Is sleep impaired in post-COVID syndrome vs. healthy controls? Preliminary data

Background: People with post-COVID syndrome (PCS) suffer from persisting symptoms, e.g. self-reported sleep disorders (31%). However, sleep has not yet been objectively measured by polysomnography (PSG) in PCS. Objective(s): To examine differences in sleep characteristics between PCS and healthy controls (HC). Method(s): People with PCS and HC were included in this prospective trial. All subjects performed baseline characteristics, 1-minute sit-to-stand test (STST), subjective impairments of sleep and a single night sleep assessment in a sleep lab via PSG and Whoop strap (digital health coach). Post-COVID functional scale (PCFS) and Ordinal Scale for Clinical Improvement (OSCI) were assessed only in PCS. Result(s): To date, 20 PCS patients (49+/-11y, FVC 87+/-12%pred., DLCO: 81+/-19%pred., PCFS: 2.8+/-0.9, OSCI: 2.7+/-1.3pts) and 3 HC (44+/-9y, FVC 92+/-3%pred., DLCO 105+/-25%pred.) completed the trial. Only PCS patients reported an impaired sleep ("Is your sleep impaired since COVID?" [yes: 89%]) mainly due to insomnia in the middle of the night (61%). Total sleep time and the distribution of sleep stages (light, deep, REM) were comparable between PCS and HC. The REM latency trended to be longer in PCS vs. HC (114+/-51 vs. 52+/-17 min.). Apnea-hypopnea index (AHI) trended to be higher in PCS (8.9+/-8.5 vs. 0.9+/-1.2 events/h), 55.6% of PCS reported an AHI>5/h. The individual quality of recovery after the study night was classified to be "adequate" (PCS: 56+/-21%, HC: 52+/-15%). Conclusion(s): In PCS, sleep seems to be subjectively and objectively impaired compared to HC. A significant number of PCS patients (44%) was diagnosed with obstructive sleep apnea. Hence, measuring sleep might be an important diagnostic tool in the management of PCS.

A PATIENT WITH COVID-19 PNEUMONIA, PULMONARY EMBOLISM, AND OSA

SESSION TITLE: Global Case Reports in Critical Care SESSION TYPE: Global Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Thrombotic complications in patients diagnosed with COVID-19 pneumonia are emerging as an important and significant morbidity and mortality burden, with overwhelming inflammation, hypoxia, immobilization, and diffuse intravascular coagulation among possible causes of a procoagulant state (1). Obstructive sleep apnea (OSA), with intermittent arterial oxygen desaturation, may in its turn contribute to a procoagulant state, causing hemodynamic alterations as polycythemia and sluggish blood flow (2). Here we report on a case of sudden and massive non-lethal pulmonary thromboembolism (PTE) in a patient with COVID-19 severe pneumonia, for whom OSA was suspected and documented as a possible concurrent mechanism of thromboembolic complication during follow-up. CASE PRESENTATION: A 55-year-old male non-smoker obese (BMI 33 Kg/m2) was admitted to our hospital after 9 days of fever. In the Emergency Room, a chest HRCT scan showed bilateral diffuse ground glass opacities. He was treated with subcutaneous Tocilizumab (324 mg) single shot, Remdesivir (200 mg/day for first day and 100/daily for further 4 days), methyl-prednisolone 40 mg/daily, Enoxaparin 6000 UI/twice daily, azithromycin 500 mg/daily, high flow nasal cannula oxygen (50 L/min, TC 34°C, FiO2 35%) for moderate acute respiratory failure due to COVID-19 pneumonia (pO2: 58 mmHg, PCO2 34 mmHg pH 7.50, P/F 275). After 10 days, patient's clinical conditions worsened, needing non-invasive respiratory support;D-dimer increased abruptly, rising to 10 ng/mL, with findings consistent with PTE at a computed tomographic angiography (CTA, Fig 1). The patient was successfully treated with 10 mg/daily subcutaneous fondaparinux for 12 days, while assisted in the Intensive Care Unit, being discharged home in room air shortly later with oral anticoagulants. At the 3-month follow-up visit, OSA was suspected due to reported excessive daytime sleepiness and weakness, snoring, disturbed night sleep, morning headache in the last 4 years. The patient underwent a home sleep apnea test (HSAT) overnight. Test results revealed an AHI of 50 events/h, with several prolonged episodes of obstructive sleep apnea (307 apnea and hypopnea (A+H) events, 70 obstructive apnea and 233 hypopnea events, with a mean duration of 10% and an average arterial saturation of 93% (Fig. 2). He was adapted to CPAP therapy, with benefit and good correction of polygraphic indexes. DISCUSSION: The pathogenetic mechanisms of COVID 19 and OSA could have played a synergistic effect on endothelial damage, thus increasing the risk of thromboembolism. CONCLUSIONS: The presence of underdiagnosed comorbidities may well worsen the clinical course and complication of COVID-19;an earlier diagnosis of OSA is a prerequisite for timely treatment and, potentially, improved long-term clinical outcomes. Reference #1: Suh YJ, et al. Pulmonary embolism and deep vein thrombosis in COVID 19: a systematic review and meta-analysis. Radiology 2021;298 (2): E70-E80. Reference #2: Alfonso-Fernandez A., Garcia Surquia A., de la Pena M. OSA is a risk factor for recurrent VTE Chest. 2016;150 (6): 1291-1301. DISCLOSURES: no disclosure on file for Antonietta Esposito;no disclosure on file for Antonella Frattari;no disclosure on file for Giustino Parruti;no disclosure on file for Giorgia Patrizio;no disclosure on file for Pierpaolo Prosperi;no disclosure on file for Giorgia Rapacchiale;No relevant relationships by ANTONELLA SPACONE no disclosure on file for Giacomo Zuccarini;

Sleep disturbances in craniopharyngioma: a challenging diagnosis

Introduction: The hypothalamus plays a crucial role in regulating vital functions and circadian rhythms. Both the tumor involving the hypothalamic area and its treatment can lead to hypothalamic dysfunction, resulting in disturbances in sleep-wake patterns, sleep fragmentation, and increased daytime sleepiness. We describe two patients with craniopharyngioma who came to our attention due to the occurrence of episodes characterized by psychomotor slowing and afinalistic limb movements, temporal and spatial disorientation, psychomotor agitation, and oneiric stupor like episodes diagnosed as severe sleep disturbances. Case reports: Patient 1 is a 19-year-old male diagnosed with surgically treated craniopharyngioma. Subsequently, episodes of psychomotor slowing, afinalistic movements of the upper limbs diagnosed as seizures in another neurological center appeared;antiepileptic treatment was started without improvement. At the first examination in our center, excessive daytime sleepiness (EDS), fragmented nighttime sleep, episodes characterized by bimanual automatic gestures occurring during drowsy state, hypnagogic hallucinations, and sudden loss of muscle tone while awake were recognized. Actigraphy demonstrated irregular bedtimes, frequent nocturnal activity, and inappropriate daytime rest episodes. The Epworth Sleepiness Scale (ESS) showed subjective EDS (ESS=19). At PSG, hypersomnolence, severe sleep-related breathing disorder (SRBD), and no interictal and ictal seizure abnormalities were found. A BiPAP NIV was started, and antiepileptic therapy was discontinued. In the following months, PSG revealed marked improvement in SRBD and 1 SOREMP, and the MSLT a mean SOL of 6 min and 10 sec and 3 SOREMPs. These data allowed the diagnosis of secondary narcolepsy, and treatment with pitolisant was initiated with clinical improvement and reduced daytime sleepiness (ESS=9). Patient 2 is a 12-year-old male, surgically treated for craniopharyngioma at the age of 4 years, who developed episodes of myoclonic jerks, temporal and spatial disorientation, and psychomotor agitation during the lockdown period for COVID-19 emergency. Surmising paroxysmal epileptic episodes, the patient was hospitalized. The anamnestic data collection revealed a sleep-wake rhythm dysregulation, fragmented nighttime sleep, EDS, oneiric stupor-like episodes during which the patient performed simple automatic gestures mimicking daily-life activity, and severe impairment of alertness. The Long-term video-EEG, including polygraphic measurements, showed destruction of the wake-NREM sleep-REM sleep boundaries, episodes of undetermined state of vigilance, and concurrence of elements typical of different sleep stages. Moreover, a severe SRBD (AHI 19/h) has been observed. The MRI showed a volumetric increase in the post-surgical interpeduncular fossa and right paramedian cysts. Therefore, a multifactorial therapeutic plan including sleep hygiene and slow-release melatonin was started with improvement in nighttime sleep, but EDS persisted. Surgical treatment of cyst fenestration improved sleep-wake rhythm and behavior;BiPAP NIV was initiated with very poor adherence. Discussion: We aim to focus on sleep disorders as a possible complication of tumors involving the hypothalamic region. Our cases highlight that the clinical manifestation of these dysfunctions can be challenging to diagnose and can lead to misdiagnosis and inappropriate treatment that can harm patients' health and the quality of life of patients and their families. Conclusion: These findings support the need to incorporate comprehensive sleep assessment in survivors from childhood brain tumors involving the suprasellar/hypothalamic region.

Moderator effect of physical activity on stress and sleep relationship in daily life: an observational study using wearable devices

Introduction: Daily sleep may be affected by several conditions, including stress. Stress has been shown to impact our physical and mental health. Perceived stress can affect sleep quantity, quality, and architecture, with a detrimental effect on emotional responses to daily stressors. Moreover, poor quantity/quality sleep can increase the risk of severe medical and mental disorders that in turn can have a negative effect on sleep. However, some beneficial sleep/stress management interventions seem to have a mediator impact on a stress-sleep relationship. Physical activity (PA) is reported to prevent the negative effects of perceived stress on sleep, in stress conditions, as COVID-19 pandemic lockdown. The study aimed to conduct a preliminary analysis on the relationship between PA, perceived daily stress (pdStress), and sleep parameters from data collected through Garmin and Apple wearable devices by LUCA app, a psychophysiological well-being application, helping to recognize and manage stress. Materials and methods: Data from Australian users have been collected for 14 consecutive days. No inclusion and exclusion criteria were applied. PA and sleep parameters were selected if present on both Garmin and Apple devices. We assessed: PA by daily calories consumption during active daily periods, and total steps;sleep as time spent asleep;pdStress as the total score obtained from four specific daily, day-framed questions investigating the ability to relax, the presence of somatic, and emotional/cognitive symptoms [total score range: 0-12;the higher is the score the higher is the pdStress.] Statistical analysis included linear mixed models, with pdStress total score as independent variable and sleep duration as dependent variable. PA parameters were added separately as moderators of pdStress and sleep relationship, with age, sex, and the brand of the wearable devices as covariates. Results: Sample: 46 Australian users (19 from Garmin and 27 Apple wearable devices), including 27 females (58.7%);age between 20 and 60 years (years;m=40.8, sd=±9.1). On average, the sample was characterized by: low to moderate levels of PA;mild levels of pdStress;and sleep duration as WHO’s recommendations. The analyses showed a statistically significant inverse association between level of pdStress and sleep duration (p < 0.001). This relationship was moderated by PA measured by active calories consumptions (p = 0.015) and total steps (p = 0.038), with higher activity levels resulting in a reduction of the strength of the inverse association between pdStress and sleep. Discussion: Our results confirm the detrimental relationship between pdStress and nighttime sleep duration, as reported by the literature. Moreover, our data show that high levels of PA can reduce the negative effect of pdStress on sleep duration. Despite the limitations concerning the limited number of subjects, device-related recording errors, indirect sleep parameters, and non-sophisticated PA measures, our results underline the importance of PA programs when daily stress conditions and sleep alterations occur. Acknowledgment: Data collection was sponsored by Mebidio LTD. We thank all participants involved in the study.

PRE-PANDEMIC CIRCADIAN PHASE PREDICTS PANDEMIC SLEEP, DEPRESSION, AND ALCOHOL USE AMONG ADOLESCENTS

Growing evidence links later circadian rhythm timing during adolescence to worse sleep, more symptoms of depression, and greater alcohol involvement, perhaps due to circadian misalignment and sleep restriction imposed by early school start times. School schedules shifted later during the initial phase of the COVID-19 pandemic, which hypothetically should reduce circadian misalignment and sleep restriction for adolescents with later circadian timing, and thus may mitigate any problems with sleep, depression, and alcohol. Here we used the pandemic as a natural experiment to test whether adolescent drinkers with later circadian timing, relative to those with earlier circadian timing, showed improved sleep, depressive symptoms, and alcohol involvement. We studied 42 high school juniors and seniors reporting alcohol use (aged 16-18;27 female participants), assessing circadian phase via the dim light melatonin onset (DLMO) during pre-pandemic conditions, and then following them over four remote assessments every 3 months during the pandemic. Sleep characteristics were assessed via the Munich Chronotype Questionnaire, depressive symptoms were assessed via the Quick Inventory of Depressive Symptomatology, and alcohol use was assessed via a 90-day Timeline Followback. Mixed-effect models focused on the pre-pandemic baseline, COVID baseline (Apr/ May 2020), and COVID-9-mo (Jan/Feb 2021) timepoints, and covaried for age, time between prepandemic and COVID baselines, and whether or not individuals were currently in school or working. In the pre-pandemic period, compared with those with earlier circadian timing, individuals with later circadian timing (later DLMO) got relatively less sleep (shorter total sleep time) on school nights. During the pandemic, earlier and later groups no longer differed on school night sleep. Over the course of the pandemic, compared with the earlier group, individuals with later circadian timing also reported larger increases in alcohol use (number of drinks, drinking days, and maximum drinks). Individuals with later circadian timing reported relatively greater depressive symptoms both pre-pandemic and 9-months into the pandemic. While individuals with later circadian timing benefitted in terms of more school night sleep during the pandemic, this did not translate to mitigating depression or alcohol use. These findings suggest that later circadian timing may contribute to risk for depression and alcohol use over and above effects due to insufficient sleep.

HALO-TRACTION INDUCED OBSTRUCTIVE SLEEP APNEA

Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. It is a multi-factorial disease with a variety of identified causes including age, male gender, obesity, craniofacial and upper airway abnormalities. We would like to describe a patient who had severe OSA following application of Halo traction, which significantly improved following the removal of the device. Report of Cases: 14-year-old male with medical history of spina bifida, chiari malformation s/p decompression, shunted hydrocephalus and severe scoliosis, was admitted to the hospital for anterior spinal discectomy L2-S1 and Halo application with traction for scoliosis. He previously had nocturnal polysomnogram (NPSG) in 2017 that demonstrated very mild mixed apnea with an apnea hypopnea index (AHI) of 5.5. Because central apneas were very brief and clustered in REM, family elected to repeat a study rather than treat. In 2019, he had a follow up study with complaints of snoring and thirst, and this demonstrated an AHI of 21 with 29 brief central apneas and 72 hypopneas, 1 obstructive apnea. He had a T&A and turbinate ablation and due to the global pandemic did not undergo repeat sleep study. During admission for his anterior spinal discectomy and Halo, he demonstrated persistent night time hypoxia. A split night sleep study showed evidence of severe OSA with pretreatment AHI of 94.4, oxygen nadir 86%. Continuous positive airway pressure (CPAP) was initiated at 5 cm of water and titrated to 11 cm of water. On CPAP of +11 severe obstructive events continued with an AHI of 40.6, oxygen nadir 92%. A bilevel positive airway pressure (BIPAP) titration study the subsequent night started at pressures of 12/6 and titrated to 21/9 with respiratory rate of 12 yet demonstrated AHI of 51, oxygen nadir 89%. Study transitioned to average volume assisted pressure support (AVAPS) with IPAP max of 26, IPAP minimum of 12 EPAP of 9, tidal volume of 175ml, rate of 12 with inadequate control of his obstructive events with an AHI of 24.8, minimum oxygen saturations of 91. While hospitalized, he remained on AVAPS with normal capillary blood gases. Halo traction was removed 2 weeks following his surgery with plan was to send him home on AVAPS and repeat NPSG in 6 weeks. However, as a result of COVID pandemic/Philips recall, CPAP was the only device available for home use, so CPAP therapy at +8 cm was trialed overnight, demonstrating oxygen nadir of 92% and a normal capillary blood gas in the morning. Patient was then discharged home on CPAP of +8 cm of water. He returned back to sleep center for a BIPAP titration study to re-establish BIPAP/AVAPS settings, as his inpatient sleep study had shown severe OSA. During the sleep study, he was started on BIPAP 12/6 and he remained on it throughout the night with 0 central and 0 obstructive events. As he did well, he was advised to continue CPAP +8 with plans to repeat the sleep study off CPAP. In clinic follow up, he reported mild skin breakdown and occasionally waking unrefreshed. Conclusion: As our patient did significantly better following the removal of Halo traction device, it is likely that Halo traction device caused fixed over flexion of the cervical spine that resulted in decrease in his airway diameter, which further worsened during his sleep, and caused severe OSA.

PRE-PANDEMIC CIRCADIAN PHASE PREDICTS PANDEMIC SLEEP, DEPRESSION, AND ALCOHOL USE AMONG ADOLESCENTS

Introduction: Growing evidence links later circadian timing during adolescence to worse sleep, more severe depression, and greater alcohol involvement, perhaps due to circadian misalignment and sleep restriction imposed by early school start times. School schedules initially shifted later during the COVID-19 pandemic, which hypothetically should reduce circadian misalignment and sleep restriction for adolescents with later circadian timing, and thus may mitigate any problems with sleep, depression, and alcohol. Here we used the pandemic as a natural experiment to test whether adolescent drinkers with later circadian timing, relative to those with earlier circadian timing, showed improved sleep, depressive symptoms, and alcohol involvement. Methods: We studied 42 high school students reporting alcohol use (aged 16-18;27 female participants), assessing circadian phase via the dim light melatonin onset (DLMO) during prepandemic conditions, and then following them over four remote assessments every 3 months during the pandemic. Sleep characteristics were assessed via the Munich Chronotype Questionnaire, depressive symptoms were assessed via the Quick Inventory of Depressive Symptomatology, and alcohol use was assessed via a 90-day Timeline Followback. Mixed-effect models focused on the pre-pandemic baseline, COVID baseline (Apr/May 2020), and COVID-9-mo (Jan/Feb 2021) timepoints, and covaried for age, time between pre-pandemic and COVID baselines, and current school/work status. Results: In the pre-pandemic period, compared to those with earlier circadian timing, individuals with later circadian timing (later DLMO) got relatively less sleep (shorter total sleep time) on school nights. During the pandemic, earlier and later groups no longer differed on school night sleep. Over the course of the pandemic, compared to the earlier group, individuals with later circadian timing also reported larger increases in alcohol use (number of drinks, drinking days, and maximum drinks). Individuals with later circadian timing reported relatively greater depressive symptoms both pre-pandemic and 9-months into the pandemic. Conclusion: While individuals with later circadian timing benefitted in terms of more school night sleep during the pandemic, this did not translate to mitigating depression or alcohol use. These findings suggest that later circadian timing may contribute to risk for depression and alcohol use over and above effects due to insufficient sleep.

Prevalence of insomnia in adults received at medical wards of Liaquat university hospital Jamshoro, during the COVID-19 pandemic

OBJECTIVE: To determine the prevalence of insomnia in adults received at medical wards of Liaquat University Hospital, Jamshoro, during the Covid-19 pandemic METHODOLOGY: This cross-sectional retrospective study was conducted from February to July 2020, on 200 patients belonging to various educational and socio-economic backgrounds received at Liaquat University Hospital, Jamshoro. The sampling technique was nonprobability, consecutive. The inclusion criteria were males and females above the age of 18 years while the exclusion criteria were individuals with sleep-disordered breathing, prior history of sleep disturbance, and psychiatric illness. This study was funded by the authors. A questionnaire was designed to record the data, including the demographics, educational and job status, and score on Athens Insomnia Scale. The collected data was analyzed on SPSS 20. RESULTS: The study included 108 males (54%) and 92 females (46%) over the age of 18 years. Seventysix individuals (38%) said their sleep quality has worsened during the pandemic, including difficulty initiating sleep in 29, difficulty staying asleep in 22, and 25 having vivid dreams. Out of these, 68% were females and 32% were males, 124 respondents (62%) did not face the above-mentioned problems but 74 (37%) did confirm going to bed later at night and sleeping for a longer duration, while 50 (25%) did not notice any change in their sleeping pattern. CONCLUSION: The Covid-19 pandemic has upturned lives in several ways, including the disruption of sleeping patterns and increased prevalence of insomnia in patients received at medical wards of Liaquat University Hospital, Jamshoro.