Abstract 5660: IGM-7354, an immunocytokine with IL-15 fused to an anti-PD-L1 IgM, induces NK and CD8+ T cell mediated cytotoxicity of PD-L1-positive tumor cells

Immunostimulatory cytokines are a promising immunotherapy for the treatment of advanced malignancies, but generally have been associated with severe toxicities when administered systemically. The recent development of antibody-cytokine fusion proteins, or immunocytokines, aims to localize cytokine activity to the tumor microenvironment and thus improve their therapeutic index. We have developed IGM-7354, a high affinity, high avidity anti-PD-L1 pentameric IgM antibody with an IL-15Rα chain and IL-15 fused to the joining (J) chain. The IGM-7354 immunocytokine was designed to deliver IL-15-mediated stimulation of NK and CD8+ T cells to PD-L1-expressing tumors and antigen-presenting cells, to enhance anti-tumor immune responses. The multivalent binding of IGM-7354 to PD-L1 provided a stronger binding avidity for human PD-L1 than the monovalent binding of IL-15 to IL-15Rb as confirmed in kinetic binding assays. In vitro IGM-7354 induced the proliferation of a cytotoxic T cell line responsive to IL-15 stimulation and enhanced the proliferation of NK and CD8+ T cells from healthy donor human PBMCs. In cytotoxicity assays with human PBMC and PD-L1+ cancer cell lines, IGM-7354 enhanced cancer cell killing through NK and CD8+ T cell expansion and cytotoxic activity, evidenced by Ki67 and Granzyme B upregulation in these cell populations. Next, in vivo pharmacodynamic studies were performed in two humanized mouse models: non-tumor-bearing BRGSF-HIS mice engrafted with human CD34+ cells, and PD-L1+ MDA-MB-231 tumor-bearing MHC-/- NSG mice engrafted with human PBMCs. In the BRGSF model, IGM-7354 increased NK cell activation and Granzyme B expression as well as NK and CD8+ T cell proliferation. In the tumor-bearing mouse model, IGM-7354 dose-dependently increased NK and CD8+ T cell proliferation in blood and infiltration of lymphocytes into the tumor. This pharmacodynamic activity correlated with IGM-7354 anti-tumor activity in the MDA-MB-231 model. Lastly, IGM-7354 increased the proliferation of NK and CD8+ T cells in cynomolgus monkeys and particularly induced the expansion of effector memory CD8+ T cells in the periphery. In summary, IGM-7354 induces NK and CD8+ T cell proliferation in both in vitro and in vivo preclinical models, resulting in the killing of PD-L1+ tumor cells. The strong avidity of IGM-7354 for PD-L1 may enhance IL-15 delivery to tumors and antigen-presenting cells and thus provide a more favorable safety profile. A Phase 1 clinical trial is planned.

Citation Format: Thierry D. Giffon, Melanie Desbois, Poonam Yakkundi, Susan Calhoun, Keerthana Sekar, Carolyn Denson, Tasnim Kothambawala, Alexander Pearson, Sivani Pandey, Deepal Pandya, Rodnie Rosete, Daniel Machado, Pat Raichlen, Dean Ng, Abhinav R. Jain, Roel Funke, Eric Humke, Paul R. Hinton, Beatrice Wang, Bruce A. Keyt, Maya F. Kotturi, Angus M. Sinclair. IGM-7354, an immunocytokine with IL-15 fused to an anti-PD-L1 IgM, induces NK and CD8+ T cell mediated cytotoxicity of PD-L1-positive tumor cells. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5660.

Abstract MP47: Sleep Disordered Breathing is Adversely Associated With Cardiac Autonomic Modulation in Adolescents

Introduction: Sleep disordered breathing (SDB), as measured by the apnea/hypopnea index (AHI), is a known risk factor for cardiovascular disease (CVD) in adults. Although SDB is prevalent in pediatric populations, there has been less focus on SDB as a primary risk factor for CVD in youth. The recent AHA scientific statement on SDB and CVD in children and adolescents suggests that, in order to better understand the long-term CVD-related risk associated with SDB in youth, additional longitudinal studies incorporating noninvasive markers of CVD are needed. The current study aimed to fill this important gap.

Hypothesis: We hypothesized that SDB is associated with decreased HRV in adolescents.

Methods: We studied 421 subjects from the Penn State Child Cohort who were 8.7 (1.7) years old at baseline and were followed-up as adolescents 16.5 (2.3) years old. We estimated the AHI from 9-hour, in-lab polysomnography (PSG), and frequency and time-domain heart rate variability (HRV) indices from 24-h Holter EKG monitoring immediately following PSG. We stratified 24-h HRV data into daytime and nighttime periods. Linear regression analyses examined the association between AHI with 24-h HRV indices, while adjusting for age, sex, race/ethnicity, BMI percentile, and metabolic syndrome (MetS) score in adolescence as well as AHI and nighttime HRV indices in childhood.

Results: While there were no significant associations between AHI and daytime (p=0.233) or nighttime (p=0.147) HR, there were significant associations with frequency and time-domain HRV indices. A higher AHI was associated with lower Log-HF, Log-LF, SDNN and RMSSD, yet higher LF/HF, for both daytime and nighttime periods (all p<0.05). For example, for each additional apnea or hypopnea per hour of sleep there was a decrease of -1.74ms (0.73) and -1.65ms (0.77) in SDNN during the daytime (p=0.018) and nighttime (p=0.033), respectively, even after adjusting for all covariates including MetS, childhood AHI and SDNN. More specifically, the 24-h SDNN of adolescents with an AHI≥5, indicative of moderate-to-severe SDB, was 10.9ms (4.4) lower than that of adolescents with an AHI=0 (p=0.014).

Conclusions: SDB is associated with impaired cardiac autonomic balance in adolescence independently of MetS, prior SDB and prior HRV status. These data further support the role of SDB as an independent risk factor for CVD early in life.

Abstract 13: Circadian Misalignment is Associated With Impaired Heart Rate Variability in Adolescents

Introduction: Adequate sleep has been recognized by AHA as part of Life’s Essential 8 in the prevention of cardiovascular disease (CVD). The circadian system, which governs the sleep-cycle, is also involved in cardiac, metabolic and autonomic regulation. Heart rate variability (HRV), a marker of cardiac autonomic modulation (CAM), is known to predict CVD. As a result, circadian misalignment of the sleep-wake cycle, which is highly prevalent in adolescents, may impact CAM and be a potential risk factor for adverse CVD outcomes in early life.

Hypothesis: We hypothesize that deviations in the circadian timing of sleep are associated with blunted HRV in adolescents.

Methods: We analyzed data from 337 population-based randomly-selected adolescents from the Penn State Child Cohort (median 16 years; 47% female; 21% racial/ethnic minority) who had at least 3-night at-home actigraphy (ACT), in-lab 9-h polysomnography (PSG) and 24-h Holter-monitoring heart rate variability (HRV) data. ACT-sleep duration and sleep midpoint (SM) were calculated as the intra-individual mean total sleep time and midpoint of the sleep period, respectively. ACT-sleep variability and sleep regularity (SR) were calculated as the intra-individual standard deviation of sleep duration and sleep midpoint across nights, respectively. Frequency and time-domain HRV indices, including HR oscillations at high frequencies (HF), standard deviation between normal heart beats or R-R intervals (SDNN), and root mean square of successive differences between normal heartbeats (RMSSD), were primary outcomes. Linear regression models tested SM and SR as predictors of HRV indices, while accounting for sex, race/ethnicity, age, body mass index, ACT-sleep duration, ACT-sleep variability, and PSG-apnea/hypopnea index.

Results: While there were no meaningful associations between SM or SR with daytime HRV, there were significant associations between SM with nighttime HRV. A later SM was associated with lower nighttime Log-HF, SDNN and RMSSD, yet higher nighttime LF/HF (all p<0.03). For each standard deviation increase in SM (i.e., 1.5 hours later), there was a decrease of -5.50ms (1.92) in nighttime RMSSD (p=0.004). More specifically, the nighttime RMSSD of adolescents with a SM at 5:30 (i.e., sleep onset at 2:00, sleep offset at 9:00), was 18.2ms (6.7) lower (p=0.007) than that of adolescents with a SM at 2:30 (i.e., sleep onset at 23:00, sleep offset at 6:00).

Conclusions: A delayed sleep phase is associated with impaired CAM in adolescents. These data support that circadian misalignment of the sleep-wake cycle may independently contribute to CVD risk.

Abstract 3438: Enhanced NK and CD8+ T cell proliferation, tumor cytotoxicity and reversal of T cell exhaustion with IGM-7354, an anti-PD-L1 IgM antibody and IL-15 cytokine fusion

Anti-PD-1/PD-L1 therapies are efficacious in certain cancer indications, but often patients relapse following a primary response Therefore rational combinations are needed to enhance initial and durable responses of anti-PD-1/PD-L1 therapies. Immunostimulatory cytokine, IL-15 is an attractive combination partner to enhance anti-tumor NK and memory CD8+ T cell expansion and survival. We are developing IGM-7354, a high affinity, high avidity anti-PD-L1 pentameric IgM antibody with an IL-15Rα chain and IL-15 fused to the joining (J) chain, designed to deliver IL-15 to PD-L1 expressing tumors for enhancing anti-tumor immune responses. IGM-7354 was generated by grafting heavy chain variable regions of a high affinity humanized anti-PD-L1 IgG onto the IgM heavy chain framework, co-expressed with the light chain and the J chain which included a single IL-15Rα and IL-15 fusion. Binding ELISAs were performed using recombinant antigens. IGM-7354 bound human and cynomolgus monkey PD-L1 with similar affinities but did not bind to rat or mouse PD-L1. In addition, the IL-15 component of IGM-7354 bound to human and cynomolgus β chain of the trimeric IL-15 receptor with similar affinities, but with weaker binding affinity to rodent IL-15Rβ. Using in vitro assays with human and cynomolgus monkey PBMCs, IGM-7354 dose-dependently enhanced the proliferation of NK and CD8+ T cells. Furthermore, in an in vitro MLR setting, IGM-7354 was able to reverse T cell exhaustion beyond that of an IL-15/IL15Rα complex or anti-PD-L1 IgM or IgG alone, as demonstrated by an increase in activation and effector cytokine secretion. In vitro cytotoxicity and ADCC assays were performed with luciferase-tagged human cancer cell lines and PBMCs. IGM-7354 enhanced in vitro killing of PD-L1-expressing cancer cells by human PBMCs in monotherapy and in combination with other therapeutic agents. Efficacy and pharmacodynamic studies in an MDA-MB-231 xenograft mouse model showed dose-dependent increases in circulating NK and CD8+ T cells and tumor-infiltrating lymphocytes, which correlated with tumor regression. In cynomolgus monkeys, IGM-7354 markedly induced the proliferation of NK and CD8+ T cells in a dose-dependent manner with a preferential expansion of effector memory CD8+ T cells and γδ T cells in the periphery. IGM-7354 stimulates NK and CD8+ T cell expansion in vitro and in vivo plus induces tumor regressions in mouse tumor models in monotherapy or combination with various agents. This approach may enhance tumor localization of the immunostimulatory cytokine IL-15 through high affinity and high avidity binding to PD-L1 thereby improving anti-tumor responses and minimizing toxicity.

Citation Format: Thierry Giffon, Melanie Desbois, Poonam Yakkundi, Keerthana Sekar, Marigold Manlusoc, Rodnie Rosete, Daniel Machado, Susan Calhoun, Tasnim Kothambawala, Dean Ng, Vu Tran, Avneesh Saini, Abhinav Jain, Beatrice Wang, Maya Kotturi, Bruce Keyt, Angus Sinclair. Enhanced NK and CD8+ T cell proliferation, tumor cytotoxicity and reversal of T cell exhaustion with IGM-7354, an anti-PD-L1 IgM antibody and IL-15 cytokine fusion [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3438.

0190 Association of Sleep Spindle Activity with Cognition in Youth from the General Population

Introduction

Sleep spindle activity has been increasingly studied as an underlying mechanism of cognition. In youth, it appears the relationship between spindle activity and cognition depends upon the spindle metric and cognitive domain examined. Prior research has been conducted primarily in highly selective experimental studies of typically developing youth. We aimed to clarify the relationship between spindle activity and lower and higher order cognitive functions in children and adolescents from the general population.

Methods

We studied 639 children aged 5-12y (median 9y) and 418 adolescents aged 12-23y (median 16y) from a population-based cohort. All subjects underwent a 9-hour, in-lab polysomnography. We calculated sleep spindle density (SSD), the total number of spindles per minute of stage 2 of non-rapid eye movement sleep, and peak spindle frequency (PSF) in the 10-16 Hz range at central, frontal and fronto-occipital derivations. Wechsler intelligence testing assessed verbal and non-verbal intelligence quotients (IQ), processing speed (coding) and working memory (digit span backward [DSB]). Multivariable-adjusted linear regression models with age, sex, race/ethnicity, body mass index, apnea/hypopnea index, and insomnia symptoms as covariates examined the association between SSD and PSF with cognitive outcomes.

Results

At ages 5-12, central SSD was positively associated with verbal IQ (p=0.04), non-verbal IQ (p=0.03), coding (p=0.01) and DSB (p&lt;0.01); additionally, frontal SSD was positively associated with coding and DSB (both p&lt;0.01) and fronto-occipital SSD with DSB (p&lt;0.01). Also, central (p&lt;0.01) and frontal (p=0.01) PSF was positively associated with DSB. At ages 12-23, fronto-occipital SSD was positively associated with non-verbal IQ (p=0.02), while no other statistically significant associations were observed for SSD or PSF with cognitive outcomes (all p≥0.08).

Conclusion

Spindle density is a strong correlate of general ability (both verbal and non-verbal IQ) in childhood, and it remains for non-verbal IQ in adolescence. Both increased spindle density and peak frequency are associated with better working memory in childhood, yet not in adolescence. These developmental differences may be due to cortical (e.g., synaptic pruning) and thalamocortical (e.g., increased myelination) maturational changes occurring during adolescence.

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National Institutes of Health (R01MH118308, UL1TR000127)

0338 Association of Evening Circadian Preference and Languid/Flexible Circadian Type with Predisposing, Perpetuating Factors, and Treatment Acceptability in Patients with Chronic Insomnia Disorder

Introduction

Circadian factors may contribute to sleep difficulties among chronic insomnia disorder (CID) patients who do not otherwise meet full criteria for a circadian rhythm sleep-wake disorder, particularly delayed and advanced sleep-wake phase disorders. Current nosology suggests that using circadian preference measures can provide important diagnostic information and aid in differential diagnosis. However, there is a lack of research identifying clinical factors associated with circadian dimensions in patients with CID.

Methods

195 patients (45.50±15.99 years old, 66.2% female, 15.9% minority) with a diagnosis of CID and absent of any other sleep disorder were evaluated at the Behavioral Sleep Medicine (BSM) program of Penn State Health Sleep Research & Treatment Center. All patients completed measures of circadian preference and type, insomnia severity, arousability, sleep reactivity, pre-sleep arousal, sleep-wake schedule and incompatible behaviors, dysfunctional beliefs and attitudes, mood and stress, and insomnia treatment acceptability. Multivariable linear regression examined which predisposing, perpetuating and treatment acceptability factors were associated with each circadian dimension, while adjusting for age, sex, race/ethnicity and insomnia severity.

Results

About 30% of the sample was classified as evening, 29% as morning, 74% as languid, and 43% as flexible types. Sleep-wake irregularity was associated with eveningness (β=-0.276, p&lt;0.01), languidity (β=0.280, p&lt;0.01) and flexibility (β=0.184, p&lt;0.01). Pre-sleep cognitive arousal (β=-0.182, p&lt;0.01) and sleep expectations (β=-0.127, p&lt;0.05) were associated with eveningness. Negative cognitions about the consequences of insomnia (β=0.230, p&lt;0.01) and sleep expectations (β=0.268, p&lt;0.01) were associated with languidity. Sleep-incompatible behaviors (β=0.165, p&lt;0.05) and perceived stress (β=0.267, p&lt;0.01) were associated with flexibility, while trait anxiety (β=-0.137, p=0.058) and negative cognitions about the consequences of insomnia (β=-0.318, p&lt;0.01) were associated with rigidity. Less agreeability to pharmacotherapy over behavioral therapy was associated with morningness (β=0.129, p&lt;0.05), while greater agreeability to behavioral therapy over pharmacotherapy (β=-0.158, p&lt;0.05) was associated with rigidity.

Conclusion

Sleep-wake irregularity in patients with CID is a perpetuating factor strongly associated with evening and languid/flexible circadian types, while other predisposing and perpetuating factors can be also determined by circadian preference and/or type. Circadian measures in the evaluation of CID patients may help clinicians individualize BSM treatments, including patients’ acceptability.

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0663 Association of Insomnia Phenotypes based on Objective Sleep Duration with Suicide Attempts, Ideation and Completion

Introduction

Sleep disturbances, including insomnia and short sleep duration, are known risk factors for suicidal ideation, attempts, and death. Insomnia is a heterogeneous disorder, with phenotypes of short and normal sleep duration based on objective sleep measures showing differential pathophysiology, natural course, cardiometabolic and neurocognitive morbidity. However, little is known about the association of these insomnia phenotypes with suicidality in adults.

Methods

We analyzed data from the Penn State Adult Cohort (N = 1741, M age = 52.46, SD = 13.43, 57.4% female), a randomly selected population-based sample who underwent a thorough clinical history and in-lab polysomnography (PSG). Suicidality was ascertained by a lifetime history of suicide attempts, suicidal ideation or suicide as cause of death by December 31 2018 (n = 102). Insomnia symptoms were defined as a complaint of moderate-to-severe difficulties initiating or maintaining sleep, early morning awakening and non-restorative sleep, or chronic insomnia (n = 719). Short sleep duration was defined as &lt; 6-h of in-lab PSG-measured sleep (n = 879). Binary logistic regression was used to examine the association between insomnia phenotypes with suicidality, while controlling for sex, age, race/ethnicity, and medical and psychiatric comorbidities. Given the low suicidality prevalence in this sample, 1000 bootstrapped samples were drawn to provide stable estimates.

Results

Compared to normal sleepers who slept &gt; 6-h, subjects with insomnia symptoms who slept &lt; 6-h and those who slept &gt; 6-h were associated with 1.96-fold (95%CI = 1.04-4.00) and 2.46-fold (95%CI = 1.30-5.04) increased odds of suicidality, respectively. After further adjusting for substance use, subjects with insomnia symptoms who slept &lt; 6-h and those who slept &gt; 6-h were associated with 1.72-fold (95%CI = 0.90-3.58) and 2.22-fold (95%CI = 1.15-4.60) increased odds of suicidality, respectively. Normal sleepers who slept &lt; 6-h were not associated with significantly increased odds of suicidality (OR = 1.32; 95%CI = 0.56-2.94).

Conclusion

Adults with insomnia, particularly those with normal sleep duration, were associated with increased suicidality. These data further support that objectively-defined insomnia phenotypes may confer risk for differential adverse health outcomes (e.g., cardiometabolic vs. psychopathologic) via distinct mechanistic pathways.

Support (If Any)

American Heart Association (14SDG19830018)

0219 Interplay of School Days and Free Days with Sleep Midpoint on the Association of Visceral Adiposity with Blood Pressure in Adolescents

Introduction

The circadian timing of sleep, including its variability, has emerged as an important contributor to obesity and cardiovascular health, such as elevated blood pressure. Adolescence is a particularly vulnerable period for circadian misalignment, which may express differently if youth are in school or on free-days. We examined whether deviations in sleep midpoint increase the impact of visceral adiposity on elevated blood pressure in adolescents as a function of being entrained to school or not.

Methods

We analyzed cross-sectional data from the Penn State Child Cohort follow-up study, a random population-based sample of 303 adolescents (16.2 ± 2.2 y; 47.5% female; 21.5% minority). Actigraphy-measured sleep midpoint was calculated as the midpoint (zeroed to midnight) of the sleep period for weekdays (5-nights) and weekends (2-nights). Actigraphy-measured sleep regularity was calculated as the intra-individual standard deviation of the 5-night weekdays sleep midpoint. Visceral adipose tissue (VAT) was measured via dual-energy X-ray absorptiometry scan. Systolic (SBP) and diastolic (DBP) blood pressure was measured three times in the seated position. Multivariable linear regression models were stratified by “in school” and “on break” to test sleep midpoint and sleep regularity as effect modifiers of VAT on SBP/DBP levels. Analyses were adjusted for sex, race/ethnicity, age, actigraphy-measured sleep duration and polysomnography-measured apnea/hypopnea index.

Results

When participants were studied while “in school”, significant interactions were found between VAT and weekdays sleep midpoint on SBP (p-interaction=0.027) and DBP (p-interaction=0.046), so that the later the sleep midpoint on school days, the greater the association of VAT with SBP/DBP. When participants were studied while “on break”, a significant interaction was found between VAT and weekdays sleep regularity on SBP (p-interaction=0.039), so that the higher the sleep irregularity on weekdays, the greater the association of VAT with SBP. No other significant interactions were found.

Conclusion

A delayed and an irregular sleep midpoint during school days and during breaks, respectively, best identified those adolescents with greater cardiovascular risk associated with visceral obesity. These data suggest that not only the circadian timing of sleep contributes to adverse cardiovascular outcomes but its distinct biomarkers require measurement under different entrainment conditions in adolescents.

Support (If Any)

National Institutes of Health (R01HL136587, UL1TR000127)

0432 Insomnia is Associated with Endothelial Dysfunction in Young Adulthood: the Penn State Child Cohort

Introduction

Clinical and population-based studies in middle-aged and older adults have shown that insomnia is associated with prevalent and incident cardiovascular diseases. However, there is a lack of studies demonstrating an association between insomnia and subclinical cardiovascular measures such as endothelial function in young adults from the general population.

Methods

We studied 200 subjects from the Penn State Child Cohort (20-30 years old, 47% male, 22% racial/ethnic minority), who underwent a thorough clinical history and physical examination to ascertain the presence of sleep disorders and body mass index (BMI), in-lab polysomnography to ascertain the apnea/hypopnea index (AHI), and Doppler ultrasound to assess flow-mediated dilation (FMD). We identified the presence of moderate-to-severe difficulties initiating and/or maintaining sleep (i.e., poor sleep) and of insomnia, the latter including a physician diagnosis of the disorder. The study outcome was FMD as a continuous measure and the square root of FMD (sqrt-FMD) to test the robustness of the analysis. General linear models adjusted for sex, age, race/ethnicity, BMI, AHI, alcohol intake, and sleep medication use.

Results

Compared to normal sleepers (0.111±0.003), subjects with poor sleep (0.104±0.006) and insomnia (0.092±0.008) showed a significant association with lower FMD levels (p-linear&lt;0.05), with subjects with insomnia having significantly lower FMD levels (p=0.029). Results remained significant and in the same direction based on sqrt-FMD (p-linear=0.015).

Conclusion

These data indicate that insomnia is associated with increased risk for cardiovascular disease as early as young adulthood, and independent of major contributors such as obesity, sleep apnea or alcohol use. These data further reinforce the need to include insomnia as a target in the preventative efforts for cardiovascular disease.

Support (If Any)

National Institutes of Health (R01HL136587, UL1TR000127)

0488 Trajectories of Insomnia Symptoms since Childhood Associated with Treatment of Internalizing Disorders in Adulthood

Introduction

Internalizing disorders (ID) are the most common form of psychopathology, with a large proportion of individuals seeking treatment in young adulthood. Childhood insomnia symptoms, i.e., difficulties initiating or maintaining sleep (DIMS), have been shown to be associated with ID, however, little is known about the developmental trajectories of insomnia symptoms and their associated risk of receiving pharmacotherapy for ID. The present study examined the longitudinal association between trajectories of childhood insomnia symptoms and risk of receiving treatment for ID in young adulthood.

Methods

We analyzed data from the Penn State Child Cohort, a population-based sample of 505 children (Mdn=9y), who were followed-up 8 years later as adolescents (Mdn=16y) and 15 years later as young adults (Mdn=24y). Insomnia symptoms were defined as parent-reported (childhood) or self-reported (adolescence and young adulthood) moderate-to-severe DIMS. The trajectories of insomnia symptoms across the three time-points were identified as never, remitted, waxing-and-waning, incident and persistent. The presence of ID was defined as a self-report of a diagnosis of mood and/or anxiety disorders, whether they had received treatment or not and whether treatment consisted of prescription psychotropic medication (i.e., antidepressants, anxiolytics). Logistic regression models were adjusted for sex, race/ethnicity, age, and any childhood or adolescent history of a psychiatric diagnosis or psychotropic medication use.

Results

Persistent (OR=3.0) and incident (OR=3.3) trajectories, but not waxing-and-waning (OR=1.1) or remitted (OR=0.8) trajectories, were associated with increased odds of ID that did not receive treatment in adulthood. Additionally, the odds of receiving treatment for ID with prescription psychotropic medication in adulthood were increased in those with persistent (OR=3.4), incident (OR=3.5) and waxing-and-waning (OR=2.1) trajectories, but not in those with a remitted trajectory (OR=0.7).

Conclusion

Childhood-onset persistent insomnia symptoms as well as adult-onset incident insomnia symptoms are strong risk factors for receiving treatment for mood/anxiety disorders in adulthood, while childhood insomnia symptoms that fully remit over time are not. Treatment of insomnia in youth should be an essential target as to decrease the risk of developing severe forms of mood/anxiety disorders requiring psychotropic treatment in adulthood.

Support (If Any)

National Institutes of Health (R01HL136587, R01MH118308, UL1TR000127)

0254 Association of Slow Wave Activity and Odds Ratio Product with Internalizing and Externalizing Problems in Children and Adolescents

Introduction

The association of metrics of sleep microstructure with internalizing and externalizing problems in youth has remained elusive. While one study found increased frontal slow wave activity (SWA) in depressed adolescents, there is lack of evidence for a relationship between dimensional measures of behavior and metrics of sleep depth/intensity. We examined the association between two measures of sleep depth/intensity, slow wave activity (SWA) and odds ratio product (ORP), with internalizing and externalizing problems in children and adolescents.

Methods

We calculated SWA and ORP during non-rapid eye movement (NREM) sleep at central, frontal and fronto-occipital derivations in 639 children (5-12y, median 9y) and 418 adolescents (12-23y, median 16y) from the Penn State Child Cohort via in-lab polysomnography. ORP provides a standardized measure of NREM sleep depth, while ORP-9 (average ORP in the 9-seconds following NREM arousals) provides a metric of arousability. SWA (0.4-4Hz) absolute power (µV2) was determined during NREM sleep. Internalizing and externalizing problems were assessed on Achenbach’s Behavior Checklist by parent (subjects≤17y) or self-report (subjects≥18y). For each scale, T-scores with a mean of 50 and standard deviation of 10 were obtained following standardized scoring. Multivariable-adjusted linear regression models examined the association between SWA/ORP and clinical outcomes.

Results

At ages 5-12, fronto-occipital SWA was negatively associated with externalizing behaviors (p=0.05), while fronto-occipital and frontal ORP, and frontal ORP-9 were positively associated with internalizing symptoms (all p&lt;0.01). At ages 12-23, central SWA was negatively associated with internalizing symptoms (p=0.05), while central (p=0.05) and frontal (p=0.03) ORP and central ORP-9 (p=0.03) were positively associated with externalizing behaviors.

Conclusion

Reductions in SWA in childhood or adolescence are associated with developmentally appropriate behavioral problems, as depression/anxiety are more prevalent in adolescence. In contrast to SWA, increased ORP (lighter sleep) and ORP-9 (greater arousability) are associated with more anxiety/depression in childhood, yet more externalizing behaviors in adolescence. These distinct associations, such as SWA with externalizing behaviors and ORP with internalizing symptoms during childhood, may reflect how SWA captures local/synaptic control, while ORP global/state control, of sleep depth, making both sleep EEG biomarkers important from a developmental standpoint.

Support (If Any)

National Institutes of Health (R01MH118308, UL1TR000127)

0536 Association of a Novel EEG Biomarker of Sleep Depth with Sleep Disordered Breathing in Adolescents

Introduction

The odds ratio product (ORP) provides a standardized, continuous measure of sleep depth that ranges from 0 (deep sleep) to 2.5 (full wakefulness). ORP has been shown to increase during adolescence, representing the decline in sleep depth that occurs during this developmental period. In adults, higher ORP has been associated with sleep disordered breathing (SDB), including obstructive sleep apnea (OSA), while there have been no studies in youth. We aimed to determine the association of ORP with SDB in adolescents.

Methods

We extracted ORP from the sleep EEG of 261 typically developing adolescents aged 12-23y (median 16y) from the Penn State Child Cohort. Higher ORP during rapid eye movement (REM) and non-REM sleep indicates less deep sleep, while higher ORP-9 (i.e., average ORP in the 9-seconds following non-REM cortical arousals) indicates greater arousability. We used general linear models, adjusted for sex, age and race/ethnicity, to examine mean differences in ORP metrics among clinically meaningful groups of SDB based on the apnea/hypopnea index (AHI) consisting of no SDB (AHI&lt;2 and no snoring, n=100), primary snoring (AHI&lt;2 and snoring, n=75), 2≤AHI&lt;5 (n=64), and AHI≥5 (n=22).

Results

Adolescents with primary snoring or 2≤AHI&lt;5 did not significantly differ in ORP metrics from those without SDB (all p≥0.12). Adolescents with AHI≥5 had higher ORP-NREM compared to those without SDB, with primary snoring or with 2≤AHI&lt;5 (all p≤0.01), while ORP-REM was significantly higher compared to those without SDB (p=0.02). ORP-9 was significantly greater in adolescents with AHI≥5 compared to those with no SDB (p&lt;0.01) and those with primary snoring (p=0.02), but not when compared to those with 2≤AHI&lt;5 (p=0.07).

Conclusion

Our data suggest that adolescents with OSA experience lower REM and non-REM sleep depth/intensity (higher ORP) compared to those without SDB. In addition, these adolescents experience a slower progression back to deep sleep following cortical arousals (higher ORP-9), which suggests they remain in a high arousability state and, thus, are more likely to repeat arousals. Commensurate with previous studies in adults, our data show that ORP is a useful sleep EEG biomarker able to capture decreased sleep depth in adolescents with OSA.

Support (If Any)

National Institutes of Health (R01MH118308, UL1TR000127)

711 IGM-7354 is an anti-PD-L1 IgM antibody and IL-15 cytokine fusion that enhances NK and CD8+ T cell proliferation and tumor cytotoxicity plus potently reverses T cell exhaustion

Background

While approved PD-1/PD-L1 inhibitory antibodies have demonstrated clinical efficacy in certain cancer patients, relapse following a primary response is often observed. Enhancing anti-tumor immune responses with an immunostimulatory cytokine, IL-15 is an attractive combination strategy to enhance anti-tumor NK and memory CD8+ T cell expansion and survival. We have developed IGM-7354, a high affinity, high avidity anti-PD-L1 pentameric IgM antibody with an IL-15Rα chain and IL-15 fused to the joining (J) chain, designed to deliver IL-15 to PD-L1 expressing tumors for enhancing anti-tumor immune responses.

Methods

IGM-7354 was generated by grafting heavy chain variable regions of a high affinity humanized anti-PD-L1 IgG onto the IgM heavy chain framework, co-expressed with the light chain and the J chain which included a single IL-15Rα and IL-15 fusion. Binding ELISAs were performed using recombinant antigens. Human and cynomolgus monkey PBMCs were used for potency testing. Reversal of T cell exhaustion was tested using in vitro MLR. In vitro cytotoxicity assays were performed with luciferase-tagged MDA-MB-231 cells and PBMCs. In vivo pharmacodynamic studies were conducted in mice and cynomolgus monkeys.

Results

IGM-7354 bound human and cynomolgus monkey PD-L1 with the same affinity but did not bind to rat or mouse PD-L1. In addition, the IL-15 component of IGM-7354 bound to human and cynomolgus β chain of the trimeric IL-15 receptor with similar affinities, but with weaker binding affinity to rodent IL-15Rβ. Using in vitro assays with PBMCs, IGM-7354 dose dependently enhanced the proliferation of human and cynomolgus monkey NK and CD8+ T cells. Furthermore, IGM-7354 was able to reverse T cell exhaustion in an in vitro MLR beyond that of an IL-15/IL15Rα complex or anti-PD-L1 IgM or IgG alone, as demonstrated by an increase in activation and effector cytokine secretion. IGM-7354 also enhanced in vitro killing of PD-L1-expressing MDA-MB-231 breast cancer cells by human PBMCs. Pharmacodynamic studies in an MDA-MB-231 xenograft mouse model showed dose-dependent increases in circulating NK and CD8+ T cells and tumor infiltrating lymphocytes, which correlated with tumor regression. In cynomolgus monkeys, intravenous administration of IGM-7354 was well tolerated and dose dependently induced the proliferation of NK and CD8+ T cells.

Conclusions

IGM-7354 stimulates NK and CD8+ T cell expansion in vitro and in vivo plus induces tumor regressions in mouse tumor models. This approach may enhance tumor localization of the immunostimulatory cytokine IL-15 through high affinity and high avidity binding to PD-L1 thereby improving anti-tumor responses and minimizing toxicity.

Ethics Approval

All animal studies were conducted according to approved Institutional Animal Care and Use Committee (IACUC) protocols of the testing facilities.

Abstract 038: Cumulative Exposure To Sleep Disordered Breathing From Childhood Through Young Adulthood Is Associated With Impaired Endothelial Function

Introduction: Clinical and population-based studies in adults have shown that sleep disordered breathing (SDB) is associated with impaired endothelial function. However, there is a lack of population-based studies demonstrating an association between SDB and endothelial dysfunction in young adults using a developmental approach.

Hypothesis: Exposure to SDB since childhood is associated with long-term impaired flow-mediated dilation (FMD) in young adulthood.

Methods: We tested this hypothesis in a subsample of the Penn State Child Cohort, a population-based study of 700 children (median age 9y), of whom 421 were followed-up 6-13 years later during adolescence (median age 16y), and 178 have been followed-up 11-19 years later during young adulthood (median age 24y). Subjects (54.5% female, 20.8% racial/ethnic minority) underwent in-lab polysomnography to ascertain the apnea/hypopnea index (AHI) at all three time points, and ultrasounds to assess FMD in young adulthood. Based on the AHI truncated at ≥5 events/hour of sleep to include subjects already on positive airway pressure therapy, we averaged the exposure to AHI over the three time points (cAHI). The study outcomes were FMD, as a continuous measure, and endothelial dysfunction, defined as FMD<10.3% based on the median of the sample. Linear and logistic regression models simultaneously adjusted for sex, age, race/ethnicity, overweight and length of follow-up.

Results: The mean cAHI was 1.31 (1.35) ranging from 0 to 5 and the mean FMD was 0.11 (0.04) ranging from 0.03 to 0.25. Linear models showed that cAHI was associated with significantly lower FMD in young adulthood (β = -0.006; 95% CI = -0.011, -0.0013; p = 0.014). To test the robustness of the analysis, we applied the same model with the square root of FMD as the outcome and similar results were obtained (β = -0.009; 95% CI = -0.016, -0.0017; p = 0.015). Logistic models showed that each point increase in cAHI was associated with 51% higher odds of endothelial dysfunction in young adulthood (OR = 1.51; 95% CI = 1.14, 2.06; p = 0.006).

Conclusions: The preliminary data of this ongoing longitudinal study indicates that exposure to SDB during early stages of life is associated with increased risk for cardiovascular disease in young adults from the general population.

Abstract MP63: Childhood-onset Obstructive Sleep Apnea Is Associated With Increased Risk Of Adolescent Hypertension

Introduction: Obstructive sleep apnea (OSA) is an established risk factor for hypertension in adults. However, the association of childhood OSA with an increased risk of hypertension has remained elusive.

Hypothesis: Childhood-onset OSA is longitudinally associated with hypertension in adolescence.

Methods: We tested this hypothesis in a population-based sample of 421 children (5-12 years) from the Penn State Child Cohort who were followed-up 6-13 years later as adolescents (12-23 years). In-lab polysomnography, to ascertain the apnea/hypopnea index (AHI), and seated blood pressure were assessed at baseline and at follow-up. The presence of hypertension at follow-up was defined based on pediatric criteria dependent upon the subject’s age (below and above 13 years). Logistic regression analyses adjusted for sex, race/ethnicity, age, body mass index percentile and systolic blood pressure percentile at baseline.

Results: Childhood OSA that persisted in the transition to adolescence was associated with 2.9-fold (95%CI=1.1-7.4) higher odds of adolescent hypertension. In contrast, childhood OSA that remitted in the transition to adolescence was not associated with increased odds of adolescent hypertension (OR=0.9, 95%CI=0.3-2.6). Adolescent-onset OSA was associated with 1.7-fold (95%CI=1.1-2.9) increased odds of adolescent hypertension.

Conclusions: Childhood-onset persistent OSA is a risk factor for hypertension in adolescence. Remission of childhood OSA during this transitional period, which previous research has shown to be highly determined by weight loss, does not confer a significant risk of adolescent hypertension. Early life chronic adverse sleep exposures predict cardiovascular risk in adolescence, a critical developmental period.

692 Longitudinal Stability of Sleep and Health Correlates in Adults with Autism Spectrum Disorder

Introduction

Individuals with Autism Spectrum Disorder (ASD) experience sleep disturbances to a greater degree than the general population. The majority of research investigating sleep disturbances in ASD has focused on children and adolescents. The aim of the current study was to determine the stability and health correlates of self-reported sleep disturbances in adults with ASD.

Methods

Participants included 55 adults with ASD recruited from state-funded Pennsylvania programs (31.2±7.6 years old, 80% male, 10.9% minority). Patient-Reported Outcomes Measurement Information System (PROMIS) measures assessing Sleep Disturbances, Sleep-Related Impairment, Fatigue, Anxiety, Depression, Anger, and Physical Health, were completed at baseline and every 90 ± 14 days over a 2-year period. Intraclass correlation coefficients (ICC) were calculated for each sleep outcome, and interpreted as 0.00–0.20=“poor stability,” 0.21–0.40=“slight stability,” 0.41–0.60=“moderate stability,” 0.61–0.80=“substantial stability,” and 0.81–1.00=“almost perfect stability” across the first three time-points. Linear mixed models examined the independent association of sleep disturbances, sleep-related impairment, and fatigue on anxiety, depression, anger, and physical health over the two-year period.

Results

Sleep-related impairment (ICC=0.73) and fatigue (ICC=0.64) were substantially stable, while sleep disturbances were moderately stable (ICC=0.58). All three sleep-related outcomes were independently associated with anxiety (sleep-related impairment p=0.012; sleep disturbance p&lt;0.001; fatigue p=&lt;0.001) and anger (sleep-related impairment p=&lt;0.001; sleep disturbance p=0.001; fatigue p&lt;0.001) across the two-year period. Sleep disturbance (p=&lt;0.001) and fatigue (p&lt;0.001), but not sleep-related impairment (p=0.267), were associated with depression across the two-year period. In contrast, none of the sleep-related outcomes (sleep-related impairment p=0.285; sleep disturbance p=0.250; fatigue p=0.709) were associated with physical health over time.

Conclusion

Measures of sleep-related impairment, fatigue, and sleep disturbance remained stable over time, suggesting that they can provide clinicians and researchers with a brief, accurate, and reliable way to assess patient-reported sleep outcomes in adults with ASD. Furthermore, given the stability of these sleep measures and their independent association with elevated mental health outcomes, there is a need for evidence-based treatments targeting sleep difficulties and associated symptomology in adults with ASD, a particularly underserved population.

Support (if any)

Pennsylvania State Bureau of Autism Services through the Autism Services, Education, Resources, and Training (ASERT) grant

628 Longitudinal Association between NREM Sleep Depth and Arousability with ADHD and Internalizing Disorders in Adolescence

Introduction

Sleep depth decreases in the transition from childhood to adolescence, even in typically developing (TD) youth. However, it remains unknown whether this developmental trajectory in NREM sleep depth differs across adolescents with psychiatric/behavioral disorders.

Methods

We analyzed the sleep EEG of 392 subjects aged 5–12 at baseline and 12–22 at follow-up (45.2% female, 23.2% racial/ethnic minority), of whom 246 were TD adolescents (controls), 62 were diagnosed with a psychiatric/behavioral disorder and were taking stimulant, anti-depressant, anxiolytic, sedative and/or anti-psychotic medications, and 84 were un-medicated. NREM sleep depth was measured at both time points using the odds ratio product (ORP), which provides a standardized continuous EEG measure of NREM sleep depth/arousability (higher ORP reflects lighter NREM sleep). General linear models examined mean differences between groups on the percent change in ORP between baseline and follow-up (ΔORP) while adjusting for sex, race/ethnicity, age, BMI and AHI at follow-up, and PSG system, psychiatric/behavioral disorders, psychoactive medications and ORP at baseline as well as time-to-follow-up.

Results

Overall, medicated (80.4%, 95%CI=66.2–94.6) and un-medicated (66.1%, 95%CI=53.0–79.1) subjects showed a higher ΔORP compared to controls (52.2%, 95%CI=40.0–64.5, p&lt;0.01 and p&lt;0.05, respectively) but did not differ between each other (p=0.134). Specifically, un-medicated subjects with ADHD (n=56) showed a higher ΔORP (77.3%, 95%CI=62.4–92.1) compared to controls (p&lt;0.01), while subjects with ADHD on stimulant medication (n=36) did not differ (66.1%, 95%CI=48.9–93.2) from controls (p=0.268) or from un-medicated ADHD subjects (p=0.303). Subjects with internalizing disorders on psychoactive medications (n=29) showed a higher ΔORP (104.9%, 95%CI=82.8–127.0) compared to controls (p&lt;0.01) and to un-medicated subjects (n=27) with internalizing disorders (60.1%, 95%CI=36.8–83.3, p&lt;0.01), who did not differ from controls (p=0.772).

Conclusion

The greater increase in ORP in the transition to adolescence in un-medicated youth with ADHD suggests that decreased NREM sleep depth may be a biomarker of the disorder. In contrast, the greater increase in ORP in medicated youth with internalizing disorders suggests that psychoactive medications impact NREM sleep depth in these children as they transition to adolescence. These data have important implications for sleep EEG studies that include medicated and un-medicated youth with comorbid psychiatric disorders.

Support (if any)

NIH Awards Number R01MH118308, R01HL136587, R01HL97165, R01HL63772, UL1TR000127

178 Sleep Disparities in Adolescent Women: Role of Pubertal Development, Menstrual Cycle and Premenstrual Symptoms

Introduction

About 20-30% of children experience sleep difficulties and about 50-60% of those persist into adolescence. Sex differences in sleep become more apparent after the onset of puberty, suggesting a role for maturational changes in the sleep of males and females. In addition, adolescent females experience greater sleep difficulties with the advancement of pubertal stages and around the time of menstruation. Although adult studies have shown sex differences in sleep continuity and architecture, there is a large gap of knowledge in adolescents.

Methods

We analyzed data from the Penn State Child Cohort, a random, population-based sample of 421 adolescents (16.5±2.3y, 53.9% male) who underwent one-night in-lab polysomnography (PSG) and seven-night at-home actigraphy (ACT) as well as a thorough physical exam and clinical history, including self-reports of Tanner staging, menstrual cycle and use of oral contraceptives (OC).

Results

Upon PSG, females had a longer sleep latency (p&lt;0.05), while males a greater number of awakenings (p&lt;0.05), longer wake after sleep onset (p&lt;0.01) and greater stage N1 (p&lt;0.05). Per ACT, females had longer total sleep time and greater sleep efficiency (p&lt;0.01). Sex differences in PSG and ACT parameters were more prominent among adolescents reporting Tanner stages 4-5, including females having greater stage N3 than males (p&lt;0.01) and females reporting premenstrual symptoms (PMS) having a longer sleep latency than males or than those not reporting PMS (P&lt;0.05). Among females, those who had their last period 8-14 days prior to the PSG had a shorter sleep latency than those who had their period within the previous 7 days (p&lt;0.01) or 15-25 days before (p&lt;0.05). Females using OC (n=38) did not show significantly different PSG or ACT parameters than those not using OC (n=156).

Conclusion

Our study provides evidence for sex-related health disparities in objective sleep arising in adolescence. Females sleep objectively better than males from a sleep continuity and sleep architecture perspective, particularly when examined at the same pubertal stage. Additionally, sleep onset is significantly impacted by the menstrual cycle and associated symptoms but females preserve greater levels of deep sleep, a sign of sleep resilience.

Support (if any)

NIH Awards Number R01MH118308, R01HL136587, R01HL97165, R01HL63772, UL1TR000127

150 Impact of Behavioral Disorders and their Pharmacological Treatment on the Maturational Trajectories of NREM Slow Wave Activity

Introduction

Slow wave activity (SWA) in the delta (0.4-4 Hz) frequency range declines in typically developing (TD) children as they transition to adolescence. However, it remains unknown whether the maturational trajectory of NREM delta power differs between TD youth and those with psychiatric/behavioral disorders.

Methods

We analyzed the sleep EEG of 664 subjects aged 6 to 21 (46.8% female, 24.7% racial/ethnic minority) from the Penn State Child Cohort, of whom 449 were TD, 123 were un-medicated and diagnosed with psychiatric/behavioral disorders, and 92 were medicated with stimulants, anti-depressants, anxiolytics, sedatives and/or anti-psychotics. Multivariable regression models adjusting for sex, race/ethnicity, BMI, AHI and PSG system tested the age-related trajectories of NREM delta power within each diagnostic group.

Results

Delta power in TD and un-medicated youth showed cubic age-related trajectories (both p-cubic&lt;0.05). In TD youth, delta power was highest at age 6.6 and lowest at age 19.9, while in un-medicated youth it was highest at age 8.9 and lowest at age 18.6. The decreasing slope in delta power was 39.7% steeper in un-medicated youth (-22422 ± 5891/year, p&lt;0.01) than TD youth (-16047 ± 2605/year, p&lt;0.01). Delta power in medicated youth showed a distinct linearly decreasing trajectory (-13518 ± 4597/year, p-linear&lt;0.01) from age 6 (highest) to age 21 (lowest).

Conclusion

TD and un-medicated youth with psychiatric/behavioral disorders show SWA trajectories typical of brain maturation biomarkers (e.g., gray matter volume), characterized by a decreasing slope at the onset of puberty that reaches its nadir by late adolescence. However, SWA in un-medicated youth peaks two years later and reaches its nadir a year earlier than in TD youth. Thus, while TD children experience a smooth decline in SWA in the transition to adolescence, those with psychiatric/behavioral disorders experience a faster steep decline. In contrast, SWA in medicated youth appears to be dampened in early childhood and its slope linearly decreases with age. These data suggest that these youth may have a more severe disorder requiring pharmacological treatment, that the latter produces greater cortical arousability reflected in lower SWA power, and/or that psychoactive medications directly impact normal neurodevelopmental processes (e.g., synaptic pruning).

Support (if any)

NIH Awards Number R01MH118308, R01HL136587, R01HL97165, R01HL63772, UL1TR000127

627 Adolescent Delayed Sleep Phase and Circadian Irregularity Associated with Substance (Mis)Use in Young Adulthood

Introduction

Substance use disorders are reaching epidemic proportions among adolescents and young adults. While disturbed, insufficient sleep is known to be associated with substance use, little is known about the role of circadian misalignment in precipitating or perpetuating substance misuse.

Methods

The Penn State Child Cohort is a population-based sample of 700 children (Mdn=9y), who were followed-up 8 years later as adolescents (N=421, Mdn=16y) and 15 years later as young adults (N=492, Mdn=24y). In adolescence, a delayed sleep phase was defined as a 7-night actigraphy-measured mean sleep midpoint later than 4:00 AM, while an irregular circadian phase as a within-subjects standard deviation in sleep midpoint greater than 1 hour. Alcohol, tobacco, and drug use was ascertained by parent- and/or self-reports in adolescence, while alcohol, tobacco and marijuana use was ascertained by self-reports in young adulthood. Logistic regression models tested the association between delayed and irregular circadian phase with substance use adjusted for age, sex, race/ethnicity, BMI, SES, mental health problems and psychoactive medications.

Results

Adolescents with a delayed sleep phase (n=164) showed later bed and wakeup times, lower morningness scores and greater circadian phase irregularity. Cross-sectionally, a delayed sleep phase in adolescence was associated with 1.9-fold odds (95%CI=1.1–3.2) of alcohol, tobacco and/or drug use; specifically, the odds of alcohol and tobacco use associated with a delayed sleep phase were 1.9-fold (95%CI=1.1–3.4) and 2.4-fold (95%CI=1.1–5.3), respectively, while non-significant for drug use (n=28) for which mental health problems were among the strongest risk factors (OR=3.0, 95%CI=1.3–6.8). Longitudinally, an irregular circadian phase in adolescence was associated with 2.2-fold odds (95%CI=1.1–4.5) of alcohol, tobacco and/or marijuana use in young adulthood; specifically, the odds of alcohol use in young adulthood associated with an irregular circadian phase in adolescence were 1.9-fold (95%CI=1.1–3.5), while non-significant for tobacco (n=58) or marijuana use (n=76) for which mental health problems were the strongest risk factor (OR=2.2, 95%CI=1.3–3.7).

Conclusion

A delayed or irregular circadian phase in adolescence is associated with substance use, particularly alcohol use in the transition to adulthood. Beyond disturbed and insufficient sleep, circadian misalignment should become a target of early interventions to prevent substance use disorders.

Support (if any)

R01MH118308, R01HL136587, R01HL97165, R01HL63772, UL1TR000127

512 Confirmatory Factor Analysis of the Sleep Inertia Questionnaire in a Clinical Sample with Sleep Disorders

Introduction

The Sleep Inertia Questionnaire (SIQ) was developed and validated in patients with mood disorders to evaluate difficulties with becoming fully awake after nighttime sleep or daytime naps in a multidimensional manner. However, few data are available regarding its psychometric properties in clinical samples with sleep disorders.

Methods

211 patients (43.0±16.4 years old, 68% female, 17% minority) evaluated at the Behavioral Sleep Medicine (BSM) program of Penn State Health Sleep Research & Treatment Center completed the SIQ. All patients were diagnosed using ICSD-3 criteria, with 111 receiving a diagnosis of chronic insomnia disorder (CID), 48 of a central disorder of hypersomnolence (CDH), and 52 of other sleep disorders (OSD). Structural equation modelling was used to conduct confirmatory factor analysis (CFA) of the SIQ.

Results

CFA supported four SIQ dimensions of “physiological”, “cognitive”, “emotional” and “response to” (RSI) sleep inertia with adequate goodness-of-fit (TLI=0.90, CFI=0.91, GFI=0.85, RMSEA=0.08). Internal consistency was high (α=0.94), including that of its dimensions (physiological α=0.89, cognitive α=0.94, emotional α=0.67, RSI α=0.78). Dimension inter-correlations were moderate to high (r=0.42–0.93, p&lt;0.01), indicating good construct validity. Convergent validity showed moderate correlations with Epworth sleepiness scale (ESS) scores (r=0.38) and large correlations with Flinders fatigue scale (FFS) scores (r=0.65). Criterion validity showed significantly (p&lt;0.01) higher scores in subjects with CDH (69.0±16.6) as compared to those with CID (54.4±18.3) or OSD (58.5±20.0). A SIQ cut-off score ≥57.5 provided a sensitivity/specificity of 0.77/0.65, while a cut-off score ≥61.5 provided a sensitivity/specificity of 0.71/0.70 to identify CDH vs. ESS&lt;10 (AUC=0.76).

Conclusion

The SIQ shows satisfactory indices of reliability and construct validity in a clinically-diverse sleep disorders sample. Its criterion validity is supported by its divergent association with hypersomnia vs. insomnia disorders, as well as its adequate sensitivity/specificity to identify patients with CDH. The SIQ can help clinicians easily assess the complex dimensionality of sleep inertia and target behavioral sleep treatments. Future studies should confirm the best SIQ cut-off score by including good sleeping controls, while clinical studies should determine its minimal clinically important difference after pharmacological or behavioral treatments.

Support (if any):

151 Sex Differences in the Maturational Trajectories of Sleep Spindles in the Transition from Childhood to Adolescence

Introduction

Sleep spindles occur as bursts of EEG activity in the sigma (11-16 Hz) frequency range and are purported biomarkers of cortical development. However, the few studies examining maturational changes in sleep spindles are limited by small samples and/or short follow-up periods. Thus, large longitudinal population-based studies are needed to determine their developmental trajectories as the child transitions to adolescence.

Methods

We analyzed the sleep EEG of 572 un-medicated subjects aged 6-21 (47.6% female, 25.9% racial/ethnic minority), of whom 332 were 5-12 years at baseline and followed-up at ages 12-22. Multivariable-adjusted models tested the cross-sectional and longitudinal trajectories of sleep spindle density, frequency, and power.

Results

From age 6 to 21, the trajectory of sleep spindle density was best fit by a quadratic model (p=0.02), particularly in males (p-quadratic=0.05). Females maintained more stable levels of sleep spindle density (p-linear=0.26), as shown by a longitudinal increase 37.6% lower than males by age 14 (p=0.01). Sleep spindle frequency increased (p-linear&lt;0.01), while sleep spindle power decreased (p-linear&lt;0.01), from age 6 to 21. The trajectory of sleep spindle frequency diverged between females (p-linear&lt;0.01) and males (p-quadratic=0.02), in whom it plateaued by age 15 onwards. Females had experienced a longitudinal increase in sleep spindle frequency 2.4% higher than males by age 20-22 (p=0.05). Males had experienced a steeper decreasing slope in sleep spindle power (p-linear&lt;0.01) than females (p-linear=0.12), as confirmed by a longitudinal decline 25.4% greater than females by age 19 (p=0.02).

Conclusion

Sleep spindle metrics follow distinct maturational trajectories from each other and from other EEG oscillations (e.g., slow wave activity). The increase in sleep spindle density from childhood to early adolescence coupled with the linear increase in sleep spindle frequency from childhood to young adulthood may represent the emergence of fast sleep spindles, which appears to occur earlier in females. Overall, males experience greater maturational changes in all sleep spindle metrics and sex differences become prominent in young adulthood, when males show lower sleep spindle density and sleep spindle frequency, indicative of less fast sleep spindles.

Support (if any)

NIH Awards Number R01MH118308, R01HL136587, R01HL97165, R01HL63772, UL1TR000127

327 Developmental Trajectories of Insomnia and Risk of Internalizing Disorders in Young Adulthood

Introduction

Internalizing disorders (ID) are the most common form of psychopathology and a large proportion of individuals experience their first onset after the age of 18. Childhood insomnia symptoms, i.e., difficulties initiating or maintaining sleep (DIMS), have been shown to be associated with ID. However, little is known about the developmental trajectories of insomnia symptoms and their associated risk of ID as the child transitions into adulthood. The present study examined the risk of ID in young adulthood associated with the longitudinal trajectories of insomnia symptoms across three developmental stages.

Methods

The Penn State Child Cohort is a population-based sample of 700 children (Mdn=9y), who were followed-up 8 years later as adolescents (N=421, Mdn=16y) and 15 years later as young adults (N=492, Mdn=24y). Insomnia symptoms were defined as parent-reported (childhood) or self-reported (adolescence and young adulthood) moderate-to-severe DIMS. The developmental trajectories of insomnia symptoms across the three time-points were identified as never, remitted, waxing-and-waning, persistent and incident. The presence of ID was defined as a self-report of a diagnosis or treatment for mood and/or anxiety disorders. Cox regression models were adjusted for sex, race/ethnicity, age and childhood/adolescent history of ID or psychoactive medication use.

Results

A persistent developmental trajectory was associated with a 2.8-fold increased risk of adult ID (HR=2.83, 95%CI=1.79–4.49) and an incident trajectory with a 1.9-fold risk (HR=1.88, 95%CI=1.10–3.20), while a waxing-and-waning trajectory was marginally associated with adult ID (HR=1.70, 95%CI=0.99–2.91). A remitting trajectory was not associated with an increased risk of adult ID (HR=0.92, 95%CI=0.38–2.24).

Conclusion

This 15-year longitudinal study with three developmental stages shows that childhood-onset insomnia symptoms that persist across the life-course are strong determinants of ID in young adulthood, independent of past diagnosis or medication use. In contrast, childhood insomnia symptoms that remit in the transition to adolescence do not confer increased risk of ID in young adulthood. Given that insomnia symptoms may precipitate and/or maintain ID, these data further reinforce the need for early sleep interventions to prevent mental health disorders.

Support (if any)

NIH Awards Number R01HL136587, R01MH118308, R01HL97165, R01HL63772, UL1TR000127

Insomnia with objective short sleep duration is associated with cognitive impairment: a first look at cardiometabolic contributors to brain health

STUDY OBJECTIVES

Insomnia with objective short sleep duration has been previously associated with adverse cardiometabolic health outcomes as well as poorer cognitive performance in otherwise noncognitively impaired adults. However, studies demonstrating an increased prevalence of cognitive impairment (CI) in this insomnia phenotype are lacking.

METHODS

We analyzed data from Penn State Adult Cohort (N = 1,524; 48.9 ± 13.4 years; 53.4% women). Self-reported sleep difficulty was defined as normal sleep (n = 899), poor sleep (n = 453), and chronic insomnia (n = 172). Objective short sleep duration was defined as less than 6-h of sleep, based on in-lab, 8-h polysomnography. CI (n = 155) and possible vascular cognitive impairment (pVCI, n = 122) were ascertained using a comprehensive neuropsychological battery. Analyses adjusted for age, sex, race, education, body mass index, apnea/hypopnea index, smoking, alcohol, psychoactive medication, and mental and physical health problems.

RESULTS

Participants who reported poor sleep or chronic insomnia and slept objectively less than 6 hours were associated with a 2-fold increased odds of CI (OR = 2.06, 95% confidence limits [CL] = 1.15-3.66 and OR = 2.18, 95% CL = 1.07-4.47, respectively) and of pVCI (OR = 1.94, 95% CL = 1.01-3.75 and OR = 2.33, 95% CL = 1.07-5.06, respectively). Participants who reported poor sleep or chronic insomnia and slept objectively more than 6 hours were not associated with increased odds of either CI (OR = 0.72, 95% CL = 0.30-1.76 and OR = 0.75, 95% CL = 0.21-2.71, respectively) or pVCI (OR = 1.08, 95% CL = 0.42-2.74 and OR = 0.76, 95% CL = 0.16-3.57, respectively).

CONCLUSIONS

Insomnia with objective short sleep duration is associated with an increased prevalence of CI, particularly as it relates to cardiometabolic health (i.e. pVCI). These data further support that this insomnia phenotype may be a more biologically severe form of the disorder associated with cardiovascular, cerebrovascular, and neurocognitive morbidity.

Natural history of insomnia symptoms in the transition from childhood to adolescence: population rates, health disparities, and risk factors

STUDY OBJECTIVES

To determine the sociodemographic, behavioral, and clinical risk factors associated with the persistence, remission, and incidence of insomnia symptoms in the transition from childhood to adolescence.

METHODS

The Penn State Child Cohort is a random, population-based sample of 700 children (5-12 years at baseline), of whom 421 were followed-up as adolescents (12-23 years at follow-up). Subjects underwent polysomnography, clinical history, physical exam, and parent- and self-reported scales at baseline and follow-up. Insomnia symptoms were defined as a parent- or self-report of difficulty falling and/or staying asleep.

RESULTS

The 421 subjects with baseline (Mage = 8.8 years) and follow-up (Mage = 17 years) data were 53.9% male and 21.9% racial/ethnic minorities. The persistence of childhood insomnia symptoms (CIS) was 56% (95% CI = 46.5-65.4), with only 30.3% (95% CI = 21.5-39.0) fully remitting. The incidence of adolescent insomnia symptoms was 31.1% (95% CI = 25.9-36.3). Female sex, racial/ethnic minority, and low socioeconomic status as well as psychiatric/behavioral or neurological disorders, obesity, smoking, and evening chronotype were associated with a higher persistence or incidence of insomnia symptoms.

CONCLUSIONS

CIS are highly persistent, with full remission occurring in only a third of children in the transition to adolescence. Sex-, racial/ethnic-, and socioeconomic-related disparities in insomnia occur as early as childhood, while different mental/physical health and lifestyle/circadian risk factors play a key role in the chronicity of CIS versus their incidence in adolescence. CIS should not be expected to developmentally remit and should become a focus of integrated pediatric/behavioral health strategies.

IGM-8444 as a potent agonistic Death Receptor 5 (DR5) IgM antibody: Induction of tumor cytotoxicity, combination with chemotherapy and in vitro safety profile

3595

Background: Death receptor 5 (DR5) is a member of the tumor necrosis factor (TNF) receptor superfamily that multimerizes when bound to its ligand, TNF-related apoptosis inducing ligand (TRAIL), to activate the extrinsic apoptotic pathway. DR5 is broadly expressed on solid and hematologic cancers and has been targeted with both recombinant TRAIL and agonistic antibodies in the clinic. However, these therapeutics have generally been unsuccessful due to toxicity or lack of efficacy. We have developed a multivalent IgM DR5 agonist, IGM-8444, that multimerizes DR5 to selectively and potently induce tumor cell apoptosis while maintaining tolerability. Methods: IGM-8444 is an engineered, pentameric IgM antibody with 10 binding sites specific for DR5. Human tumor cell lines or hepatocytes were evaluated in vitro for dose dependent IGM-8444 induced cytotoxicity. The efficacy of IGM-8444 was evaluated with or without chemotherapy, in cell line-derived xenograft (CDX) and patient-derived xenograft (PDX) mouse tumor models, with IGM-8444 administered at various dose levels and schedules when tumors reached approximately 100 mm3. Sera and tumors were analyzed for biomarkers of tumor apoptosis. Results: In vitro cytotoxicity assays identified IGM-8444 activity across cell lines from 18 solid and hematologic malignancies. In IGM-8444 partially resistant cell lines, combination with chemotherapy or a Bcl2 inhibitor enhanced in vitro cytotoxicity. IGM-8444 was efficacious as a monotherapy in CDX and PDX tumor models including colorectal, lung, and gastric indications. In a gastric PDX model, IGM-8444 induced complete and durable dose-dependent tumor regressions. In vivo, combination of IGM-8444 with standard-of-care chemotherapies, such as irinotecan, led to enhanced efficacy. IGM-8444 administration increased markers of tumor apoptosis, identifying potential clinical pharmacodynamic biomarkers. At doses several log-fold higher than efficacious doses, IGM-8444 demonstrated a favorable single agent in vitro safety profile, with little to no in vitro cytotoxicity observed using primary human hepatocytes from multiple donors. Conclusions: These data support the clinical development of IGM-8444 in both solid and hematological malignancies as a single agent and in combination with standard of care therapy. IGM-8444 is projected for IND filing in 2020.

Natural history of sleep disordered breathing in prepubertal children transitioning to adolescence

Because there is a lack of agreed upon diagnostic criteria, it is critical to understand the natural history of obstructive sleep apnoea (OSA) in children in order to establish treatment strategies based on objective data.The Penn State Child Cohort is a representative, general-population sample of 700 elementary school children at baseline, of whom 421 were reassessed 8 years later, during adolescence.The remission of childhood apnoea-hypopnoea index (AHI) ≥2 events per h in adolescence was 52.9%. Using the higher threshold of AHI ≥5 events per h, remission was 100.0%, with 50.0% partially remitting to AHI 2- <5 events per h and the other half remitting to AHI <2 events per h. The incidence of adolescent AHI ≥2 events per h in those with childhood AHI <2 events per h was 36.5%, while the incidence of AHI ≥5 events per h in those with childhood AHI <5 events per h was 10.6%. This longitudinal study confirms that prepubertal OSA tends to resolve naturally during the transition to adolescence, and that primary snoring and mild sleep disordered breathing (SDB) do not appear to be strongly associated with progression to more severe SDB.The key risk factors for SDB in adolescence are similar to those found in middle-aged adults (i.e. male sex, older age and obesity). Moreover, consistent with recent studies in adults, this study includes the novel cross-sectional finding that visceral fat is associated with SDB as early as adolescence.

Metabolic syndrome burden in apparently healthy adolescents is adversely associated with cardiac autonomic modulation--Penn State Children Cohort

BACKGROUND

Reduced cardiac autonomic modulation (CAM) has been associated with metabolic syndrome (MetS) in adults. However, the association between MetS component cluster and CAM has not been examined in adolescents.

METHODS

We conducted a cross-sectional analysis using data from the Penn State Child Cohort follow-up examination. CAM was assessed by heart rate variability (HRV) analysis of 39-h RR intervals, including frequency (high frequency, HF; low frequency, LF; and LF/HF ratio) and time (SDNN, standard deviation of all RR intervals; RMSSD, square root of the mean of the sum of the squares of differences between adjacent RR intervals; and HR, heart rate) domain variables. To assess the MetS burden, we used continuous MetS score (cMetS)--sum of the age and sex-adjusted standardized residual (Z-score) of five established MetS components. Linear mixed-effect models were used to analyze the association between cMetS and CAM in the entire population and stratified by gender.

RESULTS

After adjusting for age, sex, and race, cMetS was significantly associated with reduced HRV and higher HR. With 1 standard deviation increase in cMetS, there was a significant decrease in HF (-0.10 (SE = 0.02)), LF (-0.07 (SE = 0.01)), SDNN (-1.97 (SE = 0.50)), and RMSSD (-1.70 (SE = 0.72)), and increase in LF/HF (0.08 (SE = 0.02)) and HR (1.40 (SE = 0.26)). All cMetS components, with the exception of high-density lipoprotein (HDL), were associated with significantly decreased HRV and increased HR. High blood pressure (MAP) and triglyceride (TG) levels were also associated with an increase in LF/HF and decrease in RMSSD. An increase in high-density lipoprotein was only associated with higher LF and SDNN. Moreover, cMetS and HRV associations were more pronounced in males than in females. The associations between HRV and. MAP, TG, and HDL were more pronounced in females.

CONCLUSIONS

cMetS score is associated with lower HRV, suggesting an adverse impact on CAM, even in apparently healthy adolescents.

Sleep variability and cardiac autonomic modulation in adolescents - Penn State Child Cohort (PSCC) study

OBJECTIVE

To investigate the effects of objectively measured habitual sleep patterns on cardiac autonomic modulation (CAM) in a population-based sample of adolescents.

METHODS

We used data from 421 adolescents who completed the follow-up examination in the Penn State Children Cohort study. CAM was assessed by heart rate (HR) variability (HRV) analysis of beat-to-beat normal R-R intervals from a 39-h electrocardiogram, on a 30-min basis. The HRV indices included frequency domain (HF, LF, and LF/HF ratio), and time domain (SDNN, RMSSD, and heart rate or HR) variables. Actigraphy was used for seven consecutive nights to estimate nightly sleep duration and time in bed. The seven-night mean (SD) of sleep duration and sleep efficiency were used to represent sleep duration, duration variability, sleep efficiency, and efficiency variability, respectively. HF and LF were log-transformed for statistical analysis. Linear mixed-effect models were used to analyze the association between sleep patterns and CAM.

RESULTS

After adjusting for major confounders, increased sleep duration variability and efficiency variability were significantly associated with lower HRV and higher HR during the 39-h, as well as separated by daytime and nighttime. For instance, a 1-h increase in sleep duration variability is associated with -0.14(0.04), -0.12(0.06), and -0.16(0.05) ms(2) decrease in total, daytime, and nighttime HF, respectively. No associations were found between sleep duration, or sleep efficiency and HRV.

CONCLUSION

Higher habitual sleep duration variability and efficiency variability are associated with lower HRV and higher HR, suggesting that an irregular sleep pattern has an adverse impact on CAM, even in healthy adolescents.

Correlates of suicide ideation and attempts in children and adolescents with eating disorders

This is the first study determining correlates of suicide behavior in children with eating disorders using multiple sleep, psychological, and demographic variables. Mothers rated suicide ideation and attempts in 90 children ages 7-18 with bulimia nervosa or anorexia nervosa. Suicide ideation was more prevalent in children with bulimia nervosa (43%) than children with anorexia nervosa (20%). All children with bulimia nervosa who experienced ideation attempted suicide, whereas only 3% of children with anorexia nervosa attempted suicide. Correlates of ideation were externalizing behavior problems and sleep disturbances. Correlates of attempts were bulimia nervosa, self-induced vomiting, nightmares, and physical or sexual abuse. These problems should be assessed and targeted for intervention because of their association with suicide behavior.

Sleep problems in children

Sleep complaints and sleep disorders are common during childhood and adolescence. The impact of not getting enough sleep may affect children's' physical health as well emotional, cognitive and social development. Insomnia, sleep-disordered breathing, parasomnias and sleep disturbances associated with medical and psychiatric disorders are some of the commonly encountered sleep disorders in this age group. Changes in sleep architecture and the amount of sleep requirement associated with each stage of development should be considered during an evaluation of sleep disorders in children. Behavioral treatments should be used initially wherever possible especially considering that most pharmacologic agents used to treat pediatric sleep disorders are off-label. In this review we address the most common sleep problems in children/adolescents as they relate to prevalence, presentation and symptoms, evaluation and management.

Risk factors for incident chronic insomnia: a general population prospective study

OBJECTIVE

The few population-based, prospective studies that have examined risk factors of incident insomnia were limited by small sample size, short follow-up, and lack of data on medical disorders or polysomnography. We prospectively examined the associations between demographics, behavioral factors, psychiatric and medical disorders, and polysomnography with incident chronic insomnia.

METHODS

From a random, general population sample of 1741 individuals of the adult Penn State Sleep Cohort, 1395 were followed-up after 7.5 years. Only subjects without chronic insomnia at baseline (n = 1246) were included in this study. Structured medical and psychiatric history, personality testing, and 8-h polysomnography were obtained at baseline. Structured sleep history was obtained at baseline and follow-up.

RESULTS

Incidence of chronic insomnia was 9.3%, with a higher incidence in women (12.9%) than in men (6.2%). Younger age (20-35 years), non-white ethnicity, and obesity increased the risk of chronic insomnia. Poor sleep and mental health were stronger predictors of incident chronic insomnia compared to physical health. Higher scores in MMPI-2, indicating maladaptive personality traits, and excessive use of coffee at baseline predicted incident chronic insomnia. Polysomnographic variables, such as short sleep duration or sleep apnea, did not predict incident chronic insomnia.

CONCLUSION

Mental health, poor sleep, and obesity, but not sleep apnea, are significant risk factors for incident chronic insomnia. Focusing on these more vulnerable groups and addressing the modifiable risk factors may help reduce the incident of chronic insomnia, a common and chronic sleep disorder associated with significant medical and psychiatric morbidity and mortality.

Insomnia with short sleep duration and mortality: the Penn State cohort

STUDY OBJECTIVES

Because insomnia with objective short sleep duration is associated with increased morbidity, we examined the effects of this insomnia subtype on all-cause mortality.

DESIGN

Longitudinal.

SETTING

Sleep laboratory.

PARTICIPANTS

1,741 men and women randomly selected from Central Pennsylvania.

MEASUREMENTS

Participants were studied in the sleep laboratory and were followed-up for 14 years (men) and 10 years (women). "Insomnia" was defined by a complaint of insomnia with duration > or = 1 year. "Normal sleeping" was defined as absence of insomnia. Polysomnographic sleep duration was classified into two categories: the "normal sleep duration group" subjects who slept > or = 6 h and the "short sleep duration group" subjects who slept < 6 h. We adjusted for age, race, education, body mass index, smoking, alcohol, depression, sleep disordered breathing, and sampling weight.

RESULTS

The mortality rate was 21% for men and 5% for women. In men, mortality risk was significantly increased in insomniacs who slept less than 6 hours compared to the "normal sleep duration, no insomnia" group, (OR = 4.00, CI 1.14-13.99) after adjusting for diabetes, hypertension, and other confounders. Furthermore, there was a marginally significant trend (P = 0.15) towards higher mortality risk from insomnia and short sleep in patients with diabetes or hypertension (OR = 7.17, 95% CI 1.41-36.62) than in those without these comorbid conditions (OR = 1.45, 95% CI 0.13-16.14). In women, mortality was not associated with insomnia and short sleep duration.

CONCLUSIONS

Insomnia with objective short sleep duration in men is associated with increased mortality, a risk that has been underestimated.

Sleep-disordered breathing and cardiac autonomic modulation in children

OBJECTIVES

To investigate the adverse cardiac autonomic effects of sleep-disordered breathing (SDB) in a large population-based sample and a clinical sample of children.

METHODS

Subjects included a population-based sample of 700 and a clinically diagnosed sample of 43 SDB children. SDB was defined based on an apnea hypopnea index (AHI) 1 during one night of polysomnography. Cardiac autonomic modulation was measured by heart rate variability (HRV) analysis of the beat-to-beat RR interval data collected during polysomnography.

RESULTS

The mean (SD) age was 112 (21) months, with 49% male and 25% non-white. About 73.0% had AHI<1 (no SDB), 25.8% had 1-5 AHI (mild SDB), and 1.2% had 5 AHI (moderate SDB). Among individuals with moderate SDB in the population-based sample and the clinically diagnosed SDB patients, the mean (SE) of HRV-high frequency power (HF) was significantly lower compared to children without SDB [6.00 (0.32) and 6.24 (0.14), respectively, vs. 6.68 (0.04) ms(2), p<0.05 and p<0.01, respectively], whereas the low frequency power to high frequency power ratio (LF/HF) was significantly higher [1.62 (0.20) and 1.74 (0.09), respectively, vs. 0.99 (0.02), both p<0.01)].

CONCLUSIONS

SDB in healthy young children and in clinical patients is significantly associated with impaired cardiac autonomic modulation, i.e., sympathetic overflow and weaker parasympathetic modulation, which may contribute to increased risk of acute cardiac events in persons with SDB, even before reaching the "high risk age."

Insomnia with objective short sleep duration is associated with deficits in neuropsychological performance: a general population study

STUDY OBJECTIVES

To examine the joint effect of insomnia and objective short sleep duration on neuropsychological performance.

DESIGN

Representative cross-sectional study.

SETTING

Sleep laboratory.

PARTICIPANTS

1,741 men and women randomly selected from central Pennsylvania.

INTERVENTIONS

None.

MEASUREMENTS

Insomnia (n = 116) was defined by a complaint of insomnia with a duration > or = 1 year and the absence of sleep disordered breathing (SDB), while normal sleep (n = 562) was defined as the absence of insomnia, excessive daytime sleepiness, and SDB. Both groups were split according to polysomnographic sleep duration into 2 categories: > or = 6 h of sleep ("normal sleep duration") and < 6 h of sleep ("short sleep duration"). We compared the groups' performance on a comprehensive neuropsychological battery that measured processing speed, attention, visual memory, and verbal fluency, while controlling for age, race, gender, education, body mass index, and physical and mental health.

RESULTS

No significant differences were detected between insomniacs and controls. However, the insomnia with short sleep duration group compared to the control with normal or short sleep duration groups showed poorer neuropsychological performance in variables such as processing speed, set-switching attention, and number of visual memory errors and omissions. In contrast, the insomnia with normal sleep duration group showed no significant deficits.

CONCLUSIONS

Insomnia with objective short sleep duration is associated with deficits in set-switching attentional abilities, a key component of the "executive control of attention." These findings suggest that objective sleep duration may predict the severity of chronic insomnia, including its effect on neurocognitive function.

Sleep-disordered breathing in children is associated with impairment of sleep stage-specific shift of cardiac autonomic modulation

We examined the effects of sleep stages and sleep-disordered breathing (SDB) on autonomic modulation in 700 children. Apnea hypopnea index (AHI) during one 9 h night-time polysomnography was used to define SDB. Sleep stage-specific autonomic modulation was measured by heart rate variability (HRV) analysis of the first available 5 min RR intervals from each sleep stage. The mean [standard deviation (SD)] age was 112 (21) months (49% male and 25% non-Caucasian). The average AHI was 0.79 (SD = 1.03) h(-1), while 73.0%, 25.8% and 1.2% of children had AHI <1 (no SDB), 1-5 (mild SDB) and >or=5 (moderate SDB), respectively. In the no SDB group, the high frequency (HF) and root mean square SD (RMSSD) increased significantly from wake to Stage 2 and slow wave sleep (SWS), and then decreased dramatically when shifting into rapid eye movement (REM) sleep. In the moderate SDB group, the pattern of HRV shift was similar to that of no SDB. However, the decreases in HF and RMSSD from SWS to REM were more pronounced in moderate SDB children [between-group differences in HF (-24% in moderate SDB versus -10% in no SDB) and RMSSD (-27% versus -12%) were significant (P < 0.05)]. The REM stage HF is significantly lower in the moderate SDB group compared to the no SDB group [mean (standard error): 4.49 (0.43) versus 5.80 (0.05) ms(2), respectively, P < 0.05]. Conclusions are that autonomic modulation shifts significantly towards higher parasympathetic modulation from wake to non-rapid eye movement sleep, and reverses to a less parasympathetic modulation during REM sleep. However, the autonomic modulation is impaired among children with moderate SDB in the directions of more reduction in parasympathetic modulation from SWS to REM sleep and significantly weaker parasympathetic modulation in REM sleep, which may lead to higher arrhythmia vulnerability, especially during REM sleep.

Sleep-disordered breathing in obese children is associated with prevalent excessive daytime sleepiness, inflammation, and metabolic abnormalities

BACKGROUND

In obese adults, sleep apnea is associated with excessive daytime sleepiness (EDS) and cardiometabolic risk factors. In children, on the other hand, sleep-disordered breathing (SDB) is primarily associated with anatomic abnormalities and neurocognitive impairment, whereas studies on potential concurrent metabolic aberrations and EDS have been limited and inconsistent. In this study, we examined the joint effect of SDB and obesity in EDS as well as proinflammatory and metabolic markers.

METHODS

One hundred fifty children, aged 5-17 yr, were consecutively recruited from our sleep disorders clinic and a subset of the Penn State Children's Cohort. Every child had a thorough history and physical examination, 9-h polysomnographic study, and a single blood draw for the assessment of IL-6, TNFalpha, soluble IL-6 receptor, TNF receptor-1, hypersensitive C-reactive protein, leptin, and adiponectin. In addition, parents completed a subjective questionnaire to assess EDS. Analysis of covariance was performed on four groups that were separated by SDB severity and body mass index.

RESULTS

EDS frequency increased progressively and significantly in the four groups. There was a significant linear trend in plasma IL-6, TNF receptor-1, hypersensitive C-reactive protein, and leptin concentrations, with lowest levels observed in lean controls and highest in overweight/obese with moderate SDB. Adiponectin followed the opposite pattern.

CONCLUSIONS

This study suggests that in a clinical sample of obese children, SDB is associated with EDS, elevation of proinflammatory cytokines, increased leptin, and decreased adiponectin. All these changes point to an inflammatory/insulin resistance state, suggesting that SDB in obese children share many similarities with SDB in obese adults.

Medical complaints are more common in young school-aged children with parent reported insomnia symptoms

OBJECTIVE

Studies in adults have found significant association between sleep disturbances and various medical symptoms/disorders. However, in children, few studies have explored this complex association in clinical samples. In this study, we examined prevalence of medical complaints in children with insomnia symptoms in a large general population of school aged children.

METHODS

We conducted a cross sectional study of 700 children, ages 5-12 years, from the Penn State Children's Cohort. All children underwent a medical and psychiatric history, physical examination, 9-h overnight polysomnography, and neuropsychological testing. Comprehensive sleep and development questionnaires were completed by a parent. We compared 135 (19.3%) children with parent-reported sleep disturbances to 565 (80.7%) children with no parent-reported sleep disturbances.

RESULTS

Insomnia symptoms were significantly associated with gastrointestinal regurgitation and headaches after controlling for demographic variables, apnea hypopnea index, ADHD, learning disorder or other psychiatric/behavioral disorder, socioeconomic status, and minority status. Children with gastrointestinal regurgitation and headaches compared to children without these symptoms were 3.3 times and 2.3 times as likely to suffer from sleep disturbances, respectively. Objectively, sleep latency increased in the sleep disturbance group, and there were significant differences between groups in REM latency, slow wave, and stage 2 sleep.

DISCUSSION

These results underscore the importance of inquiring about insomnia symptoms when children present with medical complaints particularly gastrointestinal regurgitation or headaches and taking a comprehensive medical history when children present with sleep complaints. Future studies are needed to replicate these findings and explore the possible underlying pathophysiological abnormalities of such comorbidity between insomnia symptoms and medical symptoms in children.

Insomnia with objective short sleep duration is associated with type 2 diabetes: A population-based study

OBJECTIVE

We examined the joint effects of insomnia and objective short sleep duration, the combination of which is associated with higher morbidity, on diabetes risk.

RESEARCH DESIGN AND METHODS

A total of 1,741 men and women randomly selected from Central Pennsylvania were studied in the sleep laboratory. Insomnia was defined by a complaint of insomnia with duration of >or=1 year, whereas poor sleep was defined as a complaint of difficulty falling asleep, staying asleep, or early final awakening. Polysomnographic sleep duration was classified into three categories: >or=6 h of sleep (top 50% of the sample); 5-6 h (approximately third quartile of the sample); and <or=5 h (approximately the bottom quartile of the sample). Diabetes was defined either based on a fasting blood glucose >126 mg/dl or use of medication. In the logistic regression model, we simultaneously adjusted for age, race, sex, BMI, smoking, alcohol use, depression, sleep-disordered breathing, and periodic limb movement.

RESULTS

Chronic insomnia but not poor sleep was associated with a higher risk for diabetes. Compared with the normal sleeping and >or=6 h sleep duration group, the highest risk of diabetes was in individuals with insomnia and <or=5 h sleep duration group (odds ratio [95% CI] 2.95 [1.2-7.0]) and in insomniacs who slept 5-6 h (2.07 [0.68-6.4]).

CONCLUSIONS

Insomnia with short sleep duration is associated with increased odds of diabetes. Objective sleep duration may predict cardiometabolic morbidity of chronic insomnia, the medical impact of which has been underestimated.

Sleep disordered breathing in children in a general population sample: prevalence and risk factors

STUDY OBJECTIVES

Assess the prevalence based on clinically meaningful criteria (i.e., blood pressure) and identify risk factors of sleep disordered breathing (SDB) in a representative sample of elementary school children.

DESIGN

A random sample of the local elementary school children (K-5) were assessed using a two-phased strategy. In phase I a brief questionnaire was completed by a parent of each child in local elementary schools (N = 5,740), with a response rate of 78.5%. In phase II, randomly selected children and their parent spent a night in our sleep laboratory (N = 700) with a response rate of 70.0%.

SETTING

University sleep laboratory.

PARTICIPANTS

Children enrolled in local elementary schools.

INTERVENTION

None.

MEASUREMENT & RESULTS

Each child was assessed with a full polysomnogram and completed a history/physical examination including an electrocardiogram, otolaryngology examination, and pulmonary evaluation. The prevalence of moderate SDB (apnea-hypopnea index > or = 5) was 1.2%. The independent risk factors included nasal abnormalities and minority associated only with mild (1 < AHI < 5) SDB and snoring and waist circumference associated with all levels of SDB. Tonsil size, based on visual inspection, was not an independent risk factor.

CONCLUSION

The prevalence of AHI > or = 5 was 1.2% in a representative sample of elementary school children. Risk factors for SDB included waist circumference, nasal abnormalities (e.g., chronic sinusitis/rhinitis), and minority. The strong linear relationship between waist circumference and BMI across all degrees of severity of SDB suggests that, as in adults, metabolic factors may be among the most important risk factors for SDB in children.