Average Volume-assured Pressure Support as Rescue Therapy after CPAP Failure in Pediatric Obstructive Sleep Apnea: A Retrospective Case Series Study.

Background: Continuous positive airway pressure (CPAP) is frequently prescribed for patients with residual obstructive sleep apnea (OSA) following adenotonsillectomy. Objectives: The goal was to examine the efficacy of noninvasive ventilation with average volume-assured pressure support (AVAPS) as a potential option for children with failed CPAP titration. Methods: In a single-center retrospective study, we included children aged 1-17 years, with polysomnographically confirmed OSA who underwent AVAPS titration following failed CPAP titration. In addition to describing the clinical characteristics of the included patients, we compared polysomnographic parameters before and after AVAPS. Results: Nine patients met the inclusion criteria; out of them, 8 (89%) were males with an age range of 6.7 ± 3.9 years and a body mass index percentile of 81.0 ± 28.9. Reasons for failed CPAP titration were: 3 (33%) patients due to inability to control apnea-hypopnea index (AHI), 3 (33%) patients due to sleep-related hypoventilation, 2 (22%) patients due to treatment-emergent central sleep apnea, and 1 (11%) patient due to intolerance to CPAP. AVAPS resulted in a greater reduction in AHI than CPAP (reduction following CPAP = 24.6 ± 29.3, reduction following AVAPS = 42.5 ± 37.6, p = 0.008). All patients had resolution of the problems which caused CPAP failure. Conclusion: In this case a series of children with OSA and with failed CPAP titration, AVAPS resulted in a greater reduction in AHI compared with CPAP as well as resolution of the problems which caused CPAP failure.

Successful Treatment of Respiratory Failure in a Patient with Prader-Willi Syndrome with Noninvasive Ventilation with AVAPS.

Prader-Willi syndrome (PWS) is the most prevalent syndromic form of obesity, which starts during early childhood in the setting of hyperphagia. Due to the development of obesity, there is a high prevalence of obstructive sleep apnea (OSA) among these patients. This case report presents a patient with PWS with morbid obesity, severe OSA, and obesity hypoventilation syndrome admitted to the hospital for hypoxemic and hypercapnic respiratory failure. Noninvasive ventilation (NIV) with average volume-assured pressure support, a newer NIV modality, was used successfully to treat this patient, achieving major clinical and gas exchange improvement both during the hospitalization and long term after discharge.

Poor Sleep Quality and Other Risk Factors for Unemployment Among Patients on Opioid Agonist Treatment.

Purpose: Patients with opioid use disorder (OUD) face high rates of unemployment, putting them at higher risk of treatment nonadherence and poor outcomes, including overdose death. The objective of this study was to investigate sleep quality and its association with other biopsychosocial risk factors for unemployment in patients receiving opioid agonist treatment (OAT) for OUD. Methods: Using a cross-sectional survey design, participants from 3 OAT programs for OUD completed questionnaires to measure sleep quality (Pittsburgh Sleep Quality Index [PSQI]); pain disability; catastrophic thinking; injustice experience; quality of life; and self-assessed disability. Spearman's rank correlation was used to test for associations between sleep quality and other study variables. Results: Thirty-eight participants completed the study, with mean age 45.6 ± 10.9 years, 27 (71.1%) males, and 16 (42.1%) reporting a high school diploma/equivalent certification as the highest level of academic attainment. Poor sleep quality (defined as PSQI > 5) was identified in 29 participants (76.3%) and was positively correlated with pain disability (r = 0.657, P < .01), self-assessed disability (r = 0.640, P < .001), symptom catastrophizing (r = 0.499, P < .001), and injustice experience (r = 0.642, P < .001), and negatively correlated with quality of life (r = -0.623, P < .001). Conclusions: There was a high prevalence of poor sleep quality in patients with OUD on OAT and this was associated with multiple known risk factors for unemployment. These findings warrant the consideration of regular screening for sleep problems and the inclusion of sleep-related interventions to improve sleep quality, decrease the unemployment rate, and enhance the recovery process for individuals with OUD undergoing OAT.

Average volume-assured pressure support for patients with obstructive sleep apnea with failed CPAP titration.

Objectives: Obstructive sleep apnea (OSA) is a common disease, often treated using continuous positive airway pressure (CPAP) therapy. In many cases, patients fail a CPAP titration study due to inadequate control of the apnea-hypopnea index (AHI, events/hour) or due to treatment-emergent central sleep apnea (TE-CSA). We report our experience using a mode of non-invasive ventilation for alternative treatment of these patients. Material and Methods: We reviewed records of adults who had OSA with AHI≥15 diagnosed on polysomnography (PSG) with failed CPAP titration and in whom titrations with average volume-assured pressure support (AVAPS) with auto-titrating expiratory positive airway pressure were performed. Results: Forty-five patients, age 57.9±13.1 y, 26 males, body mass index (BMI) 40.2±8.7kg/m2. Reasons for CPAP titration failure included: TE-CSA (25, 55.6%) and inadequate control of AHI at maximum CPAP of 20cm H2O (20, 44.4%). Changes noted from baseline PSG to AVAPS titration: AHI: 65.3±29.3 decreased to 22.3±16.1 (p<0.001). Median time SpO2 ≤88%: 63.7 to 6.9min (p<0.001). In 16 patients the AHI was reduced to <15 and in 16 additional patients the AHI was reduced to <30. Improvement in AHI was not related to gender, age, or opioid use, but was correlated with BMI: ∆AHI=12.2 - (1.4 * BMI); p=0.05. AVAPS resulted in improved sleep architecture: median N3 sleep increased: 1.4% to 19.6% total sleep time (TST) (p<0.001), and median R sleep increased: 6.4% to 13.6% TST (p<0.01). Discussion: For patients with OSA for whom CPAP titration failed, titration with AVAPS may be an effective treatment.

Images: polysomnographic findings of nystagmus caused by a midbrain hemorrhagic stroke.

Brainstem strokes can present with an array of ophthalmologic findings depending on the location of the lesion. Eye movements are recorded on electrooculogram during polysomnography for sleep staging. We present the case of a patient with a dorsal midbrain hemorrhagic stroke and nystagmus with distinct findings on the electrooculogram during polysomnography. These eye movements from nystagmus differed in many aspects (frequency and amplitude) from the classic findings of other eye movements recorded during different stages of sleep. These polysomnography findings have not been reported in the setting of midbrain stroke. Future studies comparing nystagmus in multiple sleep stages in stroke patients would be of interest. CITATION: Shoukat U, Glick DR, Chaturvedi S, Diaz-Abad M. Images: Polysomnographic findings of nystagmus caused by a midbrain hemorrhagic stroke. J Clin Sleep Med. 2022;18(5):1479-1482.

Spirometry testing for extracorporeal membrane oxygenation (ECMO) bridge to transplant patients.

PURPOSE: ECMO can provide a bridge to transplantation and improve survival for patients with advanced lung disease. Although pulmonary function testing (PFT) is an important component of the lung allocation score (LAS), it is not always feasible on patients requiring ECMO. While generally safe, PFT testing has contraindications and is not recommended in unstable patients. Currently there are no recommendations regarding the performance of spirometry in ECMO patients. STUDY DESIGN: and Methods: We reviewed data on five patients with advanced lung disease requiring ECMO-bridge to transplant. After careful consideration of the theoretical physiologic risks associated with forced expiratory maneuvers, bedside spirometry was performed in order to update the patients' LAS. RESULTS: All patients successfully completed three forced expiratory maneuvers in the seated position with a bedside spirometer. Vital signs and ECMO flow were stable during testing and without complication. In 2 patients who had both a LAS pre and post spirometry, the LAS increased by 3-5 points. CONCLUSION: Spirometry results are pivotal to organ allocation under current organ sharing protocols. This case series demonstrates that bedside spirometry testing may be performed safely in patients on ECMO awaiting lung transplantation without appreciable side effects, leading to a more accurate LAS score.

Use of average volume-assured pressure support as a therapeutic option in patients with central sleep apnea syndrome.

PURPOSE: Central sleep apnea (CSA) syndrome commonly occurs with other medical conditions such as congestive heart failure, opiate use, and brainstem disorders. Various treatment modalities have been used with varied effectiveness in an attempt to improve ventilation and reduce the apnea-hypopnea index (AHI) in patients with CSA. This study evaluated whether or not a bilevel positive airway pressure mode of noninvasive ventilation, average volume-assured pressure support (AVAPS) is effective in treating CSA. METHODS: This was a retrospective review of patients with CSA who underwent AVAPS titration studies at our institution. We included patients with CSA with apnea-hypopnea index (events/hour) (AHI) ≥ 15, and examined the effectiveness of AVAPS in reducing AHI, improving oxygenation parameters, and improving sleep architecture. RESULTS: There were 12 patients, with mean age 62.8 ± 11.5 years, body mass index (BMI) 33.5 ± 4.7 kg/m2, 8 men, and Epworth Sleepiness Scale 9.3 ± 4.9. Five patients had CSA attributed to opiate use, 4 patients had CSA with Cheyne-Stokes respiration, and 3 patients had primary CSA. The only significant change from baseline PSG was AHI reduction with AVAPS: 63.3 ± 19.1 to 30.5 ± 30.3 (p < 0.003). In 5 patients (42%), AHI was reduced to < 15 with AVAPS use. Improvement in AHI was not related to gender, BMI, opiate use, or age. Defining response to therapy as AHI reduced to < 15, we found that lack of hypertension was the only significant predictor of response (p = 0.045). No significant changes in sleep architecture between the two studies were found. CONCLUSION: AVAPS is an effective mode of treating CSA in a significant proportion of patients. More studies are needed to confirm these findings and determine what factors are associated with response to therapy.

Assessing calorie and protein recommendations for survivors of critical illness weaning from prolonged mechanical ventilation - can we find a proper balance?

BACKGROUND & AIMS: Survivors of critical illness requiring prolonged mechanical ventilation (PMV) are predisposed to malnutrition, muscle wasting, and weakness. There is a lack of data regarding nutrition adequacy among these patients, and although nitrogen balance has been studied as a marker of adequate protein intake in healthy individuals and acutely critically ill patients, it has not been well studied in critically ill patients with PMV. The purpose of this study was to determine if patients requiring PMV admitted to a long-term acute care hospital (LTACH) achieved registered dietitian (RD) recommended goals for energy and protein intake and if the recommendations were adequate to avoid negative nitrogen balance. METHODS: Using a retrospective, cohort study design, patients requiring PMV who had orders for 24-h urine collections for urea nitrogen (24hrUUN) were included. Energy and protein intake was calculated from chart documentation of dietary intake for the 24-h period during which patients underwent a 24hrUUN. Nitrogen intake was estimated from protein intake. Dietary intake was compared to RD-recommendations to determine the percentage of RD-recommendations achieved. Nitrogen balance was calculated as nitrogen intake minus nitrogen loss, with negative balance categorized as less than -1. RESULTS: Subjects (n = 16) were 38% male and 75% African American (mean age 61.5 ± 3.2 years; mean BMI 27.5 ± 2.5 kg/m2). Duration of LTACH hospitalization was 26.5 (6-221) days. Mean energy and protein intake was 21.7 ± 2.9 kcal/kg/d and 1.1 ± 0.1 g/kg/d, respectively, which corresponded to 86% of both RD energy and protein recommendations. Ten patients achieved a positive nitrogen balance (mean 0.9 ± 1.1 g). In addition, there was a positive linear relationship between protein intake and nitrogen balance (r = 0.59, p = 0.016). CONCLUSION: Survivors of critical illness requiring PMV achieved a high percentage of RD-recommended protein and calories, and prevented a negative nitrogen balance in a majority of patients. Increasing protein intake can prevent a negative nitrogen balance. Future studies should evaluate whether these patients are able to maintain a steady state of nitrogen intake and excretion over time and how this affects time to and/or success of weaning.

Atraumatic Splenic Rupture Associated with Influenza A (H1N1) Pneumonia: Case Report and Review of the Literature.

Influenza virus infection may present with fever, chills, headache, myalgia, malaise, and respiratory symptoms, with a few cases developing into pneumonia, respiratory failure, and other organ damage. Very few cases of atraumatic splenic rupture associated with influenza infection have been reported. Atraumatic splenic rupture, while rare, is associated with high mortality. Here, we report the first case of atraumatic splenic rupture associated with influenza infection in the English literature and review the prior reported literature. The patient was diagnosed with influenza A (H1N1) pneumonia and subsequently developed hemorrhagic shock requiring emergency laparotomy and removal of the ruptured spleen.

A successful case of extracorporeal membrane oxygenation for COVID-19: walking home without oxygen supplementation.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged from Wuhan, China in December 2019 and is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19). Approximately one-third of the patients with COVID-19 require intensive care unit (ICU) admission, and almost 30% of the patients develop acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is used as salvage therapy for severe ARDS. The role of ECMO in the treatment of COVID-19 remains unclear, although there is emerging evidence that this approach may be an effective salvage therapy for severe ARDS. Case Presentation: We present a case of a previously healthy 39-year-old Hispanic male who presented to the hospital with flu-like symptoms, including headache, fatigue, and myalgia for 8 days in late April 2020. He denied dyspnea on exertion. The patient's symptoms progressed, resulting in pneumonia and acute respiratory distress syndrome (ARDS). The patient was managed with prone positioning, convalescent plasma and veno-venous extracorporeal membrane oxygenation (VV-ECMO) for 35 days. The patient successfully recovered and was able to ambulate independently and was discharged home from an acute care hospital without oxygen supplementation on hospital day 63. Conclusion: We present one of the first few documented cases of ECMO for severe ARDS due to COVID-19. After a prolonged hospital course requiring VV-ECMO, the patient was discharged home from an acute care hospital without oxygen requirement and ambulated independently, likely as a result of daily aggressive mobility-focused rehabilitation.

Granulomatous Pneumocystis jiroveci Pneumonia in an HIV-Positive Patient on Antiretroviral Therapy: A Diagnostic Challenge.

Human Immunodeficiency Virus (HIV)-related Opportunistic Infections (OI), including Pneumocystis jiroveci pneumonia (PCP), have become much less commonplace with anti-retroviral therapy (ART). Despite this, OIs are still common and it is important to remain vigilant for their presence and be aware of how ART and OI chemoprophylaxis may lead to atypical disease presentations. We present the case of a 51-year-old woman with HIV and CD4+ T helper lymphocytes cell count > 200 cells/ul on both ART and trimethoprim/sulfamethoxazole prophylaxis who presented with cavitating lung masses, mediastinal lymphadenopathy and pleural effusions. Negative bronchoalveolar lavage (BAL) and transbronchial biopsy (TBBx) prompted a second diagnostic procedure with a transthoracic core needle biopsy; the final diagnosis was granulomatous PCP. This case showcases a very rare presentation of PCP, with both large cavitating lung masses on imaging and granulomatous reaction on pathology, as well as the challenge of a potentially missed diagnosis with negative BAL and TBBx requiring transthoracic core needle biopsy for a final diagnosis.

Improving sleep medicine education among health professions trainees.

STUDY OBJECTIVES: Despite increasing recognition of its importance, sleep medicine education remains limited during medical training. We sought to assess the baseline knowledge of a group of health professions trainees and to determine whether an educational sleep medicine "boot camp" led to improvement in sleep medicine knowledge. METHODS: Participants attended a 2-day introduction to sleep medicine course designed for new sleep medicine fellows in July 2017 and 2018. Participants completed 2 validated sleep knowledge questionnaires (The Assessment of Sleep Knowledge in Medical Education and The Dartmouth Sleep Knowledge and Attitude Survey) prior to and at the conclusion of the course. RESULTS: A total of 21 health professions trainees including 14 sleep medicine fellows completed both presurveys and postsurveys. Baseline Assessment of Sleep Knowledge in Medical Education Survey score was 21.4 ± 3.4 out of 30 (71.4% ± 11.4%) and baseline Dartmouth Sleep Knowledge and Attitude Survey score was 16.1 ± 2.4 out of 24 (67.3% ± 9.9%). There was no difference in baseline scores between sleep medicine fellows and other health professions trainees. There was a statistically significant improvement in the Assessment of Sleep Knowledge in Medical Education Survey (2.9 ± 2.1 points, P = .004) and Dartmouth Sleep Knowledge and Attitude Survey (2.5 ± 3.0 points, P = .001) scores among all participants after the course, without a difference in degree of improvement among sleep medicine fellows compared to other health professions trainees. CONCLUSIONS: Our findings suggest that baseline sleep medicine knowledge is higher than previously reported among health professions trainees. An educational sleep medicine boot camp improved knowledge even in a group of learners with high baseline knowledge and interest in sleep medicine, including new sleep medicine fellows. CITATION: Wappel SR, Scharf SM, Cohen L, et al. Improving sleep medicine education among health profession trainees. J Clin Sleep Med. 2021;17(12):2461-2466.

High-Flow Nasal Oxygen Therapy in Acute Hypoxemic Respiratory Failure: Concise Review on Technology and Initial Methodology.

High-flow nasal cannula oxygen therapy (HFNCOT) system consists of an air/oxygen supply system capable of delivering up to 100% humidified and heated oxygen at a flow rate of up to 80 L/min. The system includes a blender, active humidifier, single heated tube, and nasal cannula. HFNCOT has many physiological advantages compared with other standard oxygen therapies, such as anatomical dead space washout, more constant fraction of inspired oxygen, positive end-expiratory (PEEP) effect, supplement of adequate humidification and maintenance of muco-ciliary function. HFNCOT is mostly used for hypoxemic acute respiratory failure, although it also has other indications. HFNCOT is a common choice of physicians as its technology makes it more silent and comfortable. Though HFNCOT is used in many clinical settings, there is a lack of publications addressing devices and initial settings. We present a review on HFNCOT, with focus on device and application methodology.

The role of non-invasive ventilation in weaning and decannulating critically ill patients with tracheostomy: A narrative review of the literature.

INTRODUCTION: Invasive mechanical ventilation (IMV) is associated with several complications. Placement of a long-term airway (tracheostomy) is also associated with short and long-term risks for patients. Nevertheless, tracheostomies are placed to help reduce the duration of IMV, facilitate weaning and eventually undergo successful decannulation. METHODS: We performed a narrative review by searching PubMed, Embase and Medline databases to identify relevant citations using the search terms (with synonyms and closely related words) "non-invasive ventilation", "tracheostomy" and "weaning". We identified 13 publications comprising retrospective or prospective studies in which non-invasive ventilation (NIV) was one of the strategies used during weaning from IMV and/or tracheostomy decannulation. RESULTS: In some studies, patients with tracheostomies represented a subgroup of patients on IMV. Most of the studies involved patients with underlying cardiopulmonary comorbidities and conditions, and primarily involved specialized weaning centres. Not all studies provided data on decannulation, although those which did, report high success rates for weaning and decannulation when using NIV as an adjunct to weaning patient off ventilatory support. However, a significant percentage of patients still needed home NIV after discharge. CONCLUSIONS: The review supports a potential role for NIV in weaning patients with a tracheostomy either off the ventilator and/or with its decannulation. Additional research is needed to develop weaning protocols and better characterize the role of NIV during weaning.

Invasive mechanical ventilation using a bilevel PAP ST device in a healthy swine model.

PURPOSE: The Coronavirus Disease 2019 (COVID-19) pandemic may cause an acute shortage of ventilators. Standard noninvasive bilevel positive airway pressure devices with spontaneous and timed respirations (bilevel PAP ST) could provide invasive ventilation but evidence on their effectiveness in this capacity is limited. We sought to evaluate the ability of bilevel PAP ST to effect gas exchange via invasive ventilation in a healthy swine model. METHODS: Two single limb respiratory circuits with passive filtered exhalation were constructed and evaluated. Next, two bilevel PAP ST devices, designed for sleep laboratory and home use, were tested on an intubated healthy swine model using these circuits. These devices were compared to an anesthesia ventilator. RESULTS: We evaluated respiratory mechanics, minute ventilation, oxygenation, and presence of rebreathing for all of these devices. Both bilevel PAP ST devices were able to control the measured parameters. There were noted differences in performance between the two devices. Despite these differences, both devices provided effective invasive ventilation by controlling minute ventilation and providing adequate oxygenation in the animal model. CONCLUSIONS: Commercially available bilevel PAP ST can provide invasive ventilation with a single limb respiratory circuit and in-line filters to control oxygenation and ventilation without significant rebreathing in a swine model. Further study is needed to evaluate safety and efficacy in clinical disease models. In the setting of a ventilator shortage during the COVID-19 pandemic, and in other resource-constrained situations, these devices may be considered as an effective alternative means for invasive ventilation.

Treatment-Related Changes in Heart Rate Variability in Children with Sleep Apnea.

OBJECTIVE: Heart rate variability (HRV), a noninvasive indicator of autonomic regulation of cardiac rhythm, may represent the physiologic burden of obstructive sleep apnea (OSA). We hypothesized that the treatment-related effects of OSA on HRV in children are causally attributable to the improvement in OSA severity. STUDY DESIGN: Secondary analysis of outcomes from the Childhood Adenotonsillectomy Trial (CHAT). SETTING: Analysis of database. SUBJECTS AND METHODS: Time- and frequency-domain HRV parameters along with polysomnographic (PSG) and demographic variables were obtained from the CHAT study, which compared early adenotonsillectomy (eAT) to watchful waiting (WW) in children with OSA. The relative contributions of PSG variables and covariates to each HRV parameter were quantified. The proportion of changes in HRV parameters causally attributable to changes in OSA severity, measured by the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), was estimated. RESULTS: In total, 404 children aged 5 to 10 years were included. The median (interquartile range) age was 6 (3-9) years. The median body mass index percentile was 82 (53), 195 (48%) children were male, and 147 (36%) were African American. The average heart rate during PSG was the strongest independent predictor of each HRV parameter (P < .001). Although eAT resulted in statistically significant changes in the majority of HRV parameters, these effects were not causally attributable to treatment-related changes in AHI or ODI. CONCLUSIONS: The average heart rate strongly modulates HRV in children with OSA. Although eAT results in discernible changes in HRV, it appears to not be causally attributable to specific treatment-related changes in AHI or ODI.

Gait-speed and oxygen flow during six-minute walk test predicts mortality in patients with advanced lung disease.

The six-minute walk test (6MWT) is a useful tool to predict outcomes in patients with advanced lung diseases. Greater distance walked has been shown to have more favorable prognostic value compared to other recorded variables.  We reviewed the medical records of 164 patients with advanced lung disease who underwent lung transplant evaluation. Results of the 6MWT (distance walked, oxygen required, and mean gait speed) were recorded and analyzed with respect to mortality. 6MWT mean oxygen (O2) flow via nasal cannula was 3.5 ± 3.7 L/min. The distance walked in meters (m) and % predicted were inversely associated with mortality, OR: 0.995 (0.992-0.998) and 0.970 (0.950-0.990), respectively. Patients who walked < 200 meters (OR: 2.1 (1.1-4.0)) or < 45% of predicted, OR: 2.7 (1.2-5.7) had higher mortality. O2 flow during the test had a direct association with mortality (OR: 1.1 (1.0-1.2). In multivariate analysis, O2 flow > 3.5 L/min remained predictive of mortality, OR: 1.1 (1.0-1.2). Mean gait speed was higher in patient who lived compared with patients who died (mean 0.83 ± 0.35 m/mim vs mean 0.69 ± 0.33 m/min, respectively, p= 0.03). Gait speed was a predictor of survival, OR 3.4 (1.1, 10.6). O2 flow during the 6MWT was an independent predictor of mortality in patients with advanced lung disease. The patients that required more than 3.5 L/m of O2 had a higher mortality. Faster gait speed during the 6MWT was also associated with better survival.

Evaluation and Management of Dysphagia in Amyotrophic Lateral Sclerosis: A Survey of Speech-Language Pathologists' Clinical Practice.

OBJECTIVES: The aim of this study was to determine the evaluation and management of dysphagia in amyotrophic lateral sclerosis (ALS) patients by speech-language pathologists (SLPs). METHODS: A 15-question web-based survey sent to SLPs in general clinical practice. RESULTS: Forty-nine SLPs responded. Although only 8 (17.0%) of the SLPs worked in ALS clinics, 46 (93.9%) had worked with ALS patients. A variety of dysphagia evaluation protocols were used by 43 (97.7%) SLPs. Most SLPs, 40 (88.9%), recommended instrumental assessments, but timing and indication varied greatly: 19 (42.2%) SLPs recommended this at baseline even without bulbar symptoms, whereas others recommended this based on symptoms and/or clinical assessments. CONCLUSIONS: There is currently no uniform approach as to the indication, timing, and specific methods to use in the evaluation of dysphagia in ALS patients among SLPs. There is need for further research to assist in the development of definitive guideline recommendations for this population.

A Case of Complex and Abnormal Behaviors at Night: The Role of the Epilepsy Monitoring Unit in Diagnosis.

Complex nocturnal behaviors associated with sleep have many potential causes, including parasomnias and epilepsy. Although the type of event and description can frequently lead to a diagnosis, sometimes it is challenging clinically to determine the cause of the behaviors, requiring a more in-depth investigation. We report the case of a 29-year-old woman with a long history of complex abnormal behaviors and visual hallucinations at night. An extensive clinical evaluation failed to reveal a definitive cause of these episodes, prompting a 3-day epilepsy monitoring unit admission. During the stay, several events were captured on video electroencephalography, leading to a conclusive final diagnosis. This case highlights the challenging task of finding a definitive diagnosis in cases of complex nocturnal behaviors and the potential role of an admission to an epilepsy monitoring unit to help diagnose the cause of these behaviors.

Older adult US Medicare beneficiaries with untreated obstructive sleep apnea are heavier users of health care than matched control patients.

STUDY OBJECTIVES: To examine the effect of untreated obstructive sleep apnea (OSA) on health care utilization (HCU) and costs among a nationally representative sample of Medicare beneficiaries. METHODS: Our data source was a random 5% sample of Medicare administrative claims data for years 2006-2013. OSA was operationalized as (1) receipt of one or more International Classification of Disease, Version 9, Clinical Modification diagnostic codes for OSA in combination with (2) initiation of OSA treatment with either continuous positive airway pressure or oral appliance (OA) therapy. First, HCU and costs were assessed during the 12 months prior to treatment initiation. Next, these HCU and costs were compared between beneficiaries with OSA and matched control patients without sleep-disordered breathing using generalized linear models. RESULTS: The final sample (n = 287,191) included 10,317 beneficiaries with OSA and 276,874 control patients. In fully adjusted models, during the year prior to OSA diagnosis and relative to matched control patients, beneficiaries with OSA demonstrated increased HCU and higher mean total annual costs ($19,566, 95% confidence interval [CI] $13,239, $25,894) as well as higher mean annual costs across all individual points of service. Inpatient care was associated with the highest incremental costs (ie, greater than control patients; $15,482, 95% CI $8,521, $22,443) and prescriptions were associated with the lowest incremental costs (ie, greater than control patients; $431, 95% CI $339, $522). CONCLUSIONS: In this randomly selected and nationally representative sample of Medicare beneficiaries and relative to matched control patients, individuals with untreated OSA demonstrated increased HCU and costs across all points of service.