Patients who have both chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) (OS, overlap syndrome), have increased cardiovascular morbidity and mortality, possibly due, in part, to nocturnal hypoxia with subsequent inflammation and endothelial dysfunction. Home-based exercise interventions that translate to a lifestyle with increased physical activity should improve functional status and may even reduce risk of cardiovascular-related events and death. We hypothesize that a home-based exercise program improves functional capacity in OS. OS patients enrolled in the Pulmonary Telehealth Clinic at the Salem Veterans Administration Medical Center were offered a 12-week home exercise program using a proprietary exercise program (Wii Fit). Exclusion criterion was the presence of a comorbid condition that would place the patient at undue risk for exercise. Patients were instructed to use the Wii Fit for 20 minutes at least twice a week for 12 weeks, using specific Wii Fit exercises. The intensity of these exercises ranged from 2.5 to 4 metabolic equivalents (METs). Weight, daily home exercise time and calories were downloaded from the Wii console. Demographic, spirometry, and sleep data were extracted from the Electronic Medical Records. The 6-minute walk distance (6-MWD) was measured before and after the 12-week exercise program. Pre-post outcomes were tested by Wilcoxon Signed-Rank Test. Pre-post data were available in 6 of 9 patients; the remaining 3 reported they could not exercise because of balance problems. Among those participating, the duration (minutes/day, mean ± SD) and the caloric expenditure (calories/day, mean ± SD) of exercise were 40 ± 14, and 238 ± 134, respectively. The 6-MWD improved in OS patients who used Wii Fit (mean change = 30 ± 18 (SE) m, p=0.08). This change compared favorably with the OS patients who did not exercise (post-pre change = - 5 ± 39 m. There were no adverse events reported. A home-based exercise program using Wii Fit is feasible in improving functional capacity in patients with OS. Office of Rural Health N06-FY15Q3-S1-P01507.

SESSION TITLE: Sleep Disorders Posters II: Consequences of OSA and Treatment SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Excessive daytime sleepiness (EDS) is commonly considered a cardinal sign of obstructive sleep apnea (OSA) and it may lead to decrease physical activity and capacity (6 minute walk test, 6 MWT). It is often considered to be an independent risk factor for cardiovascular morbidity and mortality. Despite this strong association little is known about the impact of EDS on Cardiac Rehabilitation (CR) outcomes in OSA patients. The aim of this cross-sectional study was to examine the impact of EDS on 6MWT and various other physiological paramters by researching OSA patients referred to a CR program after coronary re-vascularization. METHODS: Consecutive patients without history of OSA who underwent CR after coronary re-vascularization between January 2012 to December 2012 in Roanoke and Harrisonburg, VA were subsequently diagnosed with OSA after at-home polysomnography. OSA severity was reported as per American Academy of Sleep Medicine (AASM) guidelines i.e., Apnea/Hypopnea Index (AHI) = 5-15 for mild OSA, AHI = 16-30 for moderate OSA and AHI >30 for severe OSA. Normality of continuous variables was evaluated by Shapiro-Wilk test. Comparisons of continuous values between groups were performed using t test for data with normal distribution or Wilcoxon rank test, if skewed distribution. Linear regression was used to assess the relationship in Epworth Sleepiness Scale (ESS) and 6MWT (measured in minutes and meters). A two-sided p value of <0.05 was considered statistically significant. RESULTS: Subjects groups did not differ by age, body mass index, blood pressure, heart rate, AHI, nocturnal desaturations or functional capacity. Pre-CR 6MWT in minutes (p=0.04, CI = -.007 to -.0001) and meters (p=0.04, CI = -.024 to -.0006) was significantly lower in OSA patients with excessive daytime sleepiness (EDS). This effect was maintained post-CR for 6MWT in meters (p=0.001, CI = -.021 to -.004). CONCLUSIONS: EDS decreases functional capacity in OSA patients both at baseline and post-CR. CLINICAL IMPLICATIONS: Through this study we confirm that patients with EDS have decreased functional capacity. This was an indepent risk factor in patients with similar AHI score and other physciological parameters. Patients with EDS should be identified early with or without OSA and/or other co-morbidities as a high risk group and should be followed more closely during a rehabilitation program. DISCLOSURE: The following authors have nothing to disclose: Faisal Siddiqui, Madalina Macrea, Mitchell Horowitz, Thomas Martin, Tomer Pelleg, Adrian Aron No Product/Research Disclosure Information

SESSION TITLE: Sleep Disorders Posters II: Consequences of OSA and Treatment SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Chronic intermittent hypoxia (CIH) is thought to be the main component linking obstructive sleep apnea (OSA) to cardiovascular disease (CVD) and this was demonstrated in models of CIH that varied in both the frequency and severity of the hypoxic stimulus. Little is known how these findings impact cardiac performance. We therefore aimed to examine the impact of CIH on hemodynamic parameters in OSA patients with CVD. METHODS: Consecutive patients without history of OSA who underwent CR after coronary re-vascularization between January 2012 to December 2012 in Roanoke and Harrisonburg, VA were subsequently diagnosed with OSA after at-home polysomnography. Hemodynamic measurements at rest were obtained using the impedance cardiograph. Normality of continuous variables was evaluated by Shapiro-Wilk test. Comparisons of continuous values between groups were performed using t test for data with normal distribution or Wilcoxon rank test, if skewed distribution. Linear regression was used to assess the relationship with cardiac variables (Cardiac Output, Cardiac Index, Ejection Fraction, Stroke Volume and left ventricular ejection time) and CIH (lowest oxygen desaturation and amount and percentage of time spent at an oxygen saturation less than 88%). A two-sided p value of <0.05 was considered statistically significanct. RESULTS: Subjects groups did not differ by age, body mass index, blood pressure, heart rate, Apnea/Hypopnea Index (AHI), nocturnal desaturations or functional capacity. Time (0.02, CI = -6 to -0.5) and percentage of time spent at an oxygen saturation less than 88% (p= 0.01, CI = .37 to 1.29) correlated significantly with post-CR left ventricular ejection time (LVET). The change in pre-post LVET correlated with time (0.02, CI = 0.6 to 0.2) and percentage of time (p=0.04, CI = 1.7 to 0.8) spent at an oxygen saturation less than 88% as well. CONCLUSIONS: One of the mechanisms by which CIH impairs cardiac function in OSA patients could be related to LVET. CLINICAL IMPLICATIONS: Left ventricular ejection time should be considered as a surrogate of cardiac ischemia in patients with nocturnal desaturations related to OSA. DISCLOSURE: The following authors have nothing to disclose: Faisal Siddiqui, Madalina Macrea, Mitchell Horowitz, Thomas Martin, Tomer Pelleg, Adrian Aron No Product/Research Disclosure Information

Background: Sarcoidosis is a multisystem disorder that can affect virtually any organ. Commonly affecting young to middle-aged adults throughout the world, it can affect all races, ages and both sexes [ 1 ]. Cutaneous sarcoid lesions presenting in tattoos are being increasingly reported [ 2,3,4 ], while reports of systemic or pulmonary sarcoidosis presenting as a granulomatous tattoo reaction are rare [ 5,6,7,8 ]. This is a case of systemic sarcoidosis with pulmonary involvement presenting as tattoo associated skin lesions and elevated transaminases. Case presentation: A 37 year old African American man with past medical history significant for tattoos over 9 years and chronically elevated liver enzymes presented for evaluation of newonset itching and nodular lesions in the location of previous tattoos. The patient reported a 40lb weight loss over the past year but denied symptoms such as abdominal pain, shortness of breath, fevers, chills, cough or sputum production. The patient underwent an abdominal CT scan which noted cirrhosis, splenomegaly and numerous scattered micronodules in both lung bases. Subsequent CT of the chest demonstrated scatted pulmonary nodules predominately in the upper lobes with associated mediastinal and hilar adenopathy. Biopsies of the noted skin lesions revealed noncaseating granulomatous inflammation consistent with sarcoidosis. Conclusion: Systemic and pulmonary sarcoidosis presenting as a granulomatous tattoo reaction is rare. Complications often directly related to tattooing include immediate benign inflammatory reactions, allergic reactions to pigment, and transmission of infectious diseases related to contaminated equipment. Other localized or systemic reactions include discoid lupus, psoriasis, lichen planus and secondary lesions of syphilis [ 9 ]. Cutaneous lesions of sarcoidosis associated with tattooing are now being increasingly reported [ 2, 3,4 ] and the time of the appearance lesions has been reported from as little as 1 year to greater than 10 years [ 8,10 ]. As pulmonary involvement in sarcoidosis results in major morbidity and mortality associated with the disease [ 8 ] clinicians should be aware of this particular skin finding and the predisposition of tattoos to harbor these lesions as they may herald pulmonary sarcoidosis. Early recognition is essential for timely diagnosis and treatment of this disease.