Castillo, Pablo R.

Abstract Introduction Obstructive sleep apnea(OSA) is a common diagnosis associated with immediate and long-term health consequences. Due to increasing awareness, the demand for treatment with CPAP is increasing. However, CPAP compliance remains a problem, and may be improved by initial patient education targeted at common CPAP problems Methods A 10 min video depicting common CPAP related problems was created in the Mayo Clinic Florida Simulation Center using standardized patients. Newly diagnosed patients with OSA requiring CPAP were randomized into two arms: (i) the intervention arm was shown the video and received standard of care; or (ii) in the “placebo” or standard of care alone. Our standard of care includes a review of the sleep study, discussion of diagnosis and recommendation for CPAP therapy along with Mayo OSA information packet, followed by compliance visit at 3 months. Compliance is defined as >4 hours of CPAP use per night gathered from machine’s SD card. The two groups were compared for statistically significant difference in compliance at 3 months. Results 47 patients diagnosed between 10/2018-5/2019 were included in the study(21:intervention, 26:placebo). 7 (33%) and 7 (26%) patients in the intervention and the placebo came back for follow up visit (p=0.63). Among them, median CPAP usage was 362.5 min (236.0, 480.0) in intervention arm vs 351.0 min (125.0, 466.0) in placebo group and the difference was not significant. Average nightly use of >than 4 hours was 12(57.1%) in the intervention group and 17(65.4%) in placebo group. Conclusion In this group addition of an educational video to standard of care did not show benefit in CPAP compliance. There was a tendency toward greater median nightly usage. Patients receiving the video had a higher likelihood of making their follow up appointment which is pivotal, as it provides an opportunity for further intervention and enhancement of adherence. Support Mayo Clinic Jacksonville

Abstract Introduction Evidence of the relationship between periodic limb movements during sleep (PLMS) and cerebral small vessel disease (cSVD) is limited and inconsistent. Here, we aimed to assess the independent association between PLMS and the different neuroimaging signatures of cSVD. Methods Community dwelling adults aged ≥60 years enrolled in the Atahualpa Project undergoing PSG and MRI with time intervals ≤6 months were included. MRI readings focused on white matter hyperintensities (WMH) of presumed vascular origin, deep cerebral microbleeds (CMB), silent lacunar infarcts (LI), and >10 enlarged basal ganglia-perivascular spaces (BG-PVS). Data from single-night polysomnograms were interpreted according to recommendations of the American Academy of Sleep Medicine. Associations between the PLMS index and neuroimaging signatures of cSVD (as dependent variables) were assessed by means of logistic regression models, adjusted for relevant confounders. Results A total of 146 individuals (mean age: 71.4 ± 7.5 years; 64% women) were included. A PLMS index ≥15/hour were noted in 48 (33%) participants. Moderate-to-severe WMH were present in 33 individuals (23%), deep CMB in 9 (6%), silent LI in 16 (11%), and >10 BG-PVS in 44 (30%). In univariate analyses, silent LI (p=0.035) and the presence of >10 enlarged BG-PVS (p=0.034) were significantly higher among participants with a PLMS index ≥15/hour. However, fully-adjusted multivariate models showed no significant association between PLMS index ≥15/hour and any of the neuroimaging signatures of cSVD. Conclusion This study shows no independent association between the PLMS index and neuroimaging signatures of cSVD in stroke-free community-dwelling older adults. Support This study was supported by Universidad Espíritu Santo - Ecuador.

Background and Purpose— The apnea-hypopnea index (AHI) is associated with cerebral small vessel disease (cSVD), but pathogenesis of this association is elusive. We aimed to assess the effect of nighttime heart rate variability (HRV)—as a proxy of sympathetic upregulation—on the aforementioned association. Methods— Atahualpa residents aged ≥60 years undergoing brain magnetic resonance imaging, polysomnography, and 24-hour Holter monitoring (N=176) were included. The presence of moderate-to-severe white matter hyperintensities, deep cerebral microbleeds, lacunar infarcts, and >10 enlarged basal ganglia perivascular spaces were added for estimating the cSVD score. Interaction models were fitted to assess the effect modification of nighttime HRV in the association between the AHI and the cSVD score, and mediation analysis was utilized to assess the proportion of total effect by nighttime HRV on this association. Results— Generalized linear models showed a significant association between the AHI and the cSVD score ( P =0.025), as well as a significant inverse association between nighttime HRV and the cSVD score ( P =0.002), but no association between daytime HRV and the cSVD score ( P =0.097). Interaction models showed a significant interaction of nighttime HRV on the association between AHI and the cSVD score ( P =0.001), and mediation analysis found that the percent of total effect between AHI and cSVD score mediated by HRV was 30.8%. Predictive marginal means of the cSVD score were highly significant when the 10th percentile of nighttime HRV was compared across categories of 10th and 90th percentiles of the AHI (cSVD score margins, 0.61 [95% CI, 0.37–0.86] versus 1.67 [95% CI, 1.26–2.09]). Contour plots showed the effect of nighttime (but not daytime) HRV on the association between AHI and the cSVD score. Conclusions— This study shows an important effect of nighttime HRV on the association between the AHI and the cSVD score and provides further support for the role of sympathetic overactivity on this association.

There is limited information on participants’ adherence and reasons for declining consent in observational cohort studies conducted in remote rural communities. We aimed at sharing lessons learned during the Atahualpa Project, a population-based cohort study conducted in a rural Ecuadorian village. Atahualpa residents aged ≥40 years identified during door-to-door surveys who signed a consent form were enrolled. Annual surveys were conducted to assess the number of participants who moved out of the village, as well as those who died, declined consent, and newly entered the study. Reasons for declining consent were tabulated. Abstracted data included age, sex, education, disability, time between enrollment and declining consent, and reasons for withdrawal. We also counted participants who, despite expressing their willingness to continue in the study, refused specific procedures. After five years of follow-up, 54 (6.3%) of 863 enrolled individuals declined consent. Increasing age and disability had no impact on declining consent. In contrast, refusal was higher among relatives or neighbors of a given participant declining consent. Most people who declined consent did so after one or two years of enrollment. Less than 20% of enrolled individuals refused certain procedures. “Fear of the needle” was the most frequent reason for refusing blood tests, and common reasons for declining complimentary exams were lack of interest and time constraints. Cohort retention in the Atahualpa Project is high. Main reasons for this adherence include adequate selection of the village, detailed planning of procedures, assurance of sponsorship, and field personnel who continuously engage with study participants. This trial is registered with NCT01627600.