and quality – is highly prevalent, occurring in up to 70% of patients with RA2. Insomnia is associated with increased pain, fatigue, and depressive symptoms. Cognitive behavioural therapy for insomnia (CBT-I) is recommended first-line treatment for chronic insomnia3 but has not been evaluated in patients with RA until now.

Objectives

The objective of this study was to explore patients’ experiences of CBT-I and how the components of CBT-I are incorporated in their sleep management.

Methods

Participants were patients with RA who had received CBT-I as experimental treatment for insomnia in a randomised controlled trial (RCT)4. Data were collected during an individual face-to-face interview using a semi-structured interview guide. The analysis was based on reflexive thematic method by Braun and Clarke5.

Results

Eleven participants (10 women and one man) from the intervention group of the RCT were interviewed. Prior to inclusion in the RCT, they had insomnia complaints for 8 years (median; interquartile range: 3;20 years).

Five themes emerged: 1) When knowledge contributes to an altered perception of sleep referring to the reduced misperception and increased motivation that followed sleep education, 2) Overcoming habits and perceptions to accelerate sleep onset referring to barriers related to sleep behaviour and mindset and how stimulus control was enabling them to find meaningful behaviour and rhythm, 3) The sleep window of challenges in learning how to sleep right referring to that payoff from sleep restriction did not come easily or by magic, and commitment led to progress and gave them confidence to continue, 4) Relaxation becomes a behavioural habit and goes beyond sleep referring to a means to achieve a relaxed body and mind and how they thereby coped better with RA-related symptoms, and 5) Break the cycle and regain control referring to how awareness of a vicious cycle was central to their perception of sleep and how trust in one’s own accomplishment was crucial to reducing worrying (See Figure 1).

Figure 1.

The five themes with quotes from participants

Overall, the participants experienced CBT-I as challenging and demanding but at the same time meaningful. The participants considered persistency, stringency, and inflexibility necessary to succeed. After the intervention, the participants had continued using those components that enabled them individually to further improve their sleep.

Conclusion

The process towards eliminating insomnia was a bodily experience and involved a changed mindset that altered behaviour and cognitions.

References

[1]PMID: 29251034

[2]PMID: 25620673

[3]PMID: 28875581

[4]PMID: 32471477

[5]https://doi.org/10.1080/2159676X.2019.1628806

Acknowledgements

The authors thank the participants for generously sharing their experiences and the patient research partners for invaluable perspectives and contributions.

Disclosure of Interests

None declared

The association between benzodiazepine and non-benzodiazepine and suicide: a nationwide cohort study

Introduction

Benzodiazepines and non-benzodiazepines have been linked to a variety of adverse effects including addiction. Long term use of these drugs has been associated with an increased risk of suicide.

Objectives

We assessed if individuals in treatment with non-benzodiazepine (n-BZD) and benzodiazepine (BZD) had higher rates of suicide when compared to individuals not in treatment with these drugs.

Methods

We utilized a cohort design and national longitudinal data on all individuals aged 10 or above who lived in Denmark between 1995 and 2018. Treatment with either n-BZD or BZD was identified via the Danish National Prescription Registry and suicide deaths were identified in the national cause of death registries.

Results

In a total of 6,494,206 individuals, 10,862 males and 4,214 females died by suicide. Of these, 1,220 (11.2%) males and 792 (18.8%) females had been in treatment with n-BZD, resulting in adjusted IRR for suicide of 4.2 (95% CI, 4.0 – 4.5) and 3.4 (95% CI, 3.1 – 3.7) for males and females, respectively, when compared to those not in treatment. In all, 529 (4.8%) males and 395 (9.3%) females who died by suicide had been in treatment with BZD. The IRRs for suicide were 2.4 (95% CI, 2.2 – 2.6) and 2.5 (95% CI, 2.3 – 2.8) for males and females, respectively, and compared to those not in treatment.

Conclusions

In this study we find that those in treatment experienced higher suicide rates than those not in treatment, this persisted when also adjusting for a large variety of covariates.

Disclosure

No significant relationships.

0553 At-home Detection of REM Sleep Behavior Disorder using a Machine Learning Approach and Wrist Actigraphy

Introduction

Isolated rapid-eye-movement (REM) sleep behavior disorder (iRBD) affects over 1% of middle-aged and older adults and is in most cases a prodromal stage of alpha-synucleinopathy. However, a small fraction of them is currently diagnosed due to poor access to the gold-standard diagnostic procedure polysomnography (PSG). We aimed to test an ambulatory diagnostic procedure for iRBD based on wrist actigraphy alone and combined with a short questionnaire on nonmotor symptoms.

Methods

A total of 35 PSG-confirmed iRBD and 28 age-matched clinic and community control participants with and without a sleep disorder (1:1 ratio) wore high-frequency (25 Hz) wrist actigraphy for at least 7 nights and completed sleep diaries. Raw accelerometer data recorded during sleep was analyzed by deriving an activity count and extracting movement-related features for each night. Additionally, participants completed the Innsbruck RBD inventory (RBD-I) and a 3-item questionnaire on hyposmia, constipation, and orthostasis. We fitted machine learning models, specifically, boosted decision trees, in a leave-one-out cross-validation framework to classify iRBD patients from controls based on either actigraphy or questionnaire data. For each participant, model predictions from actigraphy were averaged across all available nights.

Results

The boosted decision trees classified iRBD with an area under the receiver-operator-characteristics (ROC) curve (AUC) of 0.972, a sensitivity of 97.1%, and a specificity of 89.3%. Analyses revealed that performance plateaued after one week of actigraphy. Best single feature “short immobile bursts” achieved an AUC of 0.958, a sensitivity of 94.3%, and a specificity of 78.6%. In this population, RBD-I item 3 best discriminated between groups with an AUC of 0.892, a sensitivity of 91.4%, and a specificity of 85.7%. The combination of a positive RBD-I item 3 and a positive actigraphy-based classification achieved a sensitivity of 88.6% and a specificity of 96.4%.

Conclusion

High-frequency actigraphy using machine learning detects iRBD with high accuracy. Addition of a single RBD question to this procedure increased specificity. These results need to be validated in a larger sample and lay the groundwork for an ambulatory screening paradigm in the general population.

Support (If Any)

The Klarman Family Foundation and the Feldman Foundation Ca.

0319 Age Estimation from Sleep using Deep Learning Predicts Life Expectancy

Introduction

Sleep disturbances increase with age and are predictors of mortality. However, summary metrics typically derived in sleep clinics from gold standard clinical analysis of polysomnograms (PSGs) only represent a very small fraction of data collected. In this study, we designed deep neural networks that estimate age as a proxy for overall health using full PSG signals. Age estimation was next used to evaluate association to mortality risk.

Methods

Aging was modeled using 2,500 PSGs and tested in 10,808 PSGs from men and women in 7 different cohorts aged between 20 and 90. The deep neural network was trained using as a regression model of age in the 2,500 PSGs roughly uniformly distributed across 6 to 90 years. The estimates of the network were interpreted using Gradient SHAP, which attributes relevance scores to the input in terms of the age estimate. The association between age estimate error (AEE), which is the residual of the estimate, and mortality risk was investigated with Cox proportional hazards models that adjusted for demographics, sleep, and health covariates.

Results

Ages were estimated with a mean absolute error of 5.81 ± 1.18 years, while a linear regression model using basic sleep scoring measures had an error of 15.10 ± 6.48 years. Interpretation of the network revealed that patterns such as arousal, sleep apnea, and sleep stage transitions contribute to the age estimate. Each 10-year increment in AEE was associated with increased all-cause mortality rate of 28 % (95% confidence interval: 19–38 %) and cardiovascular mortality rate of 38 % (95% confidence interval: 19 – 59 %). An increase from -10 to +10 years in AEE translates to an estimated decreased life expectancy of 6.21 years (95% confidence interval: 4.31–8.21 years).

Conclusion

Greater AEE was mostly reflected in increased sleep fragmentation, suggesting this is an important biomarker of future health independent of sleep apnea.

Support (If Any)

The Klarman Family Foundation and grants HL46380, M01 RR00080-39, T32-HL07567, RO1-46380, U01HL53916, U01HL53931, U01HL53934, U01HL53937, U01HL64360, U01HL53938, U01HL53940, U01HL53941, U01HL63463, 38-PM-07, R01HL62252, R01AG036838, R01AG058680, 1UL1RR025011, U01AG027810, U01AG042124, U01AG042139, U01AG042140, U01AG042143, U01AG042145, U01AG042168, U01AR066160, UL1TR000128, R01HL071194, R01HL070848, R01HL070847, R01HL070842, R01HL070841, R01HL070837, R01HL070838, R01HL070839, R24HL114473, and 75N92019R002.

Video-polysomnography procedures for diagnosis of rapid eye movement sleep behavior disorder (RBD) and the identification of its prodromal stages: guidelines from the International RBD Study Group

Video-polysomnography (v-PSG) is essential for diagnosing rapid eye movement (REM) sleep behavior disorder (RBD). Although there are current American Academy of Sleep Medicine standards to diagnose RBD, several aspects need to be addressed to achieve harmonization across sleep centers. Prodromal RBD is a stage in which symptoms and signs of evolving RBD are present, but do not yet meet established diagnostic criteria for RBD. However, the boundary between prodromal and definite RBD is still unclear. As a common effort of the Neurophysiology Working Group of the International RBD Study Group, this manuscript addresses the need for comprehensive and unambiguous v-PSG recommendations to diagnose RBD and identify prodromal RBD. These include: (1) standardized v-PSG technical settings; (2) specific considerations for REM sleep scoring; (3) harmonized methods for scoring REM sleep without atonia; (4) consistent methods to analyze video and audio recorded during v-PSGs and to classify movements and vocalizations; (5) clear v-PSG guidelines to diagnose RBD and identify prodromal RBD. Each section follows a common template: The current recommendations and methods are presented, their limitations are outlined, and new recommendations are described. Finally, future directions are presented. These v-PSG recommendations are intended for both practicing clinicians and researchers. Classification and quantification of motor events, RBD episodes, and vocalizations are however intended for research purposes only. These v-PSG guidelines will allow collection of homogeneous data, providing objective v-PSG measures and making future harmonized multicentric studies and clinical trials possible.

Welfare consequences of early-onset Borderline Personality Disorder: a nationwide register-based case-control study

Information regarding welfare consequences of early onset of Borderline Personality Disorder (BPD) is limited. This nationwide study aimed to estimate the educational and employment outcome and health care costs of patients with early-onset BPD compared with matched controls. All patients (< 19 years) with first diagnosis of BPD in the Danish Patient Register (NPR) during the period 1983-2015 were included. Health care costs and socioeconomic variables were extracted from national registers. A total of 171 patients was compared with 677 controls. At the age of 20 years, BPD patients had reached a statistically significantly lower educational level (including lower primary school grades) and employment status compared with the controls. When adjusting for the parents' educational level, BPD patients were nearly 22 times more likely to be unemployed (OR = 21.7, 95% CI 11.9, 39.6), and nearly 15 times more likely to be on disability pension (OR = 14.8, 95% CI 5.0, 43.9) than controls. Furthermore, the total health care costs were more than 8 times higher in the BPD group. Early onset of BPD was associated with lower educational and vocational outcome and increased health care costs as early as at the age of 20 years. Even after controlling for parents' lower socioeconomic status, the patients have poorer outcome than the control group. This underlines that initiatives to support patients in finishing school and secondary education is highly needed. Future prevention and early intervention programs should target patients with early-onset BPD and their families.

Efficacy and Acceptability of Intermittent Aerobic Exercise on Polysomnography-Measured Sleep in People With Rheumatoid Arthritis With Self-Reported Sleep Disturbance: A Randomized Controlled Trial

Objective

This study's objective was to investigate the efficacy and acceptability of intermittent aerobic exercise training on sleep parameters, fatigue, pain, depressive symptoms, physical function, and cardiorespiratory fitness in people with rheumatoid arthritis (RA).

Methods

Thirty‐eight people with RA were assigned to intermittent aerobic exercise training (three sessions/week for 6 weeks; intervention group, n = 17) or usual care (control group, n = 21). The primary outcome was a change in polysomnography‐assessed sleep efficiency from baseline to the end of the intervention. Secondary outcomes were sleep quality (Pittsburgh Sleep Quality Index), fatigue (Bristol Rheumatoid Arthritis Fatigue Multi‐Dimensional Questionnaire), depression (Center for Epidemiological Studies‐Depression), and cardiorespiratory fitness (watt max test).

Results

No between‐group differences were found in changes in polysomnography‐assessed sleep efficiency (0.04; 95% confidence interval [CI]: −0.02 to 0.09, P = 0.17). In the intervention group, sleep efficiency was improved significantly from baseline (0.84; 95% CI: 0.80‐0.88) compared with the end of the intervention (6 weeks) (0.88; 95% CI: 0.85‐0.92); however, there was no significant difference in the control group. Fatigue and depression measures were significantly lower in the intervention group than in the control group. Between‐group differences were overall fatigue (−16.1; 95% CI: −25.1 to −7.0, P = 0.001), physical fatigue (−5.0; 95% CI: −7.3 to −2.7, P = 0.0001), cognitive fatigue (−2.4; 95% CI: −4.2 to 0.6, P = 0.009), living with fatigue (−2.5; 95% CI: −4.5 to −0.5, P = 0.01), and depressive symptoms (−6.8; 95% CI: −12.4 to −1.1, P = 0.02).

Conclusion

The intervention yielded no significantly better sleep efficiency compared with usual care. However, aspects of fatigue, including physical and cognitive fatigue, and depressive symptoms were significantly improved in the intervention group.

Genetic risk for subjective reports of insomnia associates only weakly with polygraphic measures of insomnia in 2,770 adults

STUDY OBJECTIVES

Subjective insomnia complaints and objective sleep changes are mostly studied outside of clinical trial studies. In this study, we tested whether 240 genetic variants associated with subjectively reported insomnia were also associated with objective insomnia parameters extracted from polysomnographic recordings in three studies.

METHODS

The study sample (total n = 2,770) was composed of the Wisconsin Sleep Cohort (n = 1,091) and the Osteoporotic Fractures in Men (n = 1,026) study, two population-based studies, and the Stanford Sleep Cohort, a sleep center patient-based sample (n = 653). Seven objective polysomnographic features related to insomnia defined outcome variables, with each variant allele serving as predictor. Meta-regression was performed, accounting for common confounders as well as variance differences between studies. Additionally, a normalized genetic risk score was generated for each subject to serve as a predictor variable in separate linear mixed models assessing objective insomnia features.

RESULTS

After correction for multiple testing, single-nucleotide polymorphisms associated with subjective insomnia were not significantly associated with 6 of 7 objective sleep measures. Only periodic limb movement index was significantly associated with rs113851554 (MEIS1), as found in previous studies. The normalized genetic risk score was only weakly associated with arousal index and duration of wake after sleep onset.

CONCLUSIONS

Our findings suggest that subjective insomnia does not have a strong genetic signature mapping onto objective (polysomnographic) sleep variables.

CITATION

Foldager J, Peppard PE, Hagen EW, et al. Genetic risk for subjective reports of insomnia associates only weakly with polygraphic measures of insomnia in 2,770 adults. J Clin Sleep Med. 2022;18(1):21-29.

Brain tumours in children and adolescents may affect the circadian rhythm and quality of life

AIM

Children with brain and cervical medulla tumours may experience circadian abnormalities and poor health. We aimed to examine their circadian rhythm, fatigue and quality of life (QoL).

METHODS

Children with a brain or cervical medulla tumour were recruited from the Paediatric Department, Rigshospitalet, Copenhagen, Denmark, between 2016 and 2020. They were grouped by tumour location involving the circadian regulatory system, defined as diencephalon, pineal gland, brain stem and cervical medulla, or other areas. Saliva melatonin and cortisol concentrations were measured. Sleep diaries and actigraphy assessed sleep-wake patterns. The Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale and Generic Core Scale measured fatigue and QoL.

RESULTS

We included 68 children (62% males) with a median age (25th-75th percentiles) of 12.2 (7.7-16.3) years. Children with tumours involving the circadian regulatory system typically had a lower melatonin peak (p=0.06) and experienced significantly more fatigue and poorer QoL. Low melatonin profiles were observed in 31% and 4% had a phase-shifted daytime peak, compared with 14% and 0%, respectively, in children with tumours located elsewhere. Children with low melatonin profiles had significantly lower inter-daily stability than those with normal profiles.

CONCLUSION

Tumours involving the circadian regulatory system adversely affected circadian function, fatigue and QoL.

Sleep-Disordered Breathing is frequently associated with idiopathic normal pressure hydrocephalus but not other types of hydrocephalus

STUDY OBJECTIVES

Previous studies have shown sleep-disordered breathing (SDB) to be highly prevalent in patients with idiopathic normal pressure hydrocephalus (iNPH). The current study aimed to estimate and compare the prevalence of SDB in patients with different types of hydrocephalus and test if SDB was associated with changed CO2.

METHODS

We investigated the prevalence of SDB in a prospective cohort of 48 hydrocephalus patients with nocturnal polysomnography (PSG). Twenty-three of the patients also had simultaneous CO2 measurements.

RESULTS

The prevalence of SDB was high in patients with iNPH, with moderate-to-severe SDB in 21/22 (96%) of the patients and an apnea-hypopnea index (AHI) of 43.5 (95% CI 33.8-52.2). Patients with pediatric-onset hydrocephalus had moderate-to-severe SDB in 7/16 (44%), with an AHI of 16.1 (95% CI 8.16-23.8). Except for one patient, all patients with adult-onset obstructive hydrocephalus (9/10) had normal respiration or mild SDB with an AHI of 8.4 (95% CI 5.5-10.5). None of the 23 patients measured with CO2 had elevated CO2 associated with SDB and had normal CO2 during sleep, with 40.8 ± 5.5 mmHg, 42.7 ± 4.1 mmHg, 34.5-45.8 mmHg for patients with iNPH, pediatric-onset, and adult-onset, respectively.

CONCLUSION

We found a high prevalence of SDB in patients with iNPH, confirming previous findings. We extended this with the finding that the prevalence of SDB in patients with other types of hydrocephalus is not significantly different from that in the general population. Additionally, we did not find elevations of CO2 associated with SDB or CO2 retention during sleep.

Polysomnographic Plethysmography Excursions are Reduced in Obese Elderly Men

Sleep apnea is a widespread disorder and is defined by the complete or partial cessation of breathing. Obstructive sleep apnea (OSA) is caused by an obstruction in the upper airway while central sleep apnea (CSA) is characterized by a diminished or absent respiratory effort. It is crucial to differentiate between these respiratory subtypes as they require radically different treatments. Currently, diagnostic polysomnography (PSG) is used to determine respiratory thoracic and abdominal movement patterns using plethysmography belt signals, to distinguish between OSA and CSA. There is significant manual technician interrater variability between these classifications, especially in the evaluation of CSA. We hypothesize that an increased body mass index (BMI) will cause decreased belt signal excursions that increase false scorings of CSA. The hypothesis was investigated by calculating the envelope as a continuous signal of belt signals in 2833 subjects from the MrOS Sleep Study and extracting a mean value of each of the envelopes for each subject. Using linear regression, we found that an increased BMI was associated with lower excursions during REM sleep (-0.013 [mV] thoracic and -0.018 [mV] abdominal, per BMI) and non-REM (-0.014 [mV] thoracic and -0.012 [mV] abdominal, per BMI). We conclude that increased BMI leads to lower excursions in the belt signals during event-free sleep, and that OSA and CSA events are harder to distinguish in subjects with high BMI. This has a major implication for the correct identification of CSA/OSA and its treatment.

Automatic Segmentation to Cluster Patterns of Breathing in Sleep Apnea

Annotation of polysomnography (PSG) recordings for diagnosis of obstructive sleep apnea (OSA) is a standard procedure but an expensive and time-consuming process for clinicians. To aid clinicians in this process we present a data driven unsupervised hierarchical clustering approach for detection and visual presentation of breathing patterns in PSG recordings. The aim was to develop a model independent of manual annotations to detect and visualize respiratory events related to OSA. 10 recordings from the Sleep Heart Health Study database were used, and the proposed algorithm was evaluated based on the manually annotated events for each recording. The algorithm reached an F1-score of 0.58 across the 10 recordings when detecting the presence of an event vs. no event and a 100% correct diagnosis prediction of OSA when predicting if apnea-hypopnea index (AHI) ≥ 15, which is a clinically meaningful cut-off. The F1-score may be due to imprecise placement of events, difficulty distinguishing between hypopneas and stable breathing, and variations in scoring. In conclusion the performance can be improved despite the strong agreement in diagnostics. The method is a proof of concept that a clustering method can detect and visualize breathing patterns related to OSA while maintaining a correct diagnosis.

Upper Airway Classification in Sleep Endoscopy Examinations using Convolutional Recurrent Neural Networks. Annu Int Conf IEEE Eng Med Biol Soc 2021;2021:3957-3960. [PMID: 34892097 DOI: 10.1109/embc46164.2021.9630098]

Assessing the upper airway (UA) of obstructive sleep apnea patients using drug-induced sleep endoscopy (DISE) before potential surgery is standard practice in clinics to determine the location of UA collapse. According to the VOTE classification system, UA collapse can occur at the velum (V), oropharynx (O), tongue (T), and/or epiglottis (E). Analyzing DISE videos is not trivial due to anatomical variation, simultaneous UA collapse in several locations, and video distortion caused by mucus or saliva. The first step towards automated analysis of DISE videos is to determine which UA region the endoscope is in at any time throughout the video: V (velum) or OTE (oropharynx, tongue, or epiglottis). An additional class denoted X is introduced for times when the video is distorted to an extent where it is impossible to determine the region. This paper is a proof of concept for classifying UA regions using 24 annotated DISE videos. We propose a convolutional recurrent neural network using a ResNet18 architecture combined with a two-layer bidirectional long short-term memory network. The classifications were performed on a sequence of 5 seconds of video at a time. The network achieved an overall accuracy of 82% and F1-score of 79% for the three-class problem, showing potential for recognition of regions across patients despite anatomical variation. Results indicate that large-scale training on videos can be used to further predict the location(s), type(s), and degree(s) of UA collapse, showing potential for derivation of automatic diagnoses from DISE videos eventually.

Cannabidiol versus risperidone for treatment of recent-onset psychosis with comorbid cannabis use: study protocol for a randomized controlled clinical trial

BACKGROUND

Cannabis use is an important risk factor for development of psychosis and further transition to schizophrenia. The prevalence of patients with psychosis and comorbid cannabis use (dual diagnosis) is rising with no approved specialized pharmacological treatment option. Cannabidiol, a constituent of the Cannabis sativa plant, has potential both as an antipsychotic and as a cannabis substituting agent. The aim of this study is to evaluate the efficacy of cannabidiol versus a first-choice second-generation antipsychotic (risperidone) in patients with early psychosis and comorbid cannabis use.

METHODS

The study is a phase II randomized, double-blinded, parallel-group, active-comparator clinical trial. We plan to include 130 patients aged between 18 and 64 years with a recent diagnosis of psychosis, comorbid cannabis use, and currently not treated with antipsychotics. The participants will be randomized to seven weeks of treatment with either cannabidiol 600 mg (300 mg BID) or risperidone 4 mg (2 mg BID). Participants will undergo clinical assessment after 1, 3, 5 and 7 weeks, telephone assessment the weeks in between, and a safety visit two weeks after end of treatment. The primary outcomes are cessation of cannabis use (self-reported) and psychotic symptom severity. The secondary outcomes include frequency and quantity of cannabis use, global illness severity, psychosocial functioning, subjective well-being, cognition, sleep, circadian rhythmicity, and metabolomics.

DISCUSSION

The results of this trial can potentially contribute with a new treatment paradigm for patients suffering from dual diagnosis.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04105231 , registered April 23rd, 2021.

Arousal Characteristics in Patients with Parkinson's Disease and Isolated Rapid Eye Movement Sleep Behavior Disorder

STUDY OBJECTIVES

Patients diagnosed with isolated rapid eye movement (REM) sleep behavior disorder (iRBD) and Parkinson's disease (PD) have altered sleep stability reflecting neurodegeneration in brainstem structures. We hypothesize that neurodegeneration alters the expression of cortical arousals in sleep.

METHODS

We analyzed polysomnography data recorded from 88 healthy controls (HC), 22 iRBD patients, 82 de novo PD patients without RBD and 32 with RBD (PD+RBD). These patients were also investigated at a 2-year follow-up. Arousals were analyzed using a previously validated automatic system, which used a central EEG lead, electrooculography, and chin electromyography. Multiple linear regression models were fitted to compare group differences at baseline and change to follow-up for arousal index (ArI), shifts in electroencephalographic signals associated with arousals, and arousal chin muscle tone. The regression models were adjusted for known covariates affecting the nature of arousal.

RESULTS

In comparison to HC, patients with iRBD and PD+RBD showed increased ArI during REM sleep and their arousals showed a significantly lower shift in α-band power at arousals and a higher muscle tone during arousals. In comparison to HC, the PD patients were characterized by a decreased ArI in NREM sleep at baseline. ArI during NREM sleep decreased further at the 2-year follow-up, although not significantly.

CONCLUSIONS

Patients with PD and iRBD present with abnormal arousal characteristics as scored by an automated method. These abnormalities are likely to be caused by neurodegeneration of the reticular activation system due to alpha-synuclein aggregation.