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Objective To describe the cost benefit of 4 different approaches to screening for sleep apnea in a cohort of participants with moderate to severe traumatic brain injury (TBI) receiving inpatient rehabilitation from the payor’s perspective. Design A cost-benefit analysis of phased approaches to sleep apnea diagnosis. Setting Six TBI Model System Inpatient Rehabilitation Centers. Participants Trial data from participants (N=214) were used in analyses (mean age 44±18y, 82% male, 75% white, with primarily motor vehicle–related injury [44%] and falls [33%] with a sample mean emergency department Glasgow Coma Scale of 8±5). Intervention Not applicable. Main Outcome Cost benefit. Results At apnea-hypopnea index (AHI) ≥15 (34%), phased modeling approaches using screening measures (Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender [STOPBANG] [–$5291], Multivariable Apnea Prediction Index MAPI [–$5262]) resulted in greater cost savings and benefit relative to the portable diagnostic approach (–$5210) and initial use of laboratory-quality polysomnography (–$5,011). Analyses at AHI≥5 (70%) revealed the initial use of portable testing (–$6323) relative to the screening models (MAPI [–$6250], STOPBANG [–$6237) and initial assessment with polysomnography (–$5977) resulted in greater savings and cost-effectiveness. Conclusions The high rates of sleep apnea after TBI highlight the importance of accurate diagnosis and treatment of this comorbid disorder. However, financial and practical barriers exist to obtaining an earlier diagnosis during inpatient rehabilitation hospitalization. Diagnostic cost savings are demonstrated across all phased approaches and OSA severity levels with the most cost-beneficial approach varying by incidence of OSA.

Objective The purpose of this study was to describe incidence and assess predictors of adherence to Positive Airway Pressure (PAP) therapy for Obstructive Sleep Apnea (OSA) in persons with acquired brain injury (ABI). Methods A 2012–2015 retrospective analysis of consecutive ABI patients admitted for neurorehabilitation, referred for polysomnography (PSG), and prescribed PAP for OSA. Univariable linear regressions were conducted to examine predictors of average hours of nightly PAP use. Univariable logistic regressions were conducted to examine predictors of PAP adherence using the conventional clinical definition of ≥4 h per night ≥70% of the time. Persons with traumatic etiology were separately analyzed. Results ABI etiology was 51% traumatic, 36% stroke, and 13% other nontraumatic causes. Nearly two-thirds were nonadherent to PAP. For the overall sample, higher average nightly PAP usage was significantly predicted by positive hypertension diagnosis (β = 0.271, p = 0.019). Likewise, greater adherence based on the conventional cutoff was predicted by poorer motor functioning at hospital admission (OR = 0.98, p = 0.001) and lower oxygen saturation nadir (OR = 0.99, p = 0.003). For those with traumatic injuries, greater adherence was predicted by poorer functional status at hospital admission (OR = 0.98, p = 0.010) and positive hypertension diagnosis (OR = 0.16, p = 0.023). Conclusions In this study of hospitalized neurorehabilitation patients with ABI and comorbid OSA, predictors of adherence included lower oxygen saturation, poorer functional status and hypertension diagnosis, perhaps signifying the role of greater severity of illness on treatment adherence. High rates of refusal and nonadherence to frontline PAP therapy for sleep apnea is a concern for persons in recovery form ABI who are at a time of critical neural repair.

Objective To determine the diagnostic sensitivity and specificity and comparative effectiveness of traditional sleep apnea screening tools in traumatic brain injury (TBI) neurorehabilitation admissions. Design Prospective diagnostic comparative effectiveness trial of sleep apnea screening tools relative to the criterion standard, attended level 1 polysomnography including encephalography. Setting Six TBI Model System Inpatient Rehabilitation Centers. Participants Between May 2017 and February 2019, 449 of 896 screened were eligible for the trial with 345 consented (77% consented). Additional screening left 263 eligible for and completing polysomnography with final analyses completed on 248. Intervention Not applicable. Main Outcome Measures Area under the curve (AUC) of screening tools relative to total apnea hypopnea index≥15 (AHI, moderate to severe apnea) measured at a median of 47 days post-TBI (interquartile range, 29-47). Results The Berlin high-risk score (receiving operating curve [ROC] AUC=0.634) was inferior to the Multivariable Apnea Prediction Index (MAPI) (ROC AUC=0.780) (P=.0211; CI, 0.018-0.223) and Snoring, Tired, Observed, Blood Pressure, Body Mass Index, Age, Neck Circumference, and Gender (STOPBANG) score (ROC AUC=0.785) (P=.001; CI, 0.063-0.230), both of which had comparable AUC (P=.7245; CI, −0.047 to 0.068). Findings were similar for AHI≥30 (severe apnea); however, no differences across scales was observed at AHI≥5. The pattern was similar across TBI severity subgroups except for posttraumatic amnesia (PTA) status wherein the MAPI outperformed the Berlin. Youden's index to determine risk yielded lower sensitivities but higher specificities relative to non-TBI samples. Conclusion This study is the first to provide clinicians with data to support a choice for which sleep apnea screening tools are more effective during inpatient rehabilitation for TBI (STOPBANG, MAPI vs Berlin) to help reduce comorbidity and possibly improve neurologic outcome.

Background OSA is prevalent during a time of critical neural repair after traumatic brain injury (TBI). The diagnostic utility of existing sleep studies is needed to inform clinical management during acute recovery from TBI. Research Question This study aimed to evaluate the non-inferiority and diagnostic accuracy of a portable level 3 sleep study relative to level 1 polysomnography in hospitalized neurorehabilitation patients with TBI. Study Design and Methods This is a prospective clinical trial conducted at six TBI Model System study sites between May 2017 and February 2019. Of 896 admissions, 449 were screened and eligible for the trial, with 345 consented. Additional screening left 263 eligible for and completing simultaneous administration of both level 1 and level 3 sleep studies, with final analyses completed on 214 (median age = 42 years; ED Glasgow Coma Scale = 6; time to polysomnography [PSG] = 52 days). Results Agreement was moderate to strong (weighted kappa = 0.78, 95% CI, 0.72-0.83) with the misclassification commonly occurring with mild sleep apnea due to underestimation of apnea hypopnea index (AHI). Most of those with moderate to severe sleep apnea were correctly classified (n = 54/72). Non-inferiority was not demonstrated: the minimum tolerable specificity of 0.5 was achieved across all AHI cutoff scores (lower confidence limits [LCL] range, 0.807-0.943), but the minimum tolerable sensitivity of 0.8 was not (LCL range, 0.665-0.764). Interpretation Although the non-inferiority of level 3 portable diagnostic testing relative to level 1 was not established, strong agreement was seen across sleep apnea indexes. Most of those with moderate to severe sleep apnea were correctly identified; however, there was risk of misclassification with level 3 sleep studies underestimating disease severity for those with moderate to severe AHI and disease presence for those with mild AHI during early TBI neurorehabilitation.

Survivors of brain injury who have disorders of consciousness often have chronic functional deficits and disability. Obstructive sleep apnoea, a sleep-related breathing disorder, is a medical comorbid condition common among persons with brain injury and is injurious to health. Research on obstructive sleep apnoea treatment among brain-injured patients-particularly persons with disorders of consciousness-is sparse. This case study describes a patient with severe brain injury admitted for neurorehabilitation in a minimally conscious state. Obstructive sleep apnoea was identified and treated. Treatment compliance was variable, and functional motor and cognitive improvement were observed during periods of better compliance. Study design does not permit casual attribution for functional improvement, but identification and treatment of obstructive sleep apnoea are suggested as a possible way to promote recovery after brain injury.

OBJECTIVE To examine concordance of accelerometer-based actigraphy (ACG) with polysomnography (PSG) in the determination of sleep states in inpatients with traumatic brain injury (TBI), and examine the impact of injury severity and comorbid conditions (spasticity, apnea) on concordance. PARTICIPANTS This was a convenience sample of 50 participants with primarily severe TBI. DESIGN This was a retrospective chart review of concurrent administration of PSG with ACG in nonconsecutive rehabilitation admissions with TBI. MAIN MEASURES Total sleep time and sleep efficiency were measured by PSG and ACG. RESULTS Moderate to strong correlations between ACG and PSG were observed for total sleep time (r = 0.78, P < .01) and sleep efficiency (r = 0.66, P < .01). PSG and ACG estimates of total sleep time (316 minutes vs 325 minutes, respectively) and sleep efficiency (78% vs 77%, respectively) were statistically indistinguishable. CONCLUSIONS Actigraphy is a valid proxy for monitoring of sleep in this population across injury severity and common comorbidity groups. However, further research with larger sample sizes to examine concordance in patients with TBI with disorder of consciousness and spasticity is recommended.

OBJECTIVE To prospectively examine the incidence and risk factors for sleep apnea in consecutive brain injury rehabilitation admissions. SETTING Inpatient neurorehabilitation hospital. PARTICIPANTS Participants (n = 86) were consecutive neurorehabilitation admissions. DESIGN Retrospective analysis of prospectively collected data. MAIN MEASURES Polysomnography. RESULTS Half (49%) of the sample was diagnosed with sleep apnea. For the full sample, univariate logistic regression revealed age (odds ratio: 1.08; 95% confidence interval: 1.04-1.11) and hypertension (odds ratio: 7.77; 95% confidence interval: 2.81-21.47) as significant predictors of sleep apnea diagnosis. Results of logistic regression conducted within the traumatic brain injury group revealed age (odds ratio: 1.07; 95% confidence interval: 1.02-1.13) as the only significant predictor of apnea diagnosis after adjustment for other variables. Hierarchical generalized linear regression models for the prediction of apnea severity (ie, apnea-hypopnea index found that Functional Independence Measure Cognition Score (P = .01) and age (P < .01) were significant predictors. Following adjustment for all other terms, only age (P < .01) remained significant. CONCLUSION Sleep apnea is prevalent in acute neurorehabilitation admissions and traditional risk profiles for sleep apnea may not effectively screen for the disorder. Given the progressive nature of obstructive sleep apnea and morbidity associated with even mild obstructive sleep apnea, early identification and intervention may address comorbidities influencing acute and long-term outcome.

To assess the reversibility of symptoms of depression using continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA).Patients referred to our center for evaluation of OSA who had a respiratory disturbance index (RDI)or = 15 and who demonstrated a significant response to CPAP (or = 50% drop in RDI) were evaluated for the symptoms of depression using the Beck Depression Inventory (BDI), and then reassessed after 4 to 6 weeks of treatment with CPAP at home.In this group of patients, the institution of CPAP therapy resulted in a significant (p0.0001) decrease in those symptoms of depression as assessed by the BDI (BDI at baseline, 4.1 +/- 3.7; BDI after CPAP, 1.0 +/- 2.0). This change in BDI was noted both in those individuals who had received an antidepressant prescription prior to referral, and in those who had not. An analysis of variance failed to reveal any effect on these data related to gender or baseline RDI.Patients with OSA may present to their primary care physician with symptoms suggesting a diagnosis of depression. In some of these individuals, the symptoms of depression may be ameliorated with CPAP.

Uncontrolled bleeding remains the leading cause of preventable death in trauma. Hemostatic agents are effective in hemorrhage control but often fail following high-volume crystalloid resuscitation. Aggressive fluid resuscitation increases the blood pressure which may dislodge the newly formed clot causing rebleeding. The purpose of this study was to determine the systolic blood pressure (SBP) and the mean arterial pressure (MAP) at which rebleeding occurs when a clot is formed by one of these hemostatic agents (BleedArrest, TraumaDex, or Celox) compared to a control group. This was a prospective, experimental study using male 5 Yorkshire swine per group (BleedArrest, TraumaDex, Celox, or control). The femoral artery and vein were transected to simulate a traumatic injury. Subjects were allowed to bleed for 60 seconds then one of the agents was poured into the wound. The control group underwent the same procedures but without the hemostatic agent. After 30 minutes, dressings were removed and the SBP was increased incrementally using intravenous phenylephrine until rebleeding occurred or until the arterial blood pressure reached 210 mm/Hg. The SBP and MAP were significantly higher in the BleedArrest, TraumaDex, and Celox groups compared to a control group (p0.05).

Objective To prospectively characterize the prevalence, course, and impact of acute sleep abnormality among traumatic brain injury (TBI) neurorehabilitation admissions. Design Prospective observational study. Setting Freestanding rehabilitation hospital. Participants Primarily severe TBI (median emergency department Glasgow Coma Scale [GCS] score=7; N=205) patients who were mostly men (71%) and white (68%) were evaluated during acute neurorehabilitation. Interventions None. Main Outcome Measure Delirium Rating Scale-Revised-98 (DelRS-R98) was administered weekly throughout rehabilitation hospitalization. DelRS-R98 item 1 was used to classify severity of sleep-wake cycle disturbance (SWCD) as none, mild, moderate, or severe. SWCD ratings were analyzed both serially and at 1 month postinjury. Results For the entire sample, 66% (mild to severe) had SWCD at 1 month postinjury. The course of the SWCD using a subset (n=152) revealed that 84% had SWCD on rehabilitation admission, with 63% having moderate to severe ratings (median, 24d postinjury). By the third serial exam (median, 35d postinjury), 59% remained with SWCD, and 28% had moderate to severe ratings. Using general linear modeling and adjusting for age, emergency department GCS score, and days postinjury, presence of moderate to severe SWCD at 1 month postinjury made significant contributions in predicting duration of posttraumatic amnesia ( P P Conclusions Results suggest that sleep abnormalities after TBI are prevalent and decrease over time. However, a high percent remained with SWCD throughout the course of rehabilitation intervention. Given the brevity of inpatient neurorehabilitation, future studies may explore targeting SWCD to improve early outcomes, such as cognitive functioning and economic impact, after TBI.

This study sought to characterize mechanical activation in pulmonary arterial hypertension (PAH) using 2-dimensional echocardiography with tissue Doppler imaging. Whether pathologic alterations of the right ventricle in PAH affect interventricular dyssynchrony due to changes in mechanical activation of the septum and the right ventricle is unclear. We studied 20 patients with PAH (14 women, mean age 55 +/- 16 years) and 20 healthy controls (15 women, mean age 41 +/- 11 years) that underwent tissue Doppler imaging between July 2006 and May 2007. PAH was associated with accelerated right ventricular (RV) (p0.0001) and septal (p = 0.022) activation times, but no differences were found in lateral wall activation times between groups (p = 0.35). Measures of ventricular dyssynchrony indicated that patients with PAH had significantly lower RV-lateral wall delays (patients 3.2 +/- 66.2 ms vs controls 56.7 +/- 52.0 ms, p = 0.007), reflecting a faster activation of the right ventricle relative to the lateral wall than controls. In conclusion, PAH is associated with interventricular dyssynchrony manifested by accelerated RV free wall and septal activation times. Whether such dyssynchrony should serve as a therapeutic target remains to be determined.

To assess the sustainability of an improvement in symptoms of depression using CPAP therapy in patients with obstructive sleep apnea.Patients referred to our center for evaluation of obstructive sleep apnea who had a respiratory disturbance index (RDI) ofor =15 and who demonstrated a significant response to CPAP (50% or greater drop in RDI), were evaluated for symptoms of depression using the Beck Depression Inventory-Fast Screen for Medical Patients (BDI). These individuals were asked to complete the BDI assessment again after 4 to 6 weeks of treatment with CPAP (short-term follow-up), and then reassessed approximately one year later (long-term follow-up).In this group of patients, the institution of CPAP therapy resulted in a significant decrease in those symptoms of depression assessed by the BDI at both the short-term and long-term follow-up periods.For patients with OSA who continue CPAP therapy, we noted a statistically significant, sustained improvement in those symptoms of depression measured by the BDI.

To assess, in individuals referred for evaluation of obstructive sleep apnea, the potential clinical significance of brief versus longer arousals from sleep.Full-night polysomnographic tracings from 100 patients referred for evaluation of obstructive sleep apnea were analyzed to delineate the duration of each arousal event. These data were then correlated to the patient's subjective perception of sleepiness as estimated by the Epworth Sleepiness Scale (ESS).A significant relationship (p.0001, r(2) = .167) was noted between the frequency of the longer arousals (15 seconds) and the ESS. This relationship was significant, but distinctly weaker (p = .004, r(2) = .073), with the shorter arousals (3-15 seconds); moreover, the association with the brief arousals failed to remain significant (p = .678) after controlling for the effect of the longer arousals.Individuals with obstructive sleep apnea experience frequent respiratory event associated cortical arousals, many of which are greater than 15 seconds in duration. These longer arousals, which, in this study, constituted 18.4% of all arousals and accounted for 37.5% of the total arousal time, correlate more closely with the ESS than does the frequency or time attributable to the more numerous brief arousals. This suggests that these more-prolonged arousal events may have a greater impact on the restorative aspect of sleep, or on the perception thereof.

Pulse transit time (PTT) is a non-invasive index which reflects changes in peripheral vascular resistance and intrathoracic pressure. PTT arousal index (PTT Ar/I) is defined as the frequency (number/hour) of a defined decrease in PTT which may serve as a marker for respiratory events, and associated arousals which occur in patients with obstructive sleep apnea (OSA). This study was designed to evaluate the PTT Ar/I before and after patients with OSA were treated with continuous positive airway pressure (CPAP).Individuals referred for evaluation of possible OSA underwent split-night polysomnography (PSG). The findings from 144 consecutive patients with a respiratory disturbance index (RDI)/=20, who demonstrated at least a 50% drop in RDI with CPAP, provide the basis for this analysis. The PTT Ar/I measured before and after CPAP were compared to other measures of severity for OSA, including RDI and arousal index.The PTT Ar/I correlates with the RDI (r=0.43, P/=0.0001) and with the arousal index (r=0.43, P0.0001). Moreover, the decrease in RDI and arousal index that occurs with CPAP treatment correlates with a similar decrease in the PTT Ar/I (r=0.54, P0.0001).The PTT Ar/I correlates well with other standard measures of severity in patients with OSA and is potentially a non-invasive marker with which to measure the frequency of disruptive events that occur during sleep.