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Neurology Residents Gary Gallagher - The Yield of Procedures and Imaging in the initial evaluation of peripheral neuropathy Introduction: Peripheral neuropathy encompasses a heterogeneous group of disorders, including distal symmetric polyneuropathy, mononeuropathy, multiple mononeuropathies, demyelinating neuropathies, amongst many others. Peripheral neuropathy is a prevalent condition affecting approximately 2% of the general population and as many as 8% of those over the age of 55. Several recent studies have been published regarding the laboratory work-up in the initial evaluation of peripheral neuropathy, with the highest level of evidence supporting fasting blood glucose, vitamin B12 and SPEP (only level C). A significant proportion of patients also undergo evaluation with EMG and MRI. Given the current health care climate, which places a premium on cost-effective medicine, further studies are needed to determine which tests should be performed in these patients. Methods: We will perform a retrospective chart review of patients presenting to the University of Michigan Neuromuscular Clinic, a tertiary referral center, from 1/1/2007 through 12/31/2008. Patients with symptoms (parasthesias, numbness, pain, weakness) and exam findings (sensory findings, weakness, hyporeflexia) of peripheral neuropathy will be included. Those patients with evidence of compression neuropathy, traumatic neuropathy, and radiculopathy will be excluded. Patients will be evaluated for evidence of a neuropathy subtype other than distal symmetric poly neuropathy. The suspected pre-test etiology will be determined by review of the electronic medical record. We will then determine if a procedure (EMG) or imaging modality (MRI) resulted in a change in the suspected etiology or a change in management. We will also include data from a previous evaluation by a PCP or previous neurologist was performed. Results/Conclusions: We will categorize the number of tests order by referring neurologist and by neuromuscular specialists. We will examine the yield of lab tests, EMG and MRI studies. Data collection and analysis are currently in progress. Hypothesis: A change in management or the pre-test etiology will be low as a consequence of an EMG or MRI study. Rahul Karamchandani - Choice Of Anticonvulsant Prophylaxis And Risk Of Delayed Seizures, Delayed Cerebral Ischemia, And Poor Outcome After Aneurysmal Subarachnoid Hemorrhage Introduction Some retrospective studies have suggested an association between Phenytoin burden and poor neurological outcomes after aneurysmal Subarachnoid Hemorrhage (aSAH).1 Other studies report an increased rate of seizures with short-term use of Levetiracetam versus use of Phenytoin for longer duration,2 as well as the possible occurrence of Delayed Cerebral Ischemia (DCI) in association with late seizures after aSAH.3 Our objective was to evaluate the risk of in-hospital seizures, DCI, and poor outcomes in patients treated with Levetiracetam versus Phenytoin in patients with aSAH. Methods The medical records of patients with aSAH admitted between January 2005 and April 2009 were reviewed. Anticonvulsants were administered for at least 48 hours after admission in all patients. EEG monitoring was not routinely performed. Delayed Cerebral Ischemia was defined as the composite of symptomatic vasospasm and/or delayed infarction on imaging.4 Poor outcome was defined as modified Rankin scale (mRS)>2 at first follow-up. Results Only 3 of 148 (2%) patients had a seizure following initiation of anticonvulsant prophylaxis. Overall, 52 (35%) developed DCI and 61 (41%) had mRS>2 at follow up. Following multivariate logistic regression analysis, only age, DCI, and non-use of Phenytoin (OR 3.42, 95%CI 1.14-10.29, p=0.03) were found to be statistically significant associations with mRS>2. In contrast, use of Phenytoin versus Levetiracetam in the first 72 hours was not associated with poor functional outcome. Conclusions In-hospital seizures are rare when anticonvulsant prophylaxis with any agent is used after aSAH. The choice of anticonvulsant was not found to influence the risk of DCI, although the use of Phenytoin beyond the first 72 hours was associated with better functional outcomes at follow-up. Prospective, randomized clinical trials are required to inform the choice of anticonvulsant prophylaxis after aSAH. REFERENCES 1. Naidech AM, Kreiter KT, Janjua N, Ostapkovich N, Parra A, Commichau C, Connolly ES, Mayer SA, Fitzsimmons BF. Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage. Stroke. 2005 Mar;36(3):583-7. Epub 2005 Jan 20. 2. Murphy-Human T, Welch E, Zipfel G, Diringer MN, Dhar R. Comparison of short-duration levetiracetam with extended-course phenytoin for seizure prophylaxis after subarachnoid hemorrhage. World Neurosurg. 2011 Feb;75(2):269-74. 3. Sampson TR, Dhar R, Zipfel GJ. Cerebral infarction following a seizure in a patient with subarachnoid hemorrhage complicated by delayed cerebral ischemia. Surg Neurol Int. 2011 Jan 31;2:14. 4. Frontera JA, Fernandez A, Schmidt JM, Claassen J, Wartenberg KE, Badjatia N, Connolly ES, Mayer SA. Defining vasospasm after subarachnoid hemorrhage: what is the most clinically relevant definition? Stroke. 2009 Jun;40(6):1963-8. Epub 2009 Apr 9. Benjamin Bly - The Prevalence of Impaired Olfaction in Parkinson Disease is Higher than Previously Estimated. Background/Objectives There is a strong relationship between impaired olfaction and Parkinson Disease (PD). Estimates of prevalence range from about 50% to 75% [1], and even 90% [2]. Factors affecting these estimates include the type of olfactory test, sample size, normative comparison data, gender and age distribution [1]. An additional factor is the uncertainty of clinical classification in patients with symptoms suggestive of a diagnosis of PD. Subjects without evidence of dopaminergic denervation (SWEDDs) may contribute significantly to low estimates of the prevalence of dysosmia in PD. Dopaminergic imaging has become a de facto gold standard for diagnosis of PD when concordant with clinical signs. Brain imaging to confirm PD is costly and guidelines for imaging have not been adopted widely. If an inexpensive screening test can be identified for PD, it may have a large impact on health care costs. Our objective is to estimate the prevalence of olfactory dysfunction in patients with clinical signs of PD confirmed by imaging evidence of nigrostriatal denervation. If high, impaired olfaction may be a useful screening test for diagnosis of PD and will allow more appropriate selection of suitable candidates for presynaptic dopaminergic radioligand imaging in clinical practice. Ross Coleman - Appropriateness of Deep Brain Stimulation Referrals to a Tertiary Medical Center Background: Deep brain stimulation (DBS) is an effective surgical therapy for Parkinson's disease (PD), essential tremor (ET) and dystonia, and patient selection is critical to its success. Very few studies have analyzed the appropriateness of referrals made to a DBS center. Objective: To retrospectively evaluate the quality of DBS referrals to the University of Michigan Surgical Therapies Improving Movement (STIM) program in order to determine general knowledge in the medical community regarding DBS candidacy. Methods: Medical records of all patients referred to the University of Michigan STIM program for DBS from 9/1/2007 to 12/31/2011 were reviewed. Referral reason, referring physician type, number of appropriate/inappropriate patients for DBS and reason for not offering DBS were recorded. Results: A total of 243 candidates were referred to the STIM program during the time period reviewed, 158 for PD, 68 for ET/Multiple Sclerosis tremor, 16 for dystonia, and 1 for chorea. Of the 158 patients with PD, 50 were ultimately approved for DBS, while 66 were deemed inappropriate candidates. The majority of PD patients approved for DBS were referred by movement disorder specialists (68%), followed by general neurologists (26%). Of the 66 inappropriate PD candidates for DBS, 50% were referred by general neurologists and 26% by movement disorders specialists. Conclusions: In our DBS center, general neurologists referred only a quarter of the PD patients who were offered DBS surgery, but referred 50% of the inappropriate DBS candidates with PD. This suggests a lack of knowledge among the general neurology community regarding appropriate DBS referrals for PD. Michael Soileau - Caregiver Burden in Parkinson’s Disease Patients Undergoing Deep Brain Stimulation Objective: To investigate the factors associated with caregiver burden in Parkinson's disease (PD) patients undergoing deep brain stimulation (DBS). Background: While caregiver burden has been studied in PD, little is known about caregiver burden in PD patients who are being considered for DBS. Factors associated with caregiver burden are important to define in these patients as both motor and cognitive problems may contribute, but only motor symptoms would be expected to improve with DBS. Methods: We retrospectively reviewed data from a registry of PD patients who have undergone multidisciplinary DBS evaluation at our institution since January 2008. Fifteen PD patients (11 men/4 women) had caregivers who filled out the Caregiver Burden Inventory (CBI), a 24 item questionnaire measuring the amount of perceived burden across 5 separate domains. Clinical evaluations for PD patients included the Unified PD Rating Scale (MDS-UPDRS), Parkinson Fatigue Scale (PFS), Marin Apathy Scale (MAS), Geriatric Depression Score (GDS), State-Trait Anxiety Inventory (STAI), Mini-Mental State Exam (MMSE), and a comprehensive neuropsychological battery. Results: The 15 patients included in this analysis had a mean age 63.2± 8.4 years, mean disease duration of 11 years ± 4.6 years, mean levodopa equivalent dose of 1340.8 ± 580.7, and mean MDS-UPDRS motor offmedication score of 41.5 ± 10.5. There was a positive correlation between the CBI and the motor aspects of experiences of daily living portion of the MDS-UPDRS (R=0.67, p=0.007) and the total Frontal Systems Behavior Scale (FrSBe) score (R=0.73, p=0.002). CBI did not correlate with the motor portion of the MDSUPDRS, PFS, MAS, GDS, STAI, or the MMSE. Conclusion: In PD patients undergoing DBS, increased caregiver burden is associated with greater behavioral changes associated with frontal lobe dysfunction and more difficulty performing motor aspects of daily living, but not the severity of motor symptoms. This may be important when counseling patients and caregivers on post-surgical expectations as DBS may improve motor aspects of daily living, but not dysexecutive type behavioral changes. Shiao-Pei Weathers - Risky driving is related to cholinergic but not nigrostriatal dopaminergic denervation in Parkinson's disease Background: Parkinson’s disease (PD) can affect driving skills and behaviors, though the underlying reason is not well understood and may be due to a variety of factors including motor and cognitive dysfunction. The association between risky driving (a history of traffic citations or accidents) in PD and dopaminergic and cholinergic denervation on PET imaging has not been explored. Objective: To investigate differences in self-reported driving behaviors as well as dopaminergic and cholinergic uptake on PET imaging between patients with and without a history of risky driving. Methods: A driving survey was mailed to 21 subjects with PD who had undergone(+)-[11C] dihydrotetrabenazine (DTBZ) vesicular monoamine transporter 2 and [11C]methyl-4-piperidinyl propionate (PMP) acetylcholinesterase (AChE) PET imaging in a prior research study. This driving survey asked questions regarding a subject’s personaldriving history, and included the Driving Behavior Questionnaire (DBQ), a self-report survey that assesses 3 main types of aberrant drivingbehaviors (errors, lapses, and violations). Results: Twenty subjects (8F/12M) returned driving surveys, 1 in Hoehn-Yahr (HY) stage 1, 3 in HY stage 2, 11 in HY stage 2.5, and 5 in HY stage 3. Six subjects had a history of risky driving (been pulled over, had a traffic citation, or been in an accident since PD onset) while 14 had no such history (safe drivers). There was no significant difference in age, disease duration, levodopa equivalent dose, HY stage, total score/subscoresof the DBQ, or DTBZ binding between risky and safe drivers. However, there was significantly less cholinergic uptake on PMP PET imaging in the cortex (0.021 +/- 0.003 vs. 0.024 +/- 0.003, p=0.048), thalamus (0.048 +/0.006 vs. 0.057 +/- 0.005, p=0.003) and limbic areas (0.044 +/- 0.006 vs. 0.052 +/- 0.008, p=0.049) in the risky drivers compared to the safe drivers. Conclusions: Risky driving is related to cholinergic but not nigrostriatal dopaminergic denervation in Parkinson's disease. There was no difference in self-reported driving behaviors in those with a history of risky driving compared to those without, suggesting that PD patients may lack awareness of the severity and types of driving errors they commit. paminergic denervation in Parkinson's disease Jessica Stulc - Traumatic Brain Injury as an Independent Risk Factor for Stroke Background: A recent population based study demonstrated an increased risk of stroke in patients who sustained a traumatic brain injury (TBI) as long as 5 years after the event (1). Little is understood about the pathophysiology that would link trauma to an increased long term stroke risk. We sought to determine whether this finding was reproducible and to explore several hypotheses regarding the relationship of stroke and TBI: 1. Is the relationship mediated by TBI severity? 2. Is the relationship specific to TBI or to trauma in general? 3. What is the temporal relationship between TBI and stroke? Methods: We plan to use a data from the California State Inpatient and Emergency Department databases from 2005-2009 to perform a retrospective cohort study. Our patient population will include a cohort of patients who present to the ED with mild trauma including TBI and a series of patients with closed fractures. The exposure of interest, TBI, will be characterized using ICD-9 codes. This strategy will enable the broader mild trauma population to serve as a control group. To isolate the relationship between TBI and stroke from other risk factors, we will risk adjust for other known stroke risk factors including: age, sex, hypertension, hyperlipidemia and diabetes mellitus as defined by ICD-9 codes. We will also adjust for the severity of trauma using the IMAP-90 risk adjustment scheme. Cox proportional hazard regression analysis will be used to determine the association between TBI and recurrent stroke risk independent of other stroke risk factors. Secondary analyses will include: narrowing the definition of TBI (only TBI discharged from the ED, only concussion ICD-9 codes), excluding patients with short term stroke, excluding patients admitted for their initial trauma evaluation. Results: Pending Conclusions: pending Lindsey Foy - “Predictors of Epilepsy in Acute Life Threatening Events in Infants” An acute life threatening event, (ALTE), is defined by the National Institute of Health Consensus as “an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid, but occasionally erythematous or plethoric), marked change in muscle tone (usually marked by limpness), choking, or gagging.” ALTE itself is usually not a primary diagnosis, but simply a presenting symptom of an underlying disease. The most common diagnosis in a patient presenting with an ALTE is gastroesophageal reflux disease (GERD) or idiopathic. However, the differential diagnosis is broad and includes seizures. A Brazilian study reported the prevalence of epilepsy as a cause of ALTE in children presenting to the emergency department of a tertiary hospital, where two of thirty (6%) of infants presenting were given a diagnosis of epilepsy. However, diagnosing seizures in an ALTE is often difficult to make as interictal EEGs are often normal, and ictal EEGs are not frequently available, as the event can be a single isolated occurence. There is no reported evidence of the predictive value of presenting symptoms or other key features of the clinical history or exam (clinical description of the event, family history of epilepsy, developmental delay, dysmorphic features, birth history) which may clue the practitioner into a diagnosis of seizure. We therefore hypothesize in infants presenting with an apparent life threatening event, there are common signs and symptoms to their clinical presentation, history and/or physical examination, that when present, increase the likelihood of seizure as the diagnosis and etiology of the ALTE. This is an observational study of patients presenting to the emergency department or admitted to the hospital with symptoms concerning for an ALTE. The study design is a retrospective chart review of children presenting to the emergency department between January 2005-December 2008 with an apparent life threatening event and include a 2yr follow up to determine who was eventually given a diagnosis of epilepsy. Patient cohort will be selected from infants 0-12months of age, seen in the University of Michigan Emergency Department and admitted to C.S. Mott Childrens Hospital. Data will be analyzed with the use of a regression model to identify which factors would be predictors of seizures/epilepsy in the study subjects. Dane Breker: “Development of Increased Vertical Fusional Amplitudes in Patients with Thyroid Eye Disease” Introduction: Increased vertical fusional amplitudes are considered the sine qua non of congenital fourth nerve palsies, and not thought to be present in cases of acquired diplopia. We present 10 cases of patients with thyroid eye disease (TED) who developed increased vertical fusional amplitudes over the course of their disease, in several cases leading to resolution of their diplopia. In reviewing both standard texts and a Pubmed search we found no other similar reported cases. Methods: Review of charts from neuro-ophthalmology practice at a tertiary referral center. The diagnosis of TED was made on clinical criteria (proptosis, lid retraction, lid lag) and neuroimaging. Results: Of the 10 cases reviewed, all were female with ages ranging from 43-81 years. All presented with persistent or intermittent diplopia and one also complained of vision loss. Duration of disease was variable from 6 months to 10 years. One was described only as “years” duration. Vertical fusional amplitudes ranged from 5-25 diopters. Three of the cases developed a head posture which helped them fuse. Prisms were recommended during the course of disease in four cases but were only utilized in three cases. Conclusion: From these cases it can be seen that large vertical fusional amplitudes can develop over time in patients with TED. One thought is that these patients had a head posture in which they could fuse, allowing them to develop increased fusion and increase their range of single binocular vision. As the most common longstanding acquired diplopia, versus ischemic cranial nerve palsies which resolve quickly, this gives insight into the plasticity of the vergence system and suggests that perhaps prism therapy and longer followup would reduce the number of patients who need surgical correction or reduce the amount of surgery needed. Dustin Nowacek: Amyotrophic Lateral Sclerosis In-hospital Mortality Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder that results from dysfunction of upper motor neurons (UMN) and lower motor neurons (LMN) that typically results in death within years of diagnosis. The most common causes of mortality are secondary to respiratory arrest or malnutrition. The average time from symptom onset to death is approximately 45 months in limb onset ALS and 36 months in bulbar onset ALS. As a disease process, ALS is quite novel in that it progresses with minimal cognitive decline, thus providing patients with a unique degree of control over end-of-life decisions. In this project, we aim to evaluate the incidence of ALS in-hospital mortality compared to the total incidence of ALS mortality. Methods: Data was drawn from two sources to estimate the proportion of ALS patients that die in the hospital. First, to determine the total number of ALS deaths in 2009 we used the Centers for Disease Control and Prevention (CDC) Multiple Cause Mortality files which categorize all death certificates in the United States. Death certificates with any diagnosis of ALS (ICD-10 G122) were categorized as ALS deaths. Next, we used the Nationwide Inpatient Sample (NIS) to estimate the number of in-hospital ALS deaths in 2009. NIS is a nationally representative database of all hospital discharges in the United States. By dividing the number of inhospital deaths by the total number of ALS deaths we estimated the proportion of in-hospital ALS deaths. Results: In 2009, there were a total of 7,004 ALS deaths in the United States and a total of 14,188 (95% CI 13,718-14,658) ALS hospitalizations. An estimated 1,500 (1,329-1,671) ALS patients died in the hospital representing 21.4% (95% 19.0%-23.9%) of all ALS deaths. Discussion/Conclusions: ALS is usually a fatal disease, and many patients die in the hospital. This may give us an opportunity to improve the quality of end-of-life care. Future Aims: Evaluate for any potential association between the distance ALS patients live from an ALS center and inhospital mortality. Assess the association between ALS patients who want all life sustaining measures (PEG tube/mechanical ventilation) and in-hospital mortality. Design studies and protocols to evaluate if telemedicine may result in decreased ALS in-hospital mortality for those who do not have easy access to an ALS center. Clinical Neurophysiology Fellows Fawad Khan - Effects of Dexmedetomidine on Transcranial Electric Motor Evoked Potential Monitoring in Pediatric Spinal Correction Surgery Introduction: Dexmedetomidine (Dex) is a potent and specific alpha-2 adrenergic receptor agonist with sympatholytic, sedative, amnestic, and analgesic properties approved by the Food and Drug Administration (FDA) as a sedative and as an adjuvant to anesthesia. Studies have suggested that Dex has negligible effects on TceMEPs up to target plasma concentrations of 0.4 ng/ml. However, unpublished reports have claimed that Dex may affect TceMEP amplitudes. Method: 200 orthopedic spinal procedures with TceMEP, somatosensory evoked potential (SSEP), and electromyography (EMG) monitoring were reviewed. Results: 68 (41.2%) monitored surgeries observed a decreases in bilateral intrinsic hand and foot abductor TceMEPs of greater than 70% when compared to reliable obtained baselines. 37 (22.4%) monitored surgeries observed a complete loss or absence of compound muscle action potentials (CMAPs), rendering TceMEP monitoring unreliable for the surgery . Discussion: Understanding the effects of available anesthetics on TceMEP is required to avoid erroneous conclusions that changes in amplitude represent neurologic injury during surgical manipulations rather than anesthetic effects. Our study provides evidence of substantial attenuation of TceMEP CMAP amplitudes with use of Dex. Further analysis of Dex levels and dosing are warranted to study appropriate anesthetic regimens for the pediatric population undergoing procedures requiring reliable TceMEP monitoring. Victoria Wong 1. The Care and Feeding of a Montage Set The University of Michigan Department of Neurology and Department of Pediatric Neurology provide comprehensive clinical services to patients with epilepsy. Diagnostic testing including electroencephalography (EEG), in-patient long term monitoring (LTM), electrocorticography, and Wada testing are all performed at the University of Michigan. In interpreting these studies, epileptologists use a set of montages that allow them to display the data in numerous ways. Although there are a number of generally accepted standard montages used by the epilepsy community to interpret these studies, montages can be customized to the user. Such edits to preexisting montages result in redundancy, with an unwieldy number of 59 montages cluttering the montage menu. With this A3 Report, our goal is to create an organized list of montages with a standardized naming system that provides enough variety to appease all local epileptologists while keeping the list to a manageable number. 2. The portrayal of seizures and epilepsy on YouTube (to be presented with Matt Stevenson) With the rapid growth of social media and increased ease of sharing personal video recordings since the advent of YouTube, thousands of Internet videos currently reference seizures and epilepsy. Prior studies have noted that in nearly all forms of media including fictional literature, music, movies, television, magazines, and newspapers, seizures are often dramatized or presented in association with negative stereotypes. This has continued with social media on the Internet, with a large proportion of derogatory seizure “tweets” on Twitter and persistent negative attitudes about seizures within the comments on the most popular YouTube videos referencing epilepsy and seizures. However, YouTube distinguishes itself from other types of media in that it allows for persons with epilepsy to give personal accounts that may be more sympathetic. Our present study suggests that content related to seizures and epilepsy on YouTube may be more positive than in other forms of media. Sleep Medicine Fellows Anthony Barber - The Effect of Positive Airway Pressure (PAP) on Sleep State Perception in Obstructive Sleep Apnea (OSA) Patients Introduction: Sleep State Misperception (SSM) is typically seen in insomniacs; however, limited research has shown this phenomenon to occur in sleep apnea patients as well. The goal of this study is to investigate the effects of PAP therapy on SSM in OSA patients. Methods: A data base review of 302 OSA patients (≥18yo) diagnosed and titrated between January 2010 and April 2011 was done. Of these patients, 64% were males, with a mean age of 50.2 years (+/-13.2) and had a mean BMI of 35.1 (+/- 9.1). Computing the ratio of the patient’s subjective and objective TST, we defined SSM as a deviation of >12.5%. Deviation of 12.5% was used as a cut off based on the assumption that misperception >1 out of 8 hours of sleep is clinically significant (>1 STD). Utilizing a 12.5% cutoff, patients were identified as showing SSM on baseline and titration studies. The demographic/PSG variables of these patients were compared to identify patients that remained under-perceivers during PAP titration. Results: Of the 302 patients, 24.8% (N=75) showed under-perception on PSG. 57.8% (N=43) of the under- perceivers showed no misperception or over-perception of their TST during their titration. Only 15.4% of patients with no misperception on PSG showed under-perception on their titration. Upon comparison (T-test) of the demographic, Epworth Sleepiness Scale and PSG variables between patients with and without persistent under-perception; age (p<0.001), TST (P=0.039), arousals/hour of sleep (p=0.016), sleep latency (P=0.001), AHI (P=0.008), and RDI (P=0.009) achieved statistical significance. A regression model to predict those who remain under-perceivers was applied, only age was found to correlate (older age being protective) (OR=0.956, CI=0.935-0.976). Conclusion: Majority of OSA patients with under-perception on their diagnostic PSG transform to having no misperception or over-perception of TST during titration. Despite PAP titration, younger OSA patients are likely to remain under-perceivers. 2. Title: Sleep State Misperception in Obstructive Sleep Apnea . Introduction: Clinical observations and small studies suggest that sleep state misperception (SSM) occurs in patients with obstructive sleep apnea (OSA). However, the frequency of SSM is unknown. The primary goal of this study was to investigate the frequency of SSM in OSA and specifically the proportion of those who underperceive sleep time. Methods: A retrospective review was performed on patients attending a sleep laboratory between January 1, 2010 through April 15, 2011 . OSA was considered present if the apnea/hypopnea index (AHI)>5. The ratio of subjective:objective total sleep time (TST), sleep-onset latency (SOL), and sleep efficiency (SE) was calculated and SSM was defined as any value ±12.5% of the mean value for each parameter. The threshold of 12.5% was based upon an assumption that >1 hour of discrepancy per 8 hours of sleep is clinically significant. Three subgroups were defined for each sleep parameter: under-perception, no misperception and over-perception. Results: The population included 302 subjects (64% male). Mean age was 50.2±13.2years and mean BMI was 35.1±9.1kg/m2. SSM was noted in 89.8%, 52.9% and 49.5% as measured by SOL, TST and SE respectively. For TST, 142 (47%) patients showed no misperception, 75 (24.8%) had under-perception and 85 (28.2%) exhibited over-perception. For SE, frequencies were similar. Considering SOL, over-perception was found in 68%, and under-perception was found in 22%. Subjects with under-perception of TST, compared to those without, were significantly younger (44.4±12.5 vs 52.2±12.9 years, p<0.001), had higher sleep efficiency (81.6±78.6, p=0.021), fewer arousals/hr (15.1±9.5 vs. 18.8 ±13.5, p=0.012) and had a shorter latency to sleep (19.3±16.6 vs 24.4±24.1, p=0.047). In a regression model, age was the only independent variable associated with under-perceiver (OR=0.956, CI=0.935-0.976). Conclusion: SSM is common in OSA. Younger subjects are more likely to under-perceive TST. Kaanchan Gangal - Anorexia as a feature in Kleine-Levin syndrome Kleine-Levin syndrome (KLS) is a rare disorder characterized by recurrent episodic hypersomnia with associated behavioral abnormalities1. It predominantly affects males, causing symptoms for 2 days to 4 weeks, and classically includes features of hyperphagia, hypersexuality, autonomic symptoms, cognitive impairment, altered perception, and psychological changes1,2. The patient is an otherwise healthy 22-year-old man with attention deficit hyperactivity disorder (ADHD) who presented with cyclical episodes of hypersomnolence at age 15. During his episodes, he spends 7-20 days sleeping 20-23 hours a day. He is preoccupied with sex. He fears darkness and must be comforted by his parents. He has a difficult time maintaining oral intake and needs to be coaxed into eating; normally, he has a healthy appetite. He was on methylphenidate for ADHD but reports that taking it during the episodes triggered anxiety, while other symptoms remained unchanged. The patient had an extensive work-up. Evaluation with an MRI of the brain with specific attention to the hypothalamus was normal. Prolonged monitoring with electroencephalography during an episode did not show epileptiform discharges. When the patient was at his baseline, he had a polysomnogram that showed an apnea-hypopnea index (AHI) of 0.10 events/hour and multiple sleep latency testing (MSLT) that demonstrated three sleep-onset REM (SOREM) periods with a sleep onset latency (SOL) of 10.4 minutes. During one of his hypersomnia episodes, he had another polysomnogram that revealed an AHI of 5.8 events/hour and MSLT performed that demonstrated five SOREMs and a SOL of 2.2 minutes. KLS is classically linked with hyperphagia, but a case series showed that 34% of KLS patients had associated anorexia2. Atypical features within a global pattern of recurrent hypersomnia should not deter clinicians from a diagnosis of KLS3. Furthermore, polysomnography, while not diagnostic, can provide useful information to assess for other sleep disturbances and highlight ictal and interictal differences. Hillary Lowenstein - Vagus Nerve Stimulation and Sleep: an indication for polysomnogram? Introduction: Epilepsy and obstructive sleep apnea (OSA) frequently coexist and use of vagus nerve stimulation (VNS) as adjunctive treatment for partial epilepsy is typically well tolerated. Recent evidence suggests that VNS affects nocturnal respirations and has been shown to worsen pre-existing OSA. Our case outlines how it can also complicate treatment of OSA. Case: Patient R is a 22-yo man with mild static encephalopathy and medically intractable partial epilepsy who experiences excessive daytime sleepiness, witnessed apneas, and snoring. He was diagnosed with OSA in 2001, apnea-hypopnea index (AHI) 6.1, and underwent adenotonsillectomy with uvuloplasty. Repeat polysomnogram (PSG) with esophageal manometry in 2003 demonstrated persistent sleep-disordered breathing (SDB)--AHI 1.3 and excessively negative esophageal pressures. Continuous positive airway pressure (CPAP) of 5 cm of water was initiated based on titration study results. Subsequently, he underwent VNS implantation in 2008 for intractable epilepsy. PSG in 2010 (post VNS implantation) demonstrated OSA (AHI 22.3), with obstructive apneas occurring almost exclusively during VNS activation, set at 30s on-3 min off-20 Hz. Subsequent titration study performed with the VNS firing rate reduced to 30s on-5 min off-20 Hz did not find an effective pressure between 4-12 cm of water to treat the SDB; however, most of the scored respiratory events were now hypopneas (in contrast to obstructive apneas noted on the previous study), still in a 1:1 association with VNS firing. Conclusion: VNS activation worsens sleep disordered breathing and makes CPAP titration a challenge. Apneas and hypopneas are found to occur more frequently during VNS activation than during non-activation. This may also lead to difficulty in treating the sleep disordered breathing. Therefore, baseline PSG prior to and following VNS implantation should be considered. Further investigation is needed regarding CPAP titration in patients with VNS. Madhukar Kumar - Paradoxical insomnia: a precursor to mania? Paradoxical insomnia may predate the development of manic mood disturbance and serve as an early warning sign of future mania or bipolar affective disorder, as outlined by this case. Patient L, a 57 year old married male presented to the sleep clinic with a chief concern regarding a reduction in his total sleep time (TST) to 4hours/night over the last one year. He also described a highly variable sleep onset latency and wake after sleep onset time with previous normal sleep duration. He reported several periods of up to 72 hours without any sleep. His wife stated she had observed him in bed, quietly sleeping, during these periods of self-described environmental awareness. There were no complaints of daytime somnolence and daytime impairment was limited to mild changes in his short term memory. Two weeks before his evaluation, he described a period of suicidal ideation followed by several days of expansive mood and hyperactivity, resulting in psychiatric hospitalization and a diagnosis of mania. Physical examination: BMI 22.9; Friedman palate position II; Neck circumference 15 inches. Polysomnography: No sleep disordered breathing. TST - 279min, Stage N1 - 8%, Stage N2 - 50%, Stage N3 - 0%, Stage R 21%.The patient reported no subjective sleep. A diagnosis of paradoxical insomnia was given to the patient. Subjective lack of sleep is a common complaint and insomnia is a useful clinical indicator of the onset of new (or relapse of existing) mood disorders, particularly depression. Paradoxical insomnia is an uncommon condition characterized by a subjective complaint of severe insomnia without evidence of objective sleep disturbance and without daytime impairment commensurate with the degree of the reported sleep deficit. The significance of this condition remains poorly understood. Paradoxical insomnia may serve as a marker for the future development of mania, as observed in this patient. 2. Final Disposition of patients seen in the Alternatives to CPAP Clinic: A 13 year Experience Introduction: Although treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) is the gold standard, compliance remains problematic. An estimated 46-83% of patients use CPAP for less than an average of 4 hours/night. The goal of a multispecialty alternatives clinic is to offer CPAP intolerant patients other treatments for OSA. Methodology: 1739 patients with a documented history of OSA and CPAP intolerance, who were interested in alternative treatments, were seen in the Alternatives to CPAP Clinic between December 1997 and December 2011. All patients underwent a same day evaluation by a Sleep Medicine Physician, Otolaryngologist, Oral Maxillofacial Surgeon and Prosthodontist. Evaluation of each patient included a comprehensive medical and sleep history, review of polysomnography and PAP treatment parameters, head and neck examination (with flexible nasopharyngoscopy - Muller’s maneuver), cone beam computed tomography or cephalometric analysis, and dental evaluation. Results: Alternative treatments were recommended by group consensus, and patient preference was incorporated in the final treatment plan. Alternative treatments were chosen by 27% of patients. Of this group, 24% underwent surgery and 3% (n= 54) received an oral appliance. 70% of patients (n=291) who elected to undergo surgery underwent oropharyngeal and/or hypopharyngeal procedures and 30% (n=125) underwent maxillomandibular advancement. Over 50% of patients seen decided to make additional supervised attempts at positive airway pressure therapy and the remainder decided to abandon additional attempts at treatment. Conclusion: A multidisciplinary alternatives to CPAP clinic can facilitate the treatment of CPAP intolerant patients and improve communication between sleep physicians, otolaryngologists, oral surgeons, and prosthodontists. Although labor intense and time consuming, such a clinic provides an effective means to treat a subset of CPAP intolerant patients and plays a key role in the management of this challenging patient population. Shilpa Patel - A Rare Case of Large Antralchoanal Polyp presenting as Obstructive Sleep Apnea in an Adult Introduction: In rare cases, obstructive sleep apnea (OSA) can be caused by upper airway masses.We present an unusual case of a large antralchoanal polyp presenting as obstructive sleep apnea in an adult. Antralchoanal polyps are benign, polypoid lesions arising from the mucosa of maxillary antrum. They most often present in childhood with uni- or bilateral nasal obstruction or rhinorrhea. Three case reports of children with antralchoanal polyps presenting as OSA have been described, but adults presenting with OSA have not been reported to date. Case Report: A 26 year old male presented to our sleep clinic with a 10 year history of loud snoring, severe nasal obstruction and daytime sleepiness. His wife reported witnessed apneas. He was of normal body weight. A baseline polysomnogram revealed OSA with an apnea hypopnea index (AHI) of 8.0, worse in REM sleep. The patient was unable to tolerate CPAP, largely because of nasal obstruction. He was referred to otolaryngology for surgical correction of his OSA and/or nasal obstruction. Flexible nasopharyngoscopy showed a large mass emanating from his left maxillary ostia and almost entirely obstructing his naso-pharynx. A subsequent CT scan demonstrated a polypoid mass originating in the left maxillary antrum and occupying virtually the entire nasopharyngeal lumen compatible with an antrochoanal polyp. The lesion was removed endoscopically. Post-operatively, the patient’s snoring and nasal obstruction was significantly decreased and his wife no longer noticed apneic episodes. He endorsed marked improvement in his daytime sleepiness. A post-operative polysomnogram was recommended, but declined due to the resolution of his symptoms. Conclusion: This represents the first reported case of an adult with antralchoanalpolyp presenting as OSA. The patient had resolution of his symptoms after removal of the mass. Even when dealing with common disease entities such as OSA the hoof beats we hear may occasionally be from zebras. Gabriel Tudose - Polysomnographic Findings in Children with Bullying Behaviors Study Objectives: Survey data suggest that elementary schoolchildren with aggressive behaviors such as bullying are more likely than their peers to have parentally-reported symptoms of sleep-disordered breathing (SDB) and daytime sleepiness. This pilot study was conducted to explore whether objective evidence of SDB and daytime sleepiness may also be more frequent in children with bullying behaviors. Methods: As part of a larger survey study in elementary schoolchildren, a subset of children with and without frequent bullying behavior, as identified from the Conners’ Parent Rating Scale, were invited to undergo laboratory-based polysomnography and a Multiple Sleep Latency Test (MSLT) on the following day. Esophageal pressure (Pes) was monitored during the polysomnograms. Studies were scored by a registered polysomnographic technologist who was masked to subject group. Results: A total of 23 children (11 with bullying behaviors) were enrolled. Mean age was 9.4±1.3 years, BMI was 19.2±3.8kg/m2, and n=6 subjects were male. Compared to controls, children with bullying behaviors did not demonstrate differences in standard polysomnographic variables such as the arousal index (9.0±1.7 vs. 8.0±1.0; p=0.12), apnea-hypopnea index (0.8±0.8 vs. 0.9±0.2; p=0.84), respiratory disturbance index (1.1±0.9 vs. 1.0±0.2; p=0.84), or oxygen saturation nadir (92.9±2.0% vs. 93.6±2.0%; p=0.46). However, in non-rapid eye movement sleep, there were trends for children with bullying behaviors to have more negative mean Pes values (-9.6±2.8 cmH2O vs. -7.5±1.9 cmH2O; p=0.09) and Pes nadirs (-21.1±6.6 cmH2O vs. -14.9±5.0 cmH2O; p=0.05). Children with bullying behaviors spent a greater proportion of sleep time with Pes <-10 cmH2O (38.6% vs. 8.1%; p=0.03). There was no difference in mean nap latency as measured by MSLT (19.8±8.2 minutes vs. 19.6±5.7 minutes; p=0.97). Conclusions: Esophageal pressures and increased work of breathing may distinguish more effectively schoolchildren with bullying behavior than do other measures of SDB. Warangkhana Wongba - OSA Patients Managed By Sleep Medicine Specialist Demonstrate Superior Compliance with Positive Airway Pressure Therapy. Background: Obstructive sleep apnea (OSA) is the most common sleep related breathing disorder and is associated with significant comorbidity. Prior studies have proved benefits in the treatment of obstructive sleep apnea 3, 4 with Positive Airway Pressure (PAP). PAP is the gold standard treatment for OSA though adherence with this therapy can be challenging. Our hypothesis is that extensive patient education, an integral part of the clinic encounter with a sleep medicine physician is associated with better PAP compliance and adherence. Methods: We conducted a single center, retrospective chart review of the patient who had an attended overnight polysomnogram performed at the Sleep Disorders center, University of Michigan with available objective PAP compliance download from January 1st, 2010 and December 31st, 2010. Results: Total of 224 patients were included, 52 patients who received care by sleep medicine specialist and172 patients who received care by a primary care physician. Patients under treatment with sleep medicine specialist had significantly higher percent of number of days of PAP use (80.29 ± 2.7 vs. 62.3 ± 1.22 , p-value <.0001) , higher compliance [PAP ≥ 4 hours] ( 67.45± 24.6 vs.47.4± 15.4, p-value < .0001) and average time (minutes) of PAP used per session (329.8 ± 15.0, 233.4 ± 4.13, p-value < .0001). There were no different in the patient’s AHI, NREM-AHI, REM-AHI, percent of time spent for O2 saturation below 88% during baseline polysomnogram, the maximum pressure setting between these 2 groups. Higher BMI was associated with higher AHI, REM-AHI and older patients had less total day of PAP used. Conclusion: Patients receiving care for OSA by a sleep medicine physician have higher rates of compliance with PAP therapy. Severity of sleep apnea in patients followed by sleep specialist did not differ significantly from the ones managed by a primary care physician. Neurosurgery Residents Shawn Hervey-Jumper, MD Embryonal tumors are malignant neoplasms, which predominantly affect children. According to the 2007 World Health Organization (WHO) classification of central nervous system tumors, there are three types of embryonal tumors including medulloblastoma, atypical teratoid/rhabdoid tumor (AT/RT), and primitive neuroectodermal tumor (PNET) (Louis et al., 2007, WHO Classification of Tumors of the CNS ed. Louis et al IARC 2007). PNET tumors are further subdivided into neuroblastoma, ganglioneuroblastoma, medulloepithelioma, ependymoblastoma, and PNET not otherwise specified (NOS). Included within the PNET NOS category, the WHO describes an embryonal tumor with abundant neuropil and true rosettes (ETANTR) that has been considered a variant rather than a specific category. The first description of ETANTR was made in 2000 by Eberhart et al (Eberhart et al., 2000). This initial report of nine pediatric patients described tumors with hybrid features of both neuroblastoma and ependymoblastoma along with unique histological, immunohistochemical, and ultrastructural characteristics. The composite features of ETANTR initially observed by Eberhart et al. included fine and abundant fibrillary neuropil, undifferentiated neuroepithelial cells arranged in clusters, and several types of rosettes (Eberhart et al., 2000). Recently a specific amplification of 19q13.42 region containing a cluster of miRNA coding genes was found in embryonal tumors with multilayered rosettes, which can be helpful in narrowing the diagnosis of these primitive tumors (Korshunov 2010, Li 2009, Pfister 2009). ETANTR is associated with a high potential for malignancy and a poor prognosis (La Spina et al., 2006). The TSC theory suggests that the tumorigenic potential of central nervous system tumors is limited to a subpopulation of cells with stem-like properties (CD133, CD15 (Son 2009, Rich et al). It has been further suggested that these subpopulations confer chemotherapy and radiation resistance by their slow growth and ability to remain dormant, evading conventional therapeutic strategies (Raya 2001). ETANTR remains poorly characterized clinically as well as pathologically. The characterization of tumor stem like cells in ETANTR will improve our understanding in this disease, leading to a better understanding of tumor biology and treatment design. In this study, we investigate the presence of stem-like-cell tumor markers CD133, CD15, and nestin from initial diagnosis, tumor recurrence, and within different regions of a single ETANTR tumor. We observed an increase in the protein level and transcript number of the cancer stem cell marker CD133 suggesting that this population of cells had some degree of chemotherapy resistance in ETANTR. It may be necessary to develop multifaceted and targeted therapeutic strategies including those that target tumor stem like cells to treat these highly aggressive embryonal tumors. Khoi Than, MD - Intradiscal Injection of Simvastatin Results in Radiologic, Histologic, and Genetic Evidence of Disc Regeneration in a Rat Model of Degenerative Disc Disease. Introduction: A large percentage of back pain can be attributed to degeneration of the intervertebral disc (IVD). Bone morphogenetic protein-2 (BMP-2) is known to play an important role in the chondrogenesis of the IVD. Simvastatin is known to up-regulate the expression of BMP-2. Thus, we hypothesized that intradiscal injection of simvastatin in a rat model of degenerative disc disease (DDD) would result in retardation of DDD. Methods: Disc injury was induced in 272 rats via 21-gauge needle puncture. After six weeks, injured discs were treated with simvastatin in saline or a hydrogel carrier. Rats were sacrificed at predetermined time points. Outcomes measures assessed were radiologic, histologic, and genetic. Radiologically, the MRI index (the number of pixels multiplied by the corresponding image densities) was determined. Histologically, disc spaces were read by three blinded scorers based on a previously used grading scale. Genetically, nuclei pulposus were harvested and polymerase chain reaction was run to determine relative levels of aggrecan and collagen type II gene expression. Results: Radiologically, discs treated with 5 mg/ml simvastatin in hydrogel or saline demonstrated MRI indices that were normal through 8 weeks post-treatment, although this was more sustained when delivered in hydrogel. Histologically, discs treated with 5 mg/ml simvastatin in hydrogel demonstrated improved grades in comparison with discs treated at higher doses. Genetically, discs treated with 5 mg/ml of simvastatin in hydrogel demonstrated higher gene expression of aggrecan and collagen type II than control. Conclusions: Degenerate discs treated with 5 mg/ml simvastatin in a hydrogel carrier demonstrated radiographic and histologic features resembling normal, non-injured IVDs. In addition, gene expression of aggrecan and collagen type II (important constituents of the IVD extracellular matrix) was up-regulated in treated discs. Injection of simvastatin into degenerate IVDs may result in retardation of disc degeneration and represents a promising investigational therapy for the conservative treatment of DDD. 2. A Novel Model of Disc Degeneration in Yorkshire Swine via a Lateral Trans-Psoas Approach and Stab Injury. Introduction: Prior studies have determined that the large animal, non-primate spine most biomechanically similar to humans’ is that of the pig. Previous porcine models of degenerative disc disease (DDD) have involved miniature or juvenile pigs. We sought to develop a reproducible and efficiently-performed model in a larger porcine species, namely the Yorkshire pig. Methods: Ten Yorkshire pigs were anesthetized and placed in the right lateral position. Akin to a lateral trans-psoas approach and using sterile technique, fluoroscopy and a guide-wire were used to localize the mid-portion of the lumbar vertebral column. Incisions were planned and performed over the L1-L2, L3-L4, and L5-L6 disc spaces (pigs have six lumbar vertebrae). A series of METRx dilators (Medtronic, Minneapolis, MN) were used to gain access to the aforementioned disc spaces. Stab injury was induced to each disc (approximately midway, as verified by antero-posterior and lateral fluoroscopy) as follows: a 12/64” trocar at L1-L2, an 11-blade scalpel at L3-L4, and a 9/64” trocar at L5-L6. Pigs underwent magnetic resonance imaging (MRI) and sacrifice at 4, 6, and 8 weeks post-injury. Results: The surgical procedure was facile, taking approximately 30 minutes per animal. One animal (the first that underwent surgery) developed left hind leg monoplegia and was sacrificed; another (the last animal) died en route from the surgical facility to the animal housing facility due to causes unrelated to surgery. The remaining 8 animals recovered without evidence of neurologic deficit. Considering the three injury mechanisms, the 9/64” trocar was the most consistent for the early time points, although by 8 weeks all mechanisms showed evidence for disc degeneration on MRI. Histologic data is pending. Conclusions: In this large animal model of DDD, disc injury was induced efficiently, effectively, and repeatably. This large animal model may prove useful to researchers interested in studying the pathophysiology and treatment of DDD. Wajd Al-Holou, MD - Prevalence and Natural History of Arachnoid Cysts in Adults Object. Arachnoid cysts are a frequent finding on intracranial imaging. The prevalence and natural history of these cysts in adults are not well-defined. Methods. We retrospectively reviewed the electronic medical records of a consecutive series of adults who underwent brain MRI over a 12-year interval to identify those with arachnoid cysts. The MRIs were reviewed to confirm the diagnosis. For those patients with arachnoid cysts, we evaluated presenting symptoms, cyst size, and cyst location. Patients with clinical and imaging follow-up greater than 6 months were included in a natural history analysis. Results. A total of 48,417 patients underwent brain MRI over the study period. Arachnoid cysts were identified in 661 patients (1.4%). Men had a higher prevalence than women (p < 0.0001). Multiple arachnoid cysts occurred in 30 patients. Arachnoid cyst location was most often middle fossa (34%), retrocerebellar (33%), or convexity (14%). Middle fossa cysts were predominantly left-sided (70%; p < 0.001). Thirty-five patients were considered symptomatic and 24 underwent surgical treatment. Suprasellar cysts were more likely to be considered symptomatic (p < 0.00001). Middle fossa cysts were less likely to be considered symptomatic (p = 0.007). The criteria for natural history analysis were met in 203 patients with a total of 213 cysts. After a mean follow-up of 3.8 ± 2.8 years, 5 cysts increased in size (2.6%) and 2 cysts decreased in size (1%). Only 1 patient (0.05%) developed new or worsening symptoms over the follow-up period. Conclusions. Arachnoid cysts are a common incidental finding on intracranial imaging in all age groups. Although arachnoid cysts are symptomatic in a small number of patients, they are associated with a benign natural history for those presenting without symptoms. William Stetler, MD - Prasugrel is Effective and Safe for Neuro-Interventional Procedures BACKGROUND: Clopidogrel bisulfate and aspirin are routinely administered as dual antiplatelet agents for many neuro-interventional procedures, especially for intravascular stent placement. Many patients are nonresponsive to clopidogrel, either secondary to drug interactions or from variations of cytochrome P450 enzymes. Prasugrel (brand name Effient, Eli Lilly and Company) is a new antiplatelet agent that has been utilized extensively in patients undergoing cardiovascular procedures, but its safety and efficacy during neurointerventional procedures have not been evaluated. OBJECTIVE: To examine whether prasugrel is a safe and effective alternative to clopidogrel for neurointerventional procedures, especially in those patients who are either non-responders or allergic to clopidogrel. METHODS: We retrospectively reviewed medical records of all patients undergoing neuro-interventional procedures at our institution who received prasugrel between January 2009 and July 2011 at our institution. A systematic chart review was performed and the following data points were recorded: demographics, aneurysm location, endovascular techniques, peri- and post-procedural complications, hemorrhagic complications, clinical outcome, and angiographic outcome. RESULTS: Sixteen patients undergoing neuro-interventional procedures received prasugrel over a 2-year interval. All patients who had follow-up studies of P2Y12 inhibition had immediate therapeutic response to prasugrel. There were no complications related to ischemic or intracranial hemorrhage. CONCLUSION: Prasugrel is a viable alternative to clopidogrel for patients undergoing neuro-interventional procedures who are non-responders to clopidogrel. Further study is needed to evaluate the safety, efficacy, and cost-effectiveness of prasugrel compared to clopidogrel for patients undergoing neuro-interventional procedures. Thomas Wilson, MD - Comparison of the accuracy of ventricular catheter placement using free-hand placement, ultrasound guidance, and stereotactic neuronavigation Objective: To compare the accuracy of 3 methods of ventricular catheter placement during CSF shunt operations, including free-hand technique using surface anatomy, ultrasound guidance, and stereotactic neuronavigation. Methods: This retrospective cohort study included all patients from a single institution who underwent a ventricular CSF shunting procedure where a new ventricular catheter was placed between January 2005 and March 2010. Data abstracted for each patient included age, sex, diagnosis, method of ventricular catheter placement, site and side of ventricular catheter placement, Evans ratio, and bifrontal ventricular span. Postoperative radiographic studies were reviewed for accuracy of ventricular catheter placement. Medical records were also reviewed for evidence of shunt failure requiring revision through December 2011. Statistical analysis was then performed comparing the 3 methods of ventricular catheter placement and to determine risk factors for inaccurate placement. Results: There were 249 patients included in the study; 170 ventricular catheters were free-hand passed, 51 were placed using stereotactic neuronavigation, and 28 were placed under intraoperative ultrasonic guidance. There was a statistically significant difference in accuracy between free-hand catheters and stereotactic-guided catheters (P < 0.001), as well as between free-hand catheters and ultrasound-guided catheters (P < 0.001). The only risk factor for inaccurate placement identified in this study was use of the freehand technique. The use of stereotactic neuronavigation and ultrasonic guidance reduced proximal shunt failure rates (P < 0.05) in comparison to free-hand technique. Conclusion: Stereotactic- and ultrasound-guided ventricular catheter placements are significantly more accurate than free-hand placement and the use of these intraoperative guidance techniques reduced proximal shunt failure. T-32 Training Grant Kathy Wilson - Importance of Bedtime Routines in Low-Income Preschool Children Background: Sleep problems are common in preschool-age children; children growing up in poverty may be at higher risk. A regular bedtime routine and consistent bedtime is recommended to improve sleep. We sought to better define benefits of a bedtime routine and consistent bedtime among low-income preschool children. Methods: Parents of Head Start preschoolers completed sleep questionnaires as part of a larger study. Validated sleep surveys included: 1) General Sleep Information Questionnaire (GSI) to evaluate sleep schedules and sleep duration, 2) Children’s Sleep-Wake Scale (CSWS) to evaluate sleep behaviors, and 3) Children’s Sleep Hygiene Scale (CSHS) to evaluate sleeping environment and bedtime routines. Results: Among 381 preschool children (mean age 4.1 ±0.5, range 2.8-5.0 years), 49.9% were boys, 61.7% were Caucasian, and 16.3% of parents did not have a high school degree. Overall, 84.5% of children were reported to have a bedtime routine and 89.2% a consistent bedtime; average routine lasted 41.4 minutes (± 26.8 min). T-tests revealed that children with regular routines and consistent bedtimes went to bed earlier compared to children who did not (all p’s reported < 0.05); children with a regular routine also obtained an additional 2.3 hours of sleep per week(p=0.03). Bedtime routines were associated with fewer problems going to bed (p=0.02). Consistent bedtimes were associated with easier return to wakefulness in the morning (p=0.003). Both bedtime routines and consistent bedtimes were associated with fewer sleep problems (p<0.001). Conclusion: Regular bedtime routines and consistent bedtimes are associated with increased sleep duration and fewer sleep problems among Head Start preschool children. Although this correlational study cannot prove causality, establishing adequate routines and bedtimes may be important for low-income children, who may be especially vulnerable to consequences of sleep deficiency and sleep problems. Kaia Skaggs -Neurogenesis and regeneration in response to QA-induced lesioning in adult zebrafish telencephalon Zebrafish is an attractive system for the study of neurogenesis following injury because, unlike other vertebrates such as mouse and human, they are able to regenerate damaged neurons. We have developed a brain injury model to study the process of brain repair by adult-born neurons in zebrafish telencephalon. In this system, intracerebral injection of the excitotoxin quinolinic acid (QA) is used to lesion a portion of the right telencephalon. We assay for proliferation, migration, and fate of neural progenitor progeny in the lesioned hemisphere compared to the intact hemisphere, and to vehicle-injured or intact brains. Results indicate that proliferation markedly increases through 3-4 days post-injury and then gradually declines to baseline levels. Proliferative cells are found in increased numbers in both the medial (subpallial) and lateral (pallial) neurogenic zones that surround the telencephalic hemispheres and at the site of injury. By 4- and 7-days post-injury, BrdU-labeled cells appear throughout the lesioned hemisphere and are localized in increasing numbers at the site of injury. Although both QA- and vehicle-induced injuries stimulate proliferation and migration of neuronal progenitors, the excitotoxic injury induces a more robust regenerative response. We have also used immunofluorescence and various transgenic zebrafish lines to label adult-generated neurons that arise from adult progenitor cells following injury. Following QA lesioning, many newly generated cells appear in the pallial and subpallial neurogenic zones and in increasing numbers over time at the site of injury. Immunofluorescence double labeling indicates that many of these cells are neural progenitors and newly generated neurons that incorporate BrdU, co-express neural progenitor markers such as PSA-NCAM, the early neuronal marker HuC, -tubulin. These results indicate that QA-induced excitotoxic lesioning potently stimulates proliferation of adult neural progenitors, leading to the generation of new neurons that migrate to the site of injury, express neuronal markers, and contribute to regeneration and repair of brain injury in the adult zebrafish telencephalon. Katiuska Molina-Luna - Cerebellar physiology in the hesitant (Atcay) dystonic mouse model Dystonia is a movement disorder that causes the muscles to contract involuntarily and produces abnormal postures and twisting of the trunk and limbs. Some forms of dystonia in humans have been suggested to be of cerebellar origin, but the precise role of the cerebellum in dystonia is unclear. We used a mouse mutant defective in a homolog of the human Cayman ataxia gene, ATCAY, to investigate the role of the cerebellum in dystonia. The hesitant (Atcay) mouse displays a markedly dystonic gait with prominent, non-progressive limb stiffness that begins at around postnatal day 12 (P12), is clearly apparent by P15 and peaks at around P21. Brain structure in this mouse is normal, suggesting that functional changes in the brain account for the motor phenotype. Moreover, reduction of cerebellar output by lesioning the deep cerebellar nucleus improved the stiffness. To address the physiology of cerebellar neurons in dystonic hesitant mice, we used the patch-clamp technique to record from Purkinje cells and neurons of the Deep Cerebellar Nuclei (DCN) in acute cerebellar slices. Unlike Purkinje neurons from wild-type controls that displayed tonic repetitive firing, adolescent/weaning age Purkinje cells (P19-23) of hesitant mice showed a lack of normal spontaneous repetitive firing and an inability to sustain high rates of repetitive firing in response to injected current. At around P24-27 and into adulthood (6 – 8 weeks), hesitant Purkinje cells have established a tonic and repetitive firing comparable to the pattern of firing observed in wild type Purkinje cells. Slice recordings of DCN neurons showed that juvenile cells (P12 – 15) displayed a burst-firing pattern similar to that seen in vivo in the genetically dystonic rat. In contrast to the dystonic rat, however, this burst-firing pattern became regular at weaning age (P16-P17). These results suggest that there is a delay in the maturation of physiology of Purkinje neurons of hesitant mice. Our results suggest that while the abnormal cerebellar physiology is involved in manifestation of motor symptoms in hesitant mice, the locus of dystonia is likely not restricted to the cerebellum alone. Vikas Kotagal: Diabetes is associated with Postural Instability and Gait difficulty in Parkinson Disease independent of nigrostriatal dopaminergic denervation: a case-control study Objective: To investigate the association between Parkinson disease motor subtype, striatal dopaminergic denervation, and the presence of diabetes. Background:Sources of vascular injury and inflammation, including a history of diabetes, represent possible risk factors for neurodegenerative diseases and are of increasing interest with regard to neuroprotective strategies in neurodegenerative disorders. Parkinson disease (PD) occurs more commonly in patients with a history of diabetes though the mechanisms underlying the putative increased risk are not known. PD exhibits significant motor subtype heterogeneity, which is not accounted for by the severity of nigrostriatal dopaminergic denervation. Methods:We performed a case-control study (n=33) involving 11 subjects (age 67.1 yrs±6.7; duration of disease 7.1yrs ±4.6; UPDRS motor score 41.1±16.5) with PD and diabetes compared to 22 age and duration-of-disease-matched subjects with PD but without diabetes. All subjects underwent (+)-[C-11]DTBZ (VMAT2) monoaminergic PET imaging to assess striatal DTBZ distribution volume ratio (DVR) and modifiedUPDRS clinical examination to determine rigidity, bradykinesia, tremor, and postural instability and gait difficulty (PIGD) sub-scores. Results:After controlling for nigrostriatal dopaminergic denervation, PD subjects with diabetes displayed greater PIGD sub-scores (t = 3.46, p = 0.015) but not greater bradykinesia, rigidity, or tremor sub-scores in comparison to PD subjects without diabetes. There were no significant differences in striatal DTBZ binding between the two groups. Conclusions:Diabetes may be associated with a specific motor subtype of PD. Graduate Research Assistant-UM Sleep Disorders Center Jocelynn T. Owusu - The Relationship between Snoring and Pregnancy Outcomes in Pregnant Women at Korle Bu Teaching Hospital (KBTH), Accra, Ghana Background: Ghana has an overwhelming maternal mortality ratio of 450 per 100,000 live births, with 12% attributable to hypertensive disorders of pregnancy, particularly pre-eclampsia. Research suggests that pregnant women who snore (a marker of sleep-disordered breathing) are at increased risk for hypertensive disorder of pregnancy, along with perinatal morbidity. However, this has not been previously studied in developing countries like Ghana. Therefore, we hypothesized that snoring may contribute to the high prevalence of pre-eclampsia in Ghana. Methods: As a part of a larger study, Ghanaian women were recruited from maternity wards at KBTH within 48hours of delivery and interviewed about their maternal sleep quality. Snoring was defined as a positive response to: “Did you snore loudly in the past week?”. Demographic data and pregnancy outcomes were obtained from medical records. Results: Among the 234 women approached, 232 (99%) agreed to participate. Twelve participants were excluded due to missing data in medical records, thus the final sample size was 220. Mean age was 28.9±5.7 years, and mean parity was 1.35±1.38. Overall, 26 women (12%) had pre-eclampsia, and 53 women (24%) reported snoring. Women who snored, compared to those who did not, were significantly more likely to have pre-eclampsia (23% vs. 8%, p=0.005). We found no difference in gestational age at delivery (38.6±2.5 vs. 38.5±3.0 weeks; p n.s.) or birth weight (3083.27±629.56 vs. 3041.70±676.01 grams; p n.s.) of infants born to women with and without snoring. In a logistic regression, the presence of snoring was independently associated with preeclampsia with adjusted odds ratios 3.52 (95%CI 1.48-8.36, p=0.004). Conclusions: Findings are consistent with similar studies in Western countries, suggesting that snoring during pregnancy may confer a risk to maternal morbidity in Ghana. Screening for snoring during pregnancy may improve maternal health outcomes in developing countries like Ghana where maternal morbidity rates are high.