Morgenthaler, Timothy I.

Abstract Introduction Oral Appliance Therapy (OAT) is a management option for patients with Obstructive Sleep Apnea (OSA). A reported drawback to OAT is symptoms relating to Temporomandibular Joint Disorder (TMD), including post-procedure jaw pain. Some studies reported TMD in over 50% of patients prior to OAT. The aim of this study was to evaluate the prevalence of TMD and oral Parafunction Habits (PFH) in patients with OSA referred for OAT, and determine any relationship between patient characteristics, demographics, medical history, and degree of OAT advancement with post-procedure jaw pain. Methods A retrospective analysis was conducted, reviewing the electronic health records of 125 patients with OSA referred to the division of dental sleep medicine in Mayo Clinic Rochester, for OAT. Records reviewed included patient demographics, TMD-PFH symptoms and signs before and after initiation of OAT, self-reported history of, and signs of PFH, AHI pre-initiation of OAT, presence of fibromyalgia, SSRI use, and percent advancement of appliance at time of re-evaluation. Results The median age of patients reviewed was 58 (Interquartile Range (IQR) 20), median BMI 30.5 (IQR 7), median AHI 11.3 (IQR 9.5). 57% were male, 43% female. 20.8% patients had TMD history, 37.6% had TMD signs, 47.2% had PFH history (jaw clenching, lip biting, and/or thumb sucking). 96% had signs of PFH. 15.2% reported post-procedure jaw pain. There was a statistically significant relationship between both TMD history and TMD signs, with post-procedure jaw pain (p value 0.002 and 0.013 respectively), although after multi-variate analysis, only TMD history remained associated with post-procedure jaw pain (Odd’s Ratio 3.385, 95% Confidence Interval 1.081 – 10.601, p value = 0.036). Age, BMI, gender, PFH signs and history, SSRI use, fibromyalgia history, % advancement of OA had no statistical association with post-procedure jaw pain. Conclusion Having a history of TMD symptoms prior to OAT is a risk factor for post-OAT jaw pain. A thorough oral and maxillofacial history in patients being considered for OAT is important to identify patients with TMD history, to establish a clear path to initiate OAT and to closely monitor, reduce or potentially eliminate the reported side effect. Support (if any)

Abstract Introduction Several studies have shown a positive association between Obstructive Sleep Apnea (OSA) and malignancies such as lung cancer. However, the effects of intermittent hypoxemia in cancer-free survival following curative therapy are not known. We propose that OSA-related episodic hypoxemia and hypoxic burden are independent risk factors for accelerated lung cancer reoccurrence (< 2 years). Methods We performed a retrospective record review of patients 18 years and older from January 2016 to September 2023 with history of non-small cell lung cancer who received an overnight oximetry study (OXY) within three years prior to undergoing curative malignancy treatment. Subjects with history of central sleep apnea, baseline oxygen saturation (SpO2) below 90%, receiving supplemental oxygen or treatment for OSA were excluded. Results 403 patients met inclusion criteria (52% female vs 48% males; median age 74 y). The most common histologic subtypes were adenocarcinoma (68%) followed by squamous cell carcinoma (22%). Most patients fell into Stage IA1 (35%) followed by IA2 (24.1%) and IB (19%) as per TNM 8th edition classification. Over this period, 68 patients (22%) had lung cancer recurrence (median 19 months). A 4% oxygen desaturation index (ODI) of >15 and time spent in desaturation events were found to be a risk factor for cancer reappearance in less than 2 years (p< 0.001). Measures of hypoxic burden such as time spent below 89% SpO2, average SpO2 value below 89%, and single nadir oxygen levels, showed a similar association (p< 0.001). This was irrespective of histologic subtype, stage at diagnosis, and all studied demographic variables. Basal SpO2 demonstrated no correlation. A multivariate proportional hazard survival model showed that ODI>15 was no longer significant, however average SpO2 below 89% and single minimum oxygen level remained strongly correlated with accelerated recurrence. Conclusion This study showed a strong, positive association between accelerated lung cancer recurrence and OSA-related episodic hypoxemia and hypoxic burden on our univariate analysis. The multivariate model demonstrated correlation with hypoxic load measures only, suggesting the need for a larger sample to elucidate the involvement of this highly treatable risk factor. To our knowledge, this is the first study revealing this potential link. Support (if any)

Abstract Introduction The definition of respiratory events has evolved over decades. The current American Academy of Sleep Medicine scoring manual recommends hypopneas be defined by a ≥ 30% airflow reduction with either ≥ 3% desaturation or an arousal, while the prior “recommended” criteria of a ≥ 30% airflow reduction and associated ≥ 4% oxygen desaturation (with no requirement of arousal) was changed to “optional”. Consequently, events previously characterized as a respiratory effort related arousal (RERA) may now be defined as a 3% hypopnea. We hypothesized that while the 3% apnea-hypopnea index (3%AHI) will be higher than the 4%AHI, the 3%AHI will be similar to the 4% respiratory disturbance index (4%RDI), and that the measurement of RERAs under 3% scoring criteria will be clinically insignificant. Methods We prospectively collected 70 consecutive in-lab polysomnography results in 4 adult age groups. We re-scored the respiratory events utilizing the 3% hypopnea rule, and compared the differences between 3% and 4% scoring criteria. Results Among the 70 studies (mean age 50, males 46%), the 3%AHI was significantly higher than the 4%AHI (+9.247 ± 1.161, p< 0.001). This was mainly due to increased hypopnea events (+10.313 ± 1.617, p< 0.001). The 3%AHI was significantly different from the 4%RDI (+7.096 ± 1.133, p< 0.001). There were no significant differences between the 3% and 4% RERA indices, with both values being minimal. Results were similar in both diagnostic and titration phases of testing. Conclusion As previously shown, utilizing the 3% hypopnea rule results in an increased AHI. Most of this difference is related to hypopneas with negligible influence of RERAs. This may lead to increased diagnosis and severity of sleep-disordered breathing in the adult population, and potentially be associated with payer ramifications. Our findings demonstrated negligible RERA indices on average with either rule, thus calling into question the clinical significance of this index in most patients. Support (if any) NA

Mortality reviews are intended to produce transparent, non-punitive personal and organisational learning that leads to systematic improvement in care. Mayo Clinic has a well-established care review process that has accomplished that objective within our system. The establishment of a new hospital, a joint venture between Mayo Clinic and Sheikh Shakhbout Medical City (SSMC) in Abu Dhabi, provided a unique opportunity to share this care review process internationally. During a baseline measurement period, only 78.3% of mortality reviews at SSMC were completed within 45 days, 16.7 percentage points below the target of 95%. A collaboration between SSMC and Mayo Clinic aimed to accelerate the design and implementation of a care review process system. Collaboration was constrained by travel restrictions imposed by COVID-19, language barriers, legal privacy concerns, and differing electronic health records. Mayo Clinic facilitated a 12-week virtual engagement with SSMC using weekly video meetings, education and training regarding Mayo Clinic’s care review process. The engagement led to implementation of weekly mortality review huddles, restructuring of the mortality review committee to be multidisciplinary, use of a standardised taxonomy to characterise opportunities to improve care and creation of an education/communication plan regarding identified improvement opportunities using change management strategies. After the care review process for mortality reviews was instituted, SSMC achieved and sustained a target of 100% of mortality reviews completed within 45 days. The new process resulted in improved mortality review indicators and provided quality feedback to staff with engagement in performance improvement efforts. A virtual collaboration led to successful implementation of a care review process and substantial gains in the effectiveness of the quality programme at SSMC. This could serve as a model to assist other organisations, even if in-person engagement is hindered.