Welcome, everyone, to our session called New Diagnostic Tools and Treatments in OSA in Adults and Children. We're very excited to see a very packed room here, and we've got five excellent presentations coming up. I'm one of the moderators, David Zielinski, I'm a pediatric vesperologist at the Montreal Children's Hospital. And I'm Dr. Françoise Roux, and I'm an adult sleep specialist, and I am at the UConn, assistant clinical professor at UConn University. Thank you. We are happy and excited to have these sessions. So first up, we'd like to invite Dr. Kristen Sheehan for her project on validation of obstructive sleep apnea questionnaire in high-risk pregnancy. Thank you. Like you said, I'm Kristen Sheehan. I am a pulmonary and critical care fellow at Wake Forest, and I have no disclosures for this talk. Our study objectives include the introduction of a new sleep questionnaire, termed Do I Snore Preg?, and to compare its predictive ability to other well-established questionnaires when applied to a population of high-risk obstetric patients. Obstructive sleep apnea is a common but under-recognized condition, especially in pregnancy. It serves as an independent risk factor for many complications during pregnancy, including preeclampsia, gestational diabetes, refractory hypertension, and preterm delivery. However, sleep questionnaires vary in their ability to predict those pregnant patients who are at risk for OSA. We introduce a new sleep questionnaire, the Do I Snore Preg?, which was derived from the Do I Snore 50 questionnaire. The Do I Snore 50 questionnaire was previously validated in a perioperative population and was found to be predictive of OSA with an area under the curve of 0.78. This questionnaire was then modified to form the Do I Snore Preg? using features associated with high-risk pregnant patients. This study then compared the Do I Snore Preg? with the Epwer Sleepiness Scale and the Berlin questionnaire to determine the likelihood of OSA. This was an ancillary study conducted in conjunction with a placental endothelial analysis measuring the impact of OSA on endothelial levels. This prospective cohort of high-risk pregnant patients did not have a prior diagnosis of OSA. The study was powered to detect a difference in endothelial levels among an OSA prevalence of 15%. All patients completed three questionnaires, including the Do I Snore Preg? as well as underwent an at-home polysonography test using the WATCHPAT 200 that occurred after 28 weeks gestation. Of 492 patients screened in a high-risk obstetric clinic, 100 patients were consented and enrolled in the study. All patients then completed the three sleep questionnaires as well as the polysonography test. Patients with confounding comorbidities were excluded. Two patients were then excluded for insufficient sleep study results. The remaining 98 patients were stratified based on their AHI score. 39% of patients had an AHI score of greater than 5, diagnostic for OSA. Of that 39%, 29% of them were classified as either moderate or severe. In this table, we see that we tracked oxygen desaturations according to their AHI class. Patients with more severe OSA had more desaturations and those desaturations were more severe. We found that patients with OSA had a higher BMI both at the time of delivery and the time of polysonography. They also were older in maternal age. Additional factors that we looked at that were significant included postpartum length of stay which was longer in the OSA positive group. There were also more admissions to the neonatal ICU in those patients whose mothers had OSA. The do I snore PREG questionnaire outperformed both the Berlin questionnaire and the Epwer sleepiness scale. The area under the curve for the do I snore PREG was 0.74. Compared to the Berlin questionnaire was 0.58 and the Epwer sleepiness scale was 0.5 in this high risk population. By ROC analysis, a threshold of four or more positive responses on the do I snore PREG questionnaire best predicted patients at risk for OSA with a sensitivity of 89% and a specificity of 43%. Six or more positive responses had a greater probability and severity of OSA with an odds ratio of 11.7. Our study had several limitations including that it represents results from a single regional academic medical center as well as a relatively small sample size. Overall, we found that the presence of OSA among patients seen in a high risk OB clinic was higher than previously reported. The clinical consequences of longer lengths of stay, desaturations, and increased admissions to neonatal ICU highlights the need for screening in this population. The do I snore PREG questionnaire helps fill a gap where prior questionnaires have variable results. The results of this prospective trial of a self-administered do I snore PREG questionnaire helps support its use in screening patients for OSA in a high risk obstetric population. And it helps enhance provider ability to both identify and treat OSA in this population. Thank you. Thank you. We have time for a few questions. We did not include the stop. We did not include the stop bang questionnaire in this study. We chose the At-Worst Sleepiness Scale and the Berlin questionnaire as these were the most commonly used questionnaires in our OB clinics at our institution. And you did just the questionnaire as 28 weeks, right? You didn't compare the questionnaire like earlier in the pregnancy and then a bit later in the pregnancy? No, we only compared it once. Yes, as we know that the sensitivity of a questionnaire can increase as pregnancy progresses, right? Yeah. So I think it's long overdue in the sense even in women compared to male, you know, the questionnaire does not perform as well the At-Worst Sleepiness Scale. And in pregnant women, it's even more important to diagnose obstructive sleep apnea due to the adverse outcome. So thank you. That's very important finding. I'm a pediatric sleep doctor, so this is a completely question made out of ignorance. But what was the rationale behind using 15 inches for neck instead of the 16 or 17 inches in the original questionnaire? Just based on prior literature. Any other questions? There's always this dictum, right patient, right diagnostics, and right treatments. So my question to you is, so where do you go from here next? Yeah, so we specifically apply this questionnaire to those seen in a high-risk OB clinic. I think the next step would be to generalize it more to pregnant patients as well as look at some more outcomes and possibly at different points in their pregnancy to see when is the best time to give this. We struggle with this when I, as a pediatric pulmonologist, we work with our spine surgeons and we always talk about changes in pulmonary function with prior to surgery as surgery. And sometimes we never look back, I mean, never look forward and say, when do those things recover after surgery? So one of the things I wonder is, is this entirely pregnancy-induced? How much of residual disorder or disease is left and what risks does that pose in the longer term for patients, especially females? I feel like they get the short end of the stick when it comes to treating OSA. So the longer term is what I was looking for. Right, those are great follow-up studies to do to get some follow-up on those patients that were screening high-risk and then having positive polysomnographies during pregnancy to see when they need to be repeated and if their diagnosis persists. It seems that women who have a sleep apnea during pregnancy have a higher risk down the road to have adverse cardiovascular outcomes. So it's important to diagnose them during pregnancy and then follow them. One more question. A lot of OSA questionnaires seem to be inaccurate, and a lot of that may depend on the underlying endotype for why the patient has apnea. Do you have a sense of what your questionnaire might predict based on underlying endotype in pregnancy versus non-pregnant patients? So we did compare those, like our individual questionnaire questions, to see which were most predictive. And we found that insomnia, snoring, and daytime sleepiness were most predictive, although our study questionnaire as a whole outperformed any question individually. So those may be the most contributing factors, but compared to the general population, I don't know. I think in the woman population who are not pregnant, usually they tend to present more with insomnia and less with daytime hypersomnia compared to male. Thank you very much for a wonderful presentation. Thank you. So now we'll go to Dr. Clete Kushida, who is a professor at Stanford University and is going to talk about treatment of severe obstructive sleep apnea by novel oral appliances. Thank you. Thank you, and good morning. These are my disclosures and the lesson objectives. So one emerging approach to treat obstructive sleep apnea is this CARE system, which is a dental-provided guided system that leads to gradual increases in airway volume. And this study evaluated severe OSA patients treated with novel oral appliances. And there are two appliances that were tested. One is called the day and night appliance, or DNA. The other is a mandibular repositioning nighttime appliance, called mRNA. And the mRNA adds a mandibular advancement device to the DNA. And these appliances are designed to be worn about 6 to 24 months. And what it does is it actually uses slow maxillar expansion combined with mandibular advancement to increase the upper volume and improve obstructive sleep apnea. This shows the methods. The MRI device is an FDA-cleared device to treat mild to moderate OSA and snoring adults. Now, the maxillary DNA portion of both devices consists of polymer subunits with embedded metallic coils. And those are designed to gradually increase the airway volume over time. The DNA device is an FDA-registered product for palatal expansion. And the palate is able to be expanded in the anterior-posterior as well as the lateral dimensions. So here's the DNA appliance on this side, the mandibular advancement device on the side. And the mRNA device combines both of these features. So these are the methods. It was a retrospective analysis that used a research database that was initiated in 2018. And it incorporated real-world data from treating dentists through December 2021 for mRNA and through April 2022 for the DNA. This was the database provided to us was de-identified and was subject to IRB review. The database contains pre- and post-treatment without the oral appliance in place. And this is important because, as you know, standard oral appliances, you know, we measure it, you know, post-treatment with the appliance in place. So we measured the HI. We measured transpalatal width and airway volume via CVCT as well as collected safety data. And the co-primary endpoints were pre- to post-treatment HI and transpalatal width improvement. The secondary endpoints were pre- to post-treatment airway volume improvement and safety measures. And you can see the study inclusion criteria here as well as the study exclusion criteria. Now notably, it had to be, the measures had to be taken about greater than six months apart and they had to adhere to the bison. And this was self-administered or self-reported adherence at greater than or equal to 10 hours per day. So these show the results. So you can see they're pretty evenly matched for the severe as well as moderate OSA groups. The BMI was slightly higher in the severe group as was the treatment duration. Everything else was similar. These show the outcomes. Now all the outcomes showed high significance in terms of the HI, the transpalatal width and the airway volume for the severe OSA as well as with the moderate OSA. And there were really no significant safety issues were observed. Now just for a frame of reference, the transpalatal width, it's usually about 36 to 38 millimeters and the airway volume is approximately 20 to 23,000 cubic millimeters in normals depending on the normative data in the studies. Now what was interesting was when we looked at the DNA versus the mRNA changes to pre- and post-treatment, you can see that both of them are shown in the prior slide showed improvement. But there was slightly greater improvement with the DNA appliance compared to pre- and post-treatment. And so the conclusion is, as I mentioned, oral appliances historically are treated only mild to moderate OSA patients. This is probably going to change within the next five years. Not only with this product but with other products as well because it's sort of a gap in our field. But this study did show that severe OSA can be improved with oral appliances. And what we also showed was that for patients diagnosed with severe OSA, it was safe and effective as it was for moderate OSA patients as well. And as shown, patients with severe OSA patients showed more improvement in HI, transpalatal width and airway volume versus those with moderate OSA. Now interestingly, the patients, as I alluded to in the prior slide, patients with DNA, which was a maxillary expansion only, performed slightly better than patients with mRNA in these measures. And this indicates that the prior improvement mechanism could be maxillary expansion. And that goes to show even with kids, we tend to use things like maxillary expansion as well as adults. As well as adults, we tend to use things like distraction, osteogenesis with maxillary expansion and those can be very successful. So importantly, the DNA and mRNA appliances aren't advanced over conventional oral appliances since they modify the upper predominantly via maxillary expansion. And it appears that these treatment effects persist without the appliance in place. We're continuing to follow these patients to see, you know, if it's sustainable because as you know, the airway can change over time and we're hoping that it will hold true. We're also experiencing it with pediatric populations as well. Thank you. I just want to acknowledge my co-investigators on this study. Any questions? Any complications of maxillary expansion? Yeah, you know, it's pretty similar to that of those with conventional appliances. There can be slight teeth pain and slight movement, but those are the main ones that were picked up. What about TMJ? They tend to be a little self-limited. Any TMJ complications from there? Sorry? TMJ? Temporomandibular? No, no. His question was about temporomandibular joint disease and it didn't appear to be any. In severe apnea, it didn't meet the shared criteria still, right, but it is effective in moderate. Do you agree? Yes. It appeared to be effective both in moderate as well as severe. But it didn't meet the shared criteria, EHI of less than 20, absolute terms. Say that again. You mean like dropping down the EHI to less than 20? Less than 20. Yes. You know, not on all patients and, you know, oral appliances, as you know, they only work at one portion of the airway, so it is hard to get a conclusive two-step downwards, you know, to our normality or even to bring them often down to mild cases as well. Thank you. So first, this is a very nice thing for patients who don't like CPAP, obviously, and really need help. How can we as clinicians out in the real world tell if the dentists who do this kind of stuff are using modern technique or doing the old stuff? That's a good question. You know, part of the thing is, you know, one sort of tier is, you know, to always, what we tend to do is refer to American Academy of Dental Sleep Medicine, you know, providers because they have that extra layer of training. But then additionally, you know, there are ways to, you know, connect with dentists that do this type of device. You know, this particular device is manufactured by this company called Vivos, and they have a database that shows dental providers. As mentioned, you know, this is kind of like one of the first steps, you know, there's going to be a lot of different oral appliances that are probably going to be, you know, indicated for severe OSA, but this is, you know, among the first. So I'm sure each company that does it will have their own, you know, database of providers, so patients and providers can easily, you know, go into those databases and see which providers, you know, offer those treatments. Another question, would maybe, so it seems like it works better in people who have high BMI, right? You know, it was interesting because, yeah, the BMI, as I pointed out, it was a little higher. It was kind of paradoxical because that was kind of an unexpected result because normally we would think that, yeah. Yeah, because usually it doesn't work as well, that's why I was a bit surprised. Would maybe like when you consider a patient for a DNA device, would there be a cutoff of a BMI that you would consider for this patient just in practical world, you know, to? Yeah, the good thing about this database is it's continuing to collect patients and we'll be able to, you know, more accurately, you know, predict maybe an acceptable BMI cutoff. And you know, on other appliances that are currently being tested for, you know, indications for severe OSA, yeah, some of our nodes have sort of set a BMI cutoff. So that probably, you know, would be very expected in the future. Yeah, if I remember well, in general, for mandibular advancement device, it seems that in patients who have a BMI higher than 32, it doesn't work as well. Absolutely. Do you expect also another question is that it may be a good solution for people who don't want to use the CPAP and are also like a mouth breather who have nasal, higher nasal resistance when they could benefit from the DNA as opposed to the mRNA? Yeah, absolutely. Right. Yeah, that's going to be more and more expected just because, you know, CPAP, although it's terrific, you know, because the supply chain issues recalls all this, you know, there's been even more of an interest in oral appliances. So yes, absolutely. Yeah, I think it would be great also to study that actually in patients who are like in women who have REM related sleep apnea, because we know they are worse. And MED tend to work not as well in these patients. So maybe the DNA would be a good option for them. Absolutely. Yeah. Also, does it change the bite more compared to mRNA if you compared to regular MED when you use mRNA? Yeah, because of the increase in trans-palatal width, it does change the bite. But interestingly, at least in this cohort that we studied, there weren't complaints. There was some teeth pain, also teeth movement issues, but no significant complaints about changes in bite that we noticed. That's great. Thank you. Thank you so much. Oh, sorry. One more question. Sorry, quick question. Was the post-treatment data, was any of that done without the overnight appliance in place? Oh, yes, absolutely. So all the post-treatment measures were measured without the appliance in place, which is different from how we usually measure the post-treatment with appliances. Thank you very much. Very interesting presentation. Thank you. Yeah, go ahead. So we're just going to do a slight change in the order here. And I'd like to invite Dr. Matthew Epstein to discuss the development of a novel multidimensional questionnaire to evaluate sleep hygiene. Thanks, and good morning everybody. And I am from New Jersey and I have nothing to disclose. So my objectives are to discuss sleep as a component of health, to review behaviors and activities that hinder sleep, and to introduce a new sleep hygiene survey and to discuss its development, validation, and potential utility. Well, it's well established that sleep is essential to achieve optimal health. And when we have insufficient sleep, we're at risk for cardiovascular, metabolic, and neurocognitive consequences, reduced work performance and productivity, increase in accidents and impaired social functioning, mental health and quality of life. I think it also makes us grumpy. A number of expert guidelines recommend obtaining adequate sleep. Unfortunately, most of us ignore these guidelines. This is a map of the U.S. showing distribution of short sleep duration, the lighter shaded areas, about a quarter to a third of us get less than the recommended seven hours. In the darker areas, it's up to 50%. Sleep hygiene is a major determinant of good sleep, and a plethora of contemporary activities and behaviors can adversely affect sleep. These include binging, social media, working from home, screen light exposure, and relying on sleep meds and supplements. A survey that came out prior to the pandemic showed that nearly 90% of U.S. adults have lost sleep from staying up late binge-watching shows. The National Coffee Association reports that 58% of us now consider coffee to be our favorite beverage, and nearly two cups of coffee a day per capita are consumed in this country. One in five of us relies on medications to help us sleep. So a typical day for a lot of us now might include Starbucks or Dunkin' Donuts, then going back home to work, taking extra caffeine later in the day, staying up late and dozing off watching Netflix, and then trying to get to sleep using melatonin, but first going on social media and getting a little more screen light in in your bed. So clearly there's a problem with our sleep hygiene, and the first step in managing a problem is to try to measure or quantify it. And we have a variety of tools to assess sleepiness, sleep quality, fatigue, and insomnia that we're all familiar with. But unfortunately, there are few questionnaires available to assess sleep hygiene. None of them have been developed recently, nor are they relevant to the current situation with our sleep hygiene. Prior questionnaires were from the 1980s and 1990s. They weren't well-validated. The most recent study that we came across from 2006 was done in college students. It also had some methodological problems. So objectively measuring sleep hygiene could be useful to evaluate patients' sleep complaints, and identifying detrimental sleep habits could help to improve sleep, general health, and well-being, and specific medical conditions. So based on the old game show 20 questions, we came up with a 20-question sleep hygiene questionnaire. And we called it the Sleep Hygiene Questionnaire, or the SHQ. And we incorporated both long-established sleep hygiene principles, as well as a number of contemporary behaviors and activities that could impact sleep. This was developed using a current evidence-based literature review. Again, on the left column, these were the sleep hygiene variables that we incorporated. Again, from 1980s, 90s, and the 2006 study that I mentioned. And then we added or modified a number of additional factors. Well, including sleep procrastinations, screen light exposure, evening dozing, et cetera. This is the actual sleep hygiene questionnaire, and it consists of 20 questions, as I mentioned, each of which is a detrimental sleep habit. And so the higher the number on the SHQ, the worse the sleep hygiene. 700 patients completed our survey in four different offices. They all had various sleep diagnoses. This was the demographic makeup. Patients also completed a sleep quality scale, Epworth sleepiness scale, and a fatigue severity scale. And the SHQ was then compared to these latter three scales. Internal consistency was measured using Cronbach's alpha, and total scores were summarized and compared using different categorical thresholds. This is the actual data from our collection of the 700 plus patients by individual question. I'll just point out a couple things. You know, a large percentage of our patients slept less than seven hours, didn't get much exercise, consumed caffeine within eight hours of bedtime, dozed off in the evening before bed, had screen light exposure up till bedtime or in bed, and stayed up later than they should or procrastinated going to bed. We found that the SHQ significantly correlated with the Epworth score, fatigue severity score, and overall sleep quality scales. And in fact, an SHQ of eight or greater was associated with an Epworth score of 10 or greater indicating abnormal sleepiness, and a fatigue severity score of 36 or greater indicating abnormal fatigue. Internal validity remained consistent for each question in the SHQ. And this is a summary of all the questionnaires. And again, on the left, you can see that the higher the sleep questionnaire score, the worse the sleep quality score, and the greater the sleepiness and fatigue scores were. So our conclusions, sleep is fundamental to achieving good health. Our sleep is worsening in part due to poor sleep hygiene, and a current and comprehensive means to evaluate sleep hygiene has been lacking. The SHQ appears to be a valid instrument to measure sleep hygiene in adult sleep clinic patients. The SHQ strongly correlates with daytime sleepiness, fatigue, and overall subjective sleep quality in our cohort. And the SHQ could potentially improve quality of life and general health as well as specific medical conditions in which sleep plays a role. Further studies are warranted to validate applicability and broaden usage of the SHQ and other patient populations. Thank you. Any questions? I'm sorry. Is there any correlation of SHQ to AHI? Obviously, most of the patients could have come to the clinic, right? For an in-lab study. Is there a correlation between your scores and the scores of SHQ and AHI in patients? I'm sorry, which patients? In these patients, is there a correlation of SHQ score and AHI? And AHI? AHI. For example, patients who have abnormal sleep health quality. Do they have sleep apnea? Sleep quality questionnaire and were sleepy, did you do, I guess, PSG to look if they had sleep apnea and if there was a correlation between that? I mean, probably half of our patients had apnea because you're sure there is a correlation between SHQ and ESS, right? Right. So there has to be some correlation. That's why I asked. Sure. A lot of the patients were already treated, but it was a total mix. Thank you. Nikat Mehdi from Oklahoma. I'm a pediatric pulmonologist. Just a question. I, my personal observation is that a lot of children were homeschooled during COVID and many of them are still post-COVID also homeschooled. Whether, like for them, I see a lot of this thing about they are up all night, they sleep around three, four in the morning. How do we assess them? And for pediatrics, if anybody has done similar kind of, just to know, sleep habits have really changed. Like I've been in practice for 21 years and I have never seen that many kids not sleeping at night and at a regular time. It's a kind of a change from what we used to see because I ask them every time when I see a child, my part of my question is, and I think we do a lot of sleep studies too, but again, just to assess it in a more depth, what would you recommend? Like we choose similar kind of questionnaire for them. I want to study it in my population. Any suggestions? I'm sorry, is there a specific? I said, any suggestions for us? For pediatric? Yeah. Well, I mean, again, there's sort of a void in this area for both adult and peds. I think in the literature, there's actually more pediatric studies now than there are for adults. But I came across a number, maybe within the last five years for the pediatric population. I just see a trend in the sleeping habits from five years before to now, with a lot of them having a cell phone with them too. All that has played a role. So I have a question. Where do you foresee this questionnaire coming into play? Kind of a pre-screening before PSG to work on things or for those who don't want to get treatments? So, I mean, I started thinking about this a few years ago because all the sleep apnea patients and the other sleep patients that we were treating, you know, when you ask them, well, how do you sleep in general? It wasn't good. And then when you delved into their sleep hygiene, you realize that was a huge problem. So, I mean, there's a lot of areas that we're thinking about with this. The American Heart Association just came out with a big statement, you know, saying that sleep is one of their eight essential areas that they want to focus on for optimal heart health. So, you know, I think the next step is when we identify patients with poor sleep hygiene, you could just go down the list and whatever they are violating, you know, you could focus on that and say this habit is not good for you to try to modify their habits. I think that's super important. It's certainly easier to write an auto CPAP prescription than it is sometimes to fix people's habits. Yeah, and leading to that follow-up on that question, I guess, do you have any plans or do you have any data of using this in a population or using it and then instituting an intervention and see if it makes any difference? Do you have any data on that or not yet? We don't. I mean, this was really a pilot study where we just looked at our overall population, but, you know, we could look at it and, you know, a general medical clinic, diabetes, cardiovascular stuff, et cetera. Yeah, one of the questions that I have for you is why did you choose to compare your questionnaire to other questionnaires? Because some of those questionnaires are also problematic. Particularly like the Epworth, you know, many of us in practice know that the same patient on different times can give you different answers or they confuse fatigue with sleepiness to the point that many of us call it the Epworth list. So why pick those questionnaires as opposed to, you know, try to validate it against something, be it actigraphy or I'm just trying to think about why you pick those questionnaires. Just for simplicity, I suppose? They're kind of the best questionnaires that we have. They're still, you know, popularly used. So, yeah. All right, great. Thank you very much for a wonderful presentation. Yeah, thank you, I think you're it. So now our next speaker would be Dr. Refika. No, Dr. Sherry Katz. Sorry, Dr. Sherry Katz, video clip to assess for obstructive sleep apnea in children, inter-rater reliability. Sorry. Good morning. Thank you for the opportunity to speak with you. Refika and I are gonna tag team because we've been working on all these projects together and she'll present the continuation of mine. The talk for today is on inter-rater reliability of video clips to assess for obstructive sleep apnea in children. I'm a pediatric respirologist or pulmonologist in Ottawa, Canada and I hold grant funding from a number of organizations listed here. By way of background, obstructive sleep apnea, as you know, is best assessed with polysomnography in children. However, access to getting a sleep study in children is extremely limited with very long wait lists that can be up to two years in Canada. We know that history and physical exam are unreliable for the diagnosis of OSA and so we really need a better tool to help us diagnose obstructive sleep apnea in children or at the very least to help us triage referrals so that we know that we're getting to test the children who are most likely to have the disease. Our hypothesis in this is that video clips that parents could record on a smartphone may help us determine which children need the most urgent polysomnography but this is yet to be well studied. The aim of this study was therefore to determine inter-rater agreement between two pediatric sleep physicians and the assessment of obstructive sleep apnea based on the parent recorded video clips and we used two scoring methods, the Monash score based on a group from Australia who've done pilot work in this area and I'll describe that to you in a moment as well as an overall clinician impression of whether OSA was present and whether it was mild, moderate or severe. We included children aged three to 18 years of age referred for polysomnography for evaluation of suspected obstructive sleep apnea at our institution. We asked the parents to record three mobile video clips on the smartphone and the videos were reviewed by two independent blinded clinicians. The clinicians scored for the presence and severity of OSA using those two screening methods I mentioned before and we looked at the inter-rater agreement as well as agreement between the two scoring methods using an weighted Cohen's kappa. This is the first scoring method based on a paper published by Thomas last year and they've termed this the Monash obstructive sleep apnea video score. It's a score out of eight that looks at a number of factors that are rated on severity or presence including inspiratory noises, the presence of obstructive events, evidence of increased work of breathing, the presence of mouth breathing and neck hyperextension. In this study we looked at 50 children with a mean age of seven and a half years, 46% of whom were male. The mean Monash video score was 3.25. In the Monash paper they reported that a score of three or more was considered consistent with obstructive sleep apnea and the clinician impression was that 32% of our sample had obstructive sleep apnea. As you can see from these results, the weighted kappa scores show excellent agreement between the two clinicians in terms of their impression of whether OSA is present or severe using both scoring systems and whether we dichotomized it or asked people to look at the severity. We also looked at the agreement between the Monash score and clinician scores for each rater which were similarly quite high. So what we've determined, there's good agreement between raters and scoring the videos to evaluate for OSA in children. A clinician can pick out the child who likely has obstructive sleep apnea and at least they're consistent with each other. The two scoring systems also seem to perform fairly similarly. The limitation of course is that in this preliminary work the video clip rating has not been compared to any objective test or to polysomnography which is a gold standard test for the presence of obstructive sleep apnea. So our next step, which Rafiqa will explain to you, was to begin to compare the scoring of video clips to polysomnography or another form of sleep study to determine utility in video clips to identify obstructive sleep apnea in children. I think I'll stop there. Thank you. Thank you very much. We have time, but I don't know if it makes more sense. Yeah, it probably does make more sense. So what we're gonna do is we'll do, they're kind of combined, so we'll do the questions. What's that? They're combined sessions, so we'll do the questions together right after this. And finally, to introduce Dr. Rafiqa Ersoo, who's also working on this project. Thank you very much. So I'll talk about now a correlation with the polygraphy, and these are my disclosures. I also work at Children's Hospital of Eastern Ontario, and I have a couple funding. So our hypothesis, as Dr. Katz mentioned, that the video clips recorded by parents will be helpful to determine which children need most urgent polysomnography. And we also hypothesize that they can also be used for diagnosis of obstructive sleep apnea, specifically in resource-limited settings. Obstructive sleep apnea is, of course, best assessed with polysomnography in children. However, we performed this study during COVID, and there was even more limited access to polysomnography. So we used home polygraphy for diagnosis of obstructive sleep apnea. Therefore, from now on, I'll mention the results of polygraphy. So the study aims for to evaluate the association between home-recorded mobile video clips and polygraphy measures, oximetry, and pediatric sleep questionnaire in children referred for obstructive sleep apnea evaluation, and also evaluate the diagnostic characteristics of video clips, oximetry, and PSQ-4-OSA in children. So we recruited children three to 18 years of age who were referred to polysomnography for evaluation of suspected obstructive sleep apnea at the Children's Hospital of Eastern Ontario. Parents recorded, as mentioned, three video clips of children during sleep, and also completed pediatric sleep questionnaires. They underwent then home polygraphy, and the oximetry results were retrieved from the polygraphy. We accepted that children had obstructive sleep apnea based on the following, either OHI greater than or equal to 1.5, ODI 3% greater than or equal to 4.3 per hour, McGill oximetry score greater than two or more, and a PSQ score of greater than 0.33 or more. Monash score, as mentioned again, was positive if it was more than three. Sensitivity and specificity of video clips and oximetry and pediatric sleep questionnaire scores for OSA and polygraphy were assessed. So we included, so far, 33 children to the study, and mean age was 6.8, so they were on the younger side. Around 45% were female. So as a limitation of the study, only few children had moderate to severe OSA, 10%. When we looked at the variables and the positivity and the number of patients diagnosed with obstructive sleep apnea used with these methods, ODI more than, ODI 3% more than 4.3 was around 36.8%, McGill score 15.8%, PSQ 92.1%, so it was over-diagnosing, and Monash greater than three was 47.4%. When we look at the sensitivity and specificity of the video clips for diagnosing OSA, any OSA, so including mild, it was high at 75% for sensitivity and 85% for specificity. When we looked at the diagnosis of moderate obstructive sleep apnea using those methods, they were all very sensitive, so they didn't miss any, but again, limited number of patients. And McGill oximetry score or ODI 3% actually performed very well, but it's important just to note that the Monash scored performed better than the PCQ, which is important because it can be used in more resource-limited settings compared to the oximetry. So we concluded that video clips' diagnostic characteristics are better than PSQ, and at times, especially for mild OSA, close to oximetry. And of course, we can combine these methods, so if you're not limited with just using either a questionnaire or a Monash score, you can combine oximetry, and this is now what we are working on more, including more patients. And in this part of the, in this time of the study, when we reported it, low number of patients with moderate obstructive sleep apnea was our limitation. So these are the references. If you were wondering why we used these cutoffs, they were based on those published studies, and I thank you for your attention. Thank you. Thank you. All right.

sleep disorders

obstructive sleep apnea

OSA

validation

questionnaire

oral appliances

sleep hygiene

video clips