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Metabolic syndrome ifluences the severity of sleep apnea syndrome: from the cordioprev study
e106
Abstracts / Sleep Medicine 14S (2013) e93–e164
more reliable dreams diary method and explore additional features in the dreams of adolescent Canadians. Materials and methods: Fifty males and 50 females, ages 12–17, kept a diary of day’s events and dreams for 10 days. One dream per participant was scored by two independent judges, with interrater reliability, using the Hall and Van de Castle method of content analysis. All variables were controlled for dream report length by dividing by word count. DreamSAT was used for statistical comparisons and a control was used for family-wise multiple comparisons. Results: Independent samples t-tests revealed that females had significantly more words in their dreams (t (78) = 3.543, p = .001), and more female (t (98) = 2.785, p = .006) and family characters (t (98) = 2.683, p = .009.), whereas males had significantly more strangers (t (61) = 3.578, p = .001). Males had both more total aggression (t (74) = 2.452, p = .017), and more recreation implement objects (t (60) = 2.572, p = .013). In addition, a variable in DreamSAT measuring negative tone revealed that males had more negatively toned dreams than females (t (87) = 2.653, p = .009). Conclusion: These results support previous research on gender differences in the dreams of adolescents and stress the early appearance of aggression in male dreams compared to female dreams. It will be interesting to examine the evolution of these differences in older groups. Acknowledgement: Supported by a grant from the Social Sciences and Humanities Research Council of Canada. http://dx.doi.org/10.1016/j.sleep.2013.11.229
Influence of arterial hypertension on renal function in patients with obstructive sleep apnea hypopnea syndrome L. Dheryan 1, G. Podosyan 2, A. Matevosyan 3, P. Zelveian 2 1 Yerevan State Medical University, Yerevan, Armenia 2 Center of Preventive Cardiology, National Institute of Health, Yerevan, Armenia 3 Sleep Research Laboratory at the Center of Preventive Cardiology, Armenia
Introduction: Aim of the study has been an investigation of possible relationship between glomerular filtration rate (GFR) and arterial hypertension (AH) in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). Materials and methods: Forty patients (35 male, 5 female, mean age 43.3 ± 12.5 year) with OSAHS (apnea–hypopnea index (AHI) >5 episodes/h) have been included in the study. Investigated 40 patients have been divided into the two groups: patients having only OSAHS (group I) and patients having OSAHS and AH (group II). GFR has been estimated using the Cockcroft–Gault formula. Normal rates for GFR have been estimated as 100–130 ml/m/1.73 m2. For statistical analysis of GFR classified groups median values have been used as a ‘‘dividing point’’. Relationship between GFR and AH has been estimated according to Pearson v2 and Fisher exact test. Results: Increased values for GFR have been revealed in both groups. However, relatively lower rates from median values of GFR have been detected in 11 patients from group I (55%; CI 34.2– 74.2%) and in 12 patients from group II (60%; CI 38.7–78.1%). Statistically significant differences have not been observed between two groups of patients; while tendency of higher GFR values from median ones have been revealed in the group I (169.0 ± 52.5 vs. 157.5 ± 36.8 ml/m/1.73 m2, p = 0.427). Conclusion: Hyperfiltration is common for patients with OSAHS. In the same time a presence of arterial hypertension is accompanied only by tendency for decrease of absolute values of glomerular filtration rate.
Acknowledgement: Anna Petrosyan laboratory technician. http://dx.doi.org/10.1016/j.sleep.2013.11.230
Echocardiographic findings in patients with obstructive sleep apnea M. Dias 1, R. Reis 2, A. Antunes 1 1 Pneumonology Department, Centro Hospitalar Vila Nova de Gaia/ Espinho, Armenia 2 Pneumonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Armenia
Introduction: Obstructive sleep apnea (OSA) is associated with several adverse cardiovascular effects. This study aims to compare the echocardiographic findings of patients with and without OSA. Materials and methods: We performed a retrospective study which included patients referred to a pneumonology outpatient department for suspected OSA between January 2012 and June 2013. Demographic and anthropometric data, cardiovascular risk factors, echocardiographic findings and polysomnographic data were collected. Comparisons were made between subjects with and without OSA. Results: We included 127 patients with a mean age of 56 ± 12 years, 85 (67%) were male. 89 (70%) patients had OSA (34% mild, 17% moderate, 18% severe) and this group was older (58 vs. 50, p = 0.001), had higher body mass index (31.7 vs. 27.2, p < 0.001) and a higher prevalence of hypertension (83% vs. 58%, p = 0.003) and diabetes (88% vs. 66%, p = 0.048). We found that OSA was significantly associated with left atrial enlargement (41.6 mm vs. 36.6 mm, p < 0.001). In those patients with moderate and severe OSA, pulmonary hypertension was more prevalent (62% vs. 39%, p = 0.047) and the left ventricular ejection fraction (LVEF) was inferior. Moreover, there was a negative correlation between the apnea–hypopnea index (AHI) and the LVEF (rho = 0.287, p = 0.007) and an even stronger negative correlation between oxygen desaturation index (ODI) and LVEF (r = 0.327, p = 0.012). However, no correlation was found between LVEF and minimal oxygen saturation. There was no significant difference between the prevalence of ventricular hypertrophy and diastolic dysfunction in different groups. Conclusion: OSA can affect atrial diameter, pulmonary pressure and systolic function, which can be associated to a poorer prognosis. ODI was the best predictor of LVEF which seems to indicate that this index is the polysomnographic parameter more determinant in the deterioration of systolic function. The next step will be to investigate if these alterations can improve with PAP therapy. http://dx.doi.org/10.1016/j.sleep.2013.11.231
Metabolic syndrome influences the severity of sleep apnea syndrome: from the cordioprev study A. Leon Acuna 1, I. Ordonez Dios 2, P. Perez Martinez 1, A. Jimenez Romero 2, B. Jurado Gamez 2, J. Lopez Miranda 3 1 Andalucia Health Service, Lipid and Atherosclerosis Unit, IMIBIC, Spain 2 Andalucia Health Service, Department of Respiratory Medicine, Spain 3 Andalucia Health Service, Lipid and Atherosclerosis Unit, Spain
Introduction: Sleep Apnea Syndrome (SAHS) represents a significant risk factor for the development of cardiovascular disease and evidence suggests a relation with Metabolic Syndrome (MetS). However, it is not clear whether SAHS exacerbates the metabolic
Abstracts / Sleep Medicine 14S (2013) e93–e164
abnormalities in patients with MetS. Objectives: To determine the relationship between the MetS and the number of components of MetS and the severity of SAHS. Materials and methods: The CordioPrev study (NCT00924937) is an ongoing prospective, controlled trial with a mean follow up of five years duration, including patients with high-risk coronary disease. Among 245 patients from the CordioPrev cohort, SAHS was diagnosed from the nocturnal polysomnography (Apnea–Hipopnea Index (AHS) >5) and MetS was evaluated according to the diagnostic criteria of Adult Panel Treatment III. MetS patients (120 men and 30 women; aged between 45 and 68 years) were divided into three groups based on the number of MetS components: subjects with 3, 4 and 5 MetS components (N = 86, 41 and 23 respectively). Insulin resistance and other cardiometabolic parameters were analyzed. Results: 150 patients were fulfilling MetS criteria. As expected, the SAHS severity defined for AHI was significantly higher in patients with MetS (p = 0.04). However, no differences were observed between the AHI and the number of components of MetS (p = 0.27). Interestingly body mass index (BMI) was correlated independently with AHI (p = 0.003) and men with MetS presented major nocturnal desaturation compared with the rest of the population (p = 0.014). We did not find any association between SAHS severity and HOMA-IR (p = 0.39). Conclusion: Patients with MetS showed a high prevalence and severity of SAHS independently of the number of components. Moreover, obesity is an independent risk factor for the SAHS development, influencing its severity. These findings may need to be taken into consideration when treating these related diseases. Acknowledgement: To Dra. Feu Collado for her critical Reading of this paper. http://dx.doi.org/10.1016/j.sleep.2013.11.232
Validation of total sleep deprivation model in mice G. Dispersyn 1, F. Sauvet 1, C. Drogou 1, S. Ciret 1, T. Gallopin 2, M. Chennaoui 1 1 IRBA, France 2 ESPCI, France Introduction: Several models of sleep deprivation for rodents have been developed over years. One of the most relevant models is the activity wheel developed by Christie et al. for rats, presenting the advantages to induce few stress and physical activity. Even if this model is validated in rats, no data are available about its pertinence in mice. The aim of our study was to validate this model to mice by assessing that: i. the model do not generate high level of stress (determined by corticosterone assay and weight follow-up); ii. mice are awake 95% of time during sleep deprivation (determined by EEG); iii. the model induces a sleep rebound after sleep deprivation (determined by EEG, temperature and locomotor activity). Materials and methods: 24 h total sleep deprivation (TSD) was produced by a slow rotational movement of an activity wheel programmed on a schedule of 3s ‘‘ on ’’ and 12s ‘‘ off ’’ in 13 male C57BL/ 6 mice. After sessions of wheel habituations, mice were exposed to a 24 h TSD (11 a.m.–11 a.m.). A first group of 8 mice were implanted with telemetry transmitter (TA10ETA-F20, DSI, USA) recording continuously EEG, locomotor activity and temperature before, during, and after 24 h TSD. At the end of 24 h TSD, mice of group 1 were recorded during 72 h to determine the sleep rebound and a second group of 5 mice were sacrificed to collect blood samples for corticosterone assay. A third group of 5 mice were not sleep deprived and were used as control, and sacrificed at the same time (11 a.m.). Results: Corticosterone levels and weight curve were not different between control and sleep deprived mice. EEG recording during 24 h
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TSD shows that mice were awakened 97% of time. EEG recording after 24 h TSD show a significant sleep rebound by increasing quantity, non-REM sleep and delta power (0.5–4 Hz) during non-REM sleep, with no effect on REM sleep during the 24 h following TSD. Temperature and locomotor activity recording show a desynchronization of the two rhythms after 24 h TSD by modifying values of acrophase and amplitude. Conclusion: Total sleep deprivation was effective by limiting mice sleep at 3% during 24 h, by inducing a sleep rebound during the 24 h following the end of privation (increase of non-REM sleep and delta power), and desynchronising locomotor activity and temperature rhythms. In conclusion, this model is as little stressful for mice as rats and can be used as a validated method for total sleep deprivation in rodents. Acknowledgement: Direction General de l’Armement Grant PDH-1SMO-2–0506. http://dx.doi.org/10.1016/j.sleep.2013.11.233
A study on a gender based comparative association between dietary intake and obstructive sleep apnea syndrome S. Dixit 1, A. Dubey 2, S. Kant 3, S. Tiwari 4 1 Department of Nutrition, IT College, India 2 KGMU, India 3 Department of Pulmonary Medicine, KGMU, India 4 Department of Physiology, KGMU, India Introduction: Obesity is identified as the most important risk factor for obstructive sleep apnea syndrome (OSAS). Excessive weight gain results in deposition of the excessive visceral fat by the decrease in basal metabolism and the amount of less momentum despite of unchanging appetite which results in weight gain and upper respiratory tract becomes narrower, and it worsens obstructive sleep apnea syndrome (OSAS). The aim of this paper was to understand the Gender based Comparative Association between Dietary Intake and Obstructive Sleep Apnea Syndrome. Materials and methods: Overnight sleep study was carried out in 190 index subjects in polysomnography unit of Department of Pulmonary Medicine, KGMU, UP, India. Obesity is measured in terms of anthropometric parameters (weight (wt) and body mass index (BMI) = wt (kilogram)/height (meter2)) and dietary intake was assessed by 24 h dietary recall method. Results: In females significant association was found with calories (p = 0.040), proteins (p;= 0.034), number of meals in a day (0.008), Apnea Hypopnea Index (AHI) (p = 0.000) and Epworth Sleepiness Score (ESS) (p = 0.002) whereas in males significant association was absent. Conclusion: Dietary factors are significantly associated with females. Acknowledgements: I would like to thank my guide and my coguides who help me to walk in a right direction. I would also like to thank all the subjects who respond me so patiently. I would also like to thank to God for being with me throughout my work. http://dx.doi.org/10.1016/j.sleep.2013.11.234
Consequences of rem-predominant and rem-exclusive sleep apnea on motor memory consolidation during sleep M. Igue 1, M. Guo 1, A. Malhotra 2, R. Stickgold 3, I. Djonlagic 1 1 Brigham and Women’s Hospital, Harvard Medical School, United States 2 Division of Pulmonary and Critical Care Medicine, University of California San Diego, United States 3 Beth Israel Deaconess Medical Center, Harvard Medical School, United States
Abstracts / Sleep Medicine 14S (2013) e93–e164
more reliable dreams diary method and explore additional features in the dreams of adolescent Canadians. Materials and methods: Fifty males and 50 females, ages 12–17, kept a diary of day’s events and dreams for 10 days. One dream per participant was scored by two independent judges, with interrater reliability, using the Hall and Van de Castle method of content analysis. All variables were controlled for dream report length by dividing by word count. DreamSAT was used for statistical comparisons and a control was used for family-wise multiple comparisons. Results: Independent samples t-tests revealed that females had significantly more words in their dreams (t (78) = 3.543, p = .001), and more female (t (98) = 2.785, p = .006) and family characters (t (98) = 2.683, p = .009.), whereas males had significantly more strangers (t (61) = 3.578, p = .001). Males had both more total aggression (t (74) = 2.452, p = .017), and more recreation implement objects (t (60) = 2.572, p = .013). In addition, a variable in DreamSAT measuring negative tone revealed that males had more negatively toned dreams than females (t (87) = 2.653, p = .009). Conclusion: These results support previous research on gender differences in the dreams of adolescents and stress the early appearance of aggression in male dreams compared to female dreams. It will be interesting to examine the evolution of these differences in older groups. Acknowledgement: Supported by a grant from the Social Sciences and Humanities Research Council of Canada. http://dx.doi.org/10.1016/j.sleep.2013.11.229
Influence of arterial hypertension on renal function in patients with obstructive sleep apnea hypopnea syndrome L. Dheryan 1, G. Podosyan 2, A. Matevosyan 3, P. Zelveian 2 1 Yerevan State Medical University, Yerevan, Armenia 2 Center of Preventive Cardiology, National Institute of Health, Yerevan, Armenia 3 Sleep Research Laboratory at the Center of Preventive Cardiology, Armenia
Introduction: Aim of the study has been an investigation of possible relationship between glomerular filtration rate (GFR) and arterial hypertension (AH) in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). Materials and methods: Forty patients (35 male, 5 female, mean age 43.3 ± 12.5 year) with OSAHS (apnea–hypopnea index (AHI) >5 episodes/h) have been included in the study. Investigated 40 patients have been divided into the two groups: patients having only OSAHS (group I) and patients having OSAHS and AH (group II). GFR has been estimated using the Cockcroft–Gault formula. Normal rates for GFR have been estimated as 100–130 ml/m/1.73 m2. For statistical analysis of GFR classified groups median values have been used as a ‘‘dividing point’’. Relationship between GFR and AH has been estimated according to Pearson v2 and Fisher exact test. Results: Increased values for GFR have been revealed in both groups. However, relatively lower rates from median values of GFR have been detected in 11 patients from group I (55%; CI 34.2– 74.2%) and in 12 patients from group II (60%; CI 38.7–78.1%). Statistically significant differences have not been observed between two groups of patients; while tendency of higher GFR values from median ones have been revealed in the group I (169.0 ± 52.5 vs. 157.5 ± 36.8 ml/m/1.73 m2, p = 0.427). Conclusion: Hyperfiltration is common for patients with OSAHS. In the same time a presence of arterial hypertension is accompanied only by tendency for decrease of absolute values of glomerular filtration rate.
Acknowledgement: Anna Petrosyan laboratory technician. http://dx.doi.org/10.1016/j.sleep.2013.11.230
Echocardiographic findings in patients with obstructive sleep apnea M. Dias 1, R. Reis 2, A. Antunes 1 1 Pneumonology Department, Centro Hospitalar Vila Nova de Gaia/ Espinho, Armenia 2 Pneumonology Department, Centro Hospitalar Trás-os-Montes e Alto Douro, Armenia
Introduction: Obstructive sleep apnea (OSA) is associated with several adverse cardiovascular effects. This study aims to compare the echocardiographic findings of patients with and without OSA. Materials and methods: We performed a retrospective study which included patients referred to a pneumonology outpatient department for suspected OSA between January 2012 and June 2013. Demographic and anthropometric data, cardiovascular risk factors, echocardiographic findings and polysomnographic data were collected. Comparisons were made between subjects with and without OSA. Results: We included 127 patients with a mean age of 56 ± 12 years, 85 (67%) were male. 89 (70%) patients had OSA (34% mild, 17% moderate, 18% severe) and this group was older (58 vs. 50, p = 0.001), had higher body mass index (31.7 vs. 27.2, p < 0.001) and a higher prevalence of hypertension (83% vs. 58%, p = 0.003) and diabetes (88% vs. 66%, p = 0.048). We found that OSA was significantly associated with left atrial enlargement (41.6 mm vs. 36.6 mm, p < 0.001). In those patients with moderate and severe OSA, pulmonary hypertension was more prevalent (62% vs. 39%, p = 0.047) and the left ventricular ejection fraction (LVEF) was inferior. Moreover, there was a negative correlation between the apnea–hypopnea index (AHI) and the LVEF (rho = 0.287, p = 0.007) and an even stronger negative correlation between oxygen desaturation index (ODI) and LVEF (r = 0.327, p = 0.012). However, no correlation was found between LVEF and minimal oxygen saturation. There was no significant difference between the prevalence of ventricular hypertrophy and diastolic dysfunction in different groups. Conclusion: OSA can affect atrial diameter, pulmonary pressure and systolic function, which can be associated to a poorer prognosis. ODI was the best predictor of LVEF which seems to indicate that this index is the polysomnographic parameter more determinant in the deterioration of systolic function. The next step will be to investigate if these alterations can improve with PAP therapy. http://dx.doi.org/10.1016/j.sleep.2013.11.231
Metabolic syndrome influences the severity of sleep apnea syndrome: from the cordioprev study A. Leon Acuna 1, I. Ordonez Dios 2, P. Perez Martinez 1, A. Jimenez Romero 2, B. Jurado Gamez 2, J. Lopez Miranda 3 1 Andalucia Health Service, Lipid and Atherosclerosis Unit, IMIBIC, Spain 2 Andalucia Health Service, Department of Respiratory Medicine, Spain 3 Andalucia Health Service, Lipid and Atherosclerosis Unit, Spain
Introduction: Sleep Apnea Syndrome (SAHS) represents a significant risk factor for the development of cardiovascular disease and evidence suggests a relation with Metabolic Syndrome (MetS). However, it is not clear whether SAHS exacerbates the metabolic
Abstracts / Sleep Medicine 14S (2013) e93–e164
abnormalities in patients with MetS. Objectives: To determine the relationship between the MetS and the number of components of MetS and the severity of SAHS. Materials and methods: The CordioPrev study (NCT00924937) is an ongoing prospective, controlled trial with a mean follow up of five years duration, including patients with high-risk coronary disease. Among 245 patients from the CordioPrev cohort, SAHS was diagnosed from the nocturnal polysomnography (Apnea–Hipopnea Index (AHS) >5) and MetS was evaluated according to the diagnostic criteria of Adult Panel Treatment III. MetS patients (120 men and 30 women; aged between 45 and 68 years) were divided into three groups based on the number of MetS components: subjects with 3, 4 and 5 MetS components (N = 86, 41 and 23 respectively). Insulin resistance and other cardiometabolic parameters were analyzed. Results: 150 patients were fulfilling MetS criteria. As expected, the SAHS severity defined for AHI was significantly higher in patients with MetS (p = 0.04). However, no differences were observed between the AHI and the number of components of MetS (p = 0.27). Interestingly body mass index (BMI) was correlated independently with AHI (p = 0.003) and men with MetS presented major nocturnal desaturation compared with the rest of the population (p = 0.014). We did not find any association between SAHS severity and HOMA-IR (p = 0.39). Conclusion: Patients with MetS showed a high prevalence and severity of SAHS independently of the number of components. Moreover, obesity is an independent risk factor for the SAHS development, influencing its severity. These findings may need to be taken into consideration when treating these related diseases. Acknowledgement: To Dra. Feu Collado for her critical Reading of this paper. http://dx.doi.org/10.1016/j.sleep.2013.11.232
Validation of total sleep deprivation model in mice G. Dispersyn 1, F. Sauvet 1, C. Drogou 1, S. Ciret 1, T. Gallopin 2, M. Chennaoui 1 1 IRBA, France 2 ESPCI, France Introduction: Several models of sleep deprivation for rodents have been developed over years. One of the most relevant models is the activity wheel developed by Christie et al. for rats, presenting the advantages to induce few stress and physical activity. Even if this model is validated in rats, no data are available about its pertinence in mice. The aim of our study was to validate this model to mice by assessing that: i. the model do not generate high level of stress (determined by corticosterone assay and weight follow-up); ii. mice are awake 95% of time during sleep deprivation (determined by EEG); iii. the model induces a sleep rebound after sleep deprivation (determined by EEG, temperature and locomotor activity). Materials and methods: 24 h total sleep deprivation (TSD) was produced by a slow rotational movement of an activity wheel programmed on a schedule of 3s ‘‘ on ’’ and 12s ‘‘ off ’’ in 13 male C57BL/ 6 mice. After sessions of wheel habituations, mice were exposed to a 24 h TSD (11 a.m.–11 a.m.). A first group of 8 mice were implanted with telemetry transmitter (TA10ETA-F20, DSI, USA) recording continuously EEG, locomotor activity and temperature before, during, and after 24 h TSD. At the end of 24 h TSD, mice of group 1 were recorded during 72 h to determine the sleep rebound and a second group of 5 mice were sacrificed to collect blood samples for corticosterone assay. A third group of 5 mice were not sleep deprived and were used as control, and sacrificed at the same time (11 a.m.). Results: Corticosterone levels and weight curve were not different between control and sleep deprived mice. EEG recording during 24 h
e107
TSD shows that mice were awakened 97% of time. EEG recording after 24 h TSD show a significant sleep rebound by increasing quantity, non-REM sleep and delta power (0.5–4 Hz) during non-REM sleep, with no effect on REM sleep during the 24 h following TSD. Temperature and locomotor activity recording show a desynchronization of the two rhythms after 24 h TSD by modifying values of acrophase and amplitude. Conclusion: Total sleep deprivation was effective by limiting mice sleep at 3% during 24 h, by inducing a sleep rebound during the 24 h following the end of privation (increase of non-REM sleep and delta power), and desynchronising locomotor activity and temperature rhythms. In conclusion, this model is as little stressful for mice as rats and can be used as a validated method for total sleep deprivation in rodents. Acknowledgement: Direction General de l’Armement Grant PDH-1SMO-2–0506. http://dx.doi.org/10.1016/j.sleep.2013.11.233
A study on a gender based comparative association between dietary intake and obstructive sleep apnea syndrome S. Dixit 1, A. Dubey 2, S. Kant 3, S. Tiwari 4 1 Department of Nutrition, IT College, India 2 KGMU, India 3 Department of Pulmonary Medicine, KGMU, India 4 Department of Physiology, KGMU, India Introduction: Obesity is identified as the most important risk factor for obstructive sleep apnea syndrome (OSAS). Excessive weight gain results in deposition of the excessive visceral fat by the decrease in basal metabolism and the amount of less momentum despite of unchanging appetite which results in weight gain and upper respiratory tract becomes narrower, and it worsens obstructive sleep apnea syndrome (OSAS). The aim of this paper was to understand the Gender based Comparative Association between Dietary Intake and Obstructive Sleep Apnea Syndrome. Materials and methods: Overnight sleep study was carried out in 190 index subjects in polysomnography unit of Department of Pulmonary Medicine, KGMU, UP, India. Obesity is measured in terms of anthropometric parameters (weight (wt) and body mass index (BMI) = wt (kilogram)/height (meter2)) and dietary intake was assessed by 24 h dietary recall method. Results: In females significant association was found with calories (p = 0.040), proteins (p;= 0.034), number of meals in a day (0.008), Apnea Hypopnea Index (AHI) (p = 0.000) and Epworth Sleepiness Score (ESS) (p = 0.002) whereas in males significant association was absent. Conclusion: Dietary factors are significantly associated with females. Acknowledgements: I would like to thank my guide and my coguides who help me to walk in a right direction. I would also like to thank all the subjects who respond me so patiently. I would also like to thank to God for being with me throughout my work. http://dx.doi.org/10.1016/j.sleep.2013.11.234
Consequences of rem-predominant and rem-exclusive sleep apnea on motor memory consolidation during sleep M. Igue 1, M. Guo 1, A. Malhotra 2, R. Stickgold 3, I. Djonlagic 1 1 Brigham and Women’s Hospital, Harvard Medical School, United States 2 Division of Pulmonary and Critical Care Medicine, University of California San Diego, United States 3 Beth Israel Deaconess Medical Center, Harvard Medical School, United States