 Now, today's webinar is Clinical Features of RIMS Sleep Behavior Disorder in the Population Base, LSA cohort. Can we improve the screening tools? Let me introduce our speaker, Qin Yao. Qin Yao is a PhD candidate in neuroscience at McGill University. His work focuses primarily on setting the clinical features and these progression in RIMS Sleep Behavior Disorder under the supervision of Dr. Ronald B. Pestuma. Qin completed his master's science in Chinese medicine training in preventative medicine at China Medical University, Taiwan. So welcome, Qin, and I'll let you go ahead and take control of the webinar and go ahead and start. All right. Thanks, everyone. Thank you, COSA, for giving us a chance to present our work on RIMS Sleep Behavior Disorder in the Population Base cohort study. So today we'll be talking, like we mentioned earlier, we'll be talking about RIMS Sleep Behavior Disorder study in COSA. And the goal today is to discuss about screening tools, the improvement screen tools specifically. All right. All right. So for the next 40 to 45 minutes of this webinar, we will go through two topics. The first one is on assessing the associated factors to the RBD screen positives. The second one will be on the global clinical features of parties that can screen positive with possible RBDs. Can you guys see the mouse moving? No, I don't think we can. Okay. Can you see now? Sorry. Okay. Yeah. Okay. I don't know if it's a good lag, but if you give it some time, I think maybe you can go ahead and do it. All right. I'm just going to move on. All right. Okay. So before we start to talk about our research, let's talk a little bit about what's RIMS Sleep Behavior Disorder, or RIMS stands for Rapid Eye Movement Sleep. So RIMS Sleep is one of the stages during your sleep you go through non-RIMS sleep stages and to RIMS Sleep, which we normally know it as like Rapid Eye Movement, like your eye moves really fast. And during the stages, in general, your body, your brainstem and your body will be inhibiting your muscles to move. So what we call it RIMS Sleep Paralysis, which is a normal stage as some people, some studies suggested that it has protective factors for our body to make our brain rest, especially our motor cortex to rest a little bit and our muscles to rest. But for RIMS Sleep Behavior Disorder patients in clinic, what will happen is that they will come into a clinic either getting injured because they act out their dream dream RIMS sleep. Usually the dream enactment episodes are really violent. It can be punching, screaming, or kicking. Now, oftentimes patients are not aware of what happened to doing their sleep. On this they get injured, they fall off the bed. So in general, patients will come into clinic with their bed partners and their bed partners will be complaining to the physicians and saying that my husband or my wife act out their dream and I end up couldn't sleep because I'm struggling trying to stay asleep and at the same time trying to protect myself not being accidentally injured by them. And so this is what generally one of the complaints that will happen in sleep clinic. And so patients will have to go under some sleep studies to confirm that they have RIMS Behavior Disorder. Now, RBD, which is RIMS Behavior Disorder, now we know that it has a conversion, and phenoconversion rates up to 80% to 85% to Parkinson's or Parkinson's Relative Diseases. Now, this makes RBD by far the strongest prodromal symptoms of Parkinson's disease, which means that if you have RIMS Behavior Disorder, you have a really high chance to become Parkinson's disease later. Parkinson's disease patient later. Now, so far, most of the studies are done in small clinical trial, small clinical studies. So we know that like Parkinson's disease, RBD patients are more likely to be men and they're more likely to be married or in a long-term relationship or with a bed partner. Now, smoking and antidepressants and drinking behaviors are also linked with RBD, but interestingly, smoking and drinking behaviors are actually known as protective factors. Now, I quote-unquote protective factors as most like in clinic, we don't really think that it's a really protective factor as it can be shown as a sign of neurodegeneration as smoking and drinking does not promote any excitement or any of the needs anymore because of neurodegeneration. Now, the onset of RIMS Behavior Disorder usually starts around 40 years old. That's what we see in clinic, but there's more need to be confirmed as because usually patients will only come when they're injured or because their bed partner required them to come in. So we don't really know exactly when do they start it, but based on the recode, that's around 40 years old. So as I mentioned before, so far most of the studies are done in clinic. The next question that we want to ask for this part of the study is to figure out whether or not we also see the similar associations between some of these factors that we see in clinic in a general population. Now, before I go into our study, I just want to remind everyone the go-to-center diagnosis of RBD. So RBD is characterized as loose of atonia during REM sleep. And usually in clinic, physicians will take histories. Well, detailed history would generally give the physicians an idea whether or not the patient may be under the spectrum of REM sleep either paracomia or under because due to the influence of apnea or any other neurological disorders. Now, a go-to-center diagnosis of RBD requires polysomogram. But polysomography is really expensive. On average, it costs around $400 to $500 per person per night. And it takes the technician at least one week to go through everything for that night to make sure that they classify it well, and then it will be able to present to the physicians. And physicians will take time to diagnose. So overall, it's a really time-consuming and really expensive procedure. So in general, it's really hard to have everyone out there to take a sleep test. So a lot of questionnaires has been developed for screening possible REMCB 30 soldiers, which means that people act out their dream and we think that they probably have, or possibly, I would say possibly here, possibly have REMCB 30 soldier. And then put them on, probably invite them to sleep clinic and put them under a machine to test it out to see if they have the disorder. All right. So for the first part, I'll be talking about the associated factors of possible REMCB 30 soldier. The goal here is to check out whether or not the risk factors that we see in clinic or in small-scale studies are similar to what we see in the association to PRBDs in population. So we use the COSA Comprehensive Cohort, which like everyone, most of the people here will know that COSA recruits people from 45 years old to 85 years old. It has a really good ratio of male to female participants of close to 50-50%. In one of the sleep questionnaires, Dr. Ronald Pustuma introduced RBD 1Q as the screening questionnaire to screen REMCB 30 soldier. And the questionnaire goes like this. Have you ever been told or suspected yourself that you seem to act out of your dream while asleep? Now, this questionnaire in general is a ministry to the patient. But we recommend in sleep clinic, we'll recommend the bed partners or the caretakers to come in to confirm what the patient described. And oftentimes, this is really useful information because as we mentioned earlier, we don't sometimes like patients, they're not aware of them acting out their dream. So, yeah. All right. So out of all the 30,000 subjects, we first exclude certain participants because they already endorse some form of defined neurological disorder. Here, we are only interested in idiopathic form of REMCB 30 soldier, which means that patients or participants here, they screen positive on RBD, do not have any defined neurological disorders such as Parkinson's disease or Alzheimer's disease. Moving on, the next stage, what we want to do is that we want to exclude some potential bias or potential confounders. Or here, we will call it differential diagnosis, which are apnea. When patients with apnea, they suffocate or they feel like cannot breathe in the middle of night. Patients sometimes they will act out their dream because they just trying to wake up and take a deep breath and trying to make sure they can still breathe in. So that can also be one of the issue that patients act out their dream. So that's one of the big reason why we want to exclude subjects who screen positive on apnea. Now, we also want to exclude subjects who are potentially endorsing non-RENCB behavior disorder, which usually the onset age is earlier. Here, we said an onset age before 20 years old. So they're more likely to be sleepwalkers. I personally don't have experience of being a sleepwalker. But if some of you may be parents and you know that your kids may be walking, like wake up in the middle of the night, sign to walk around the house. And usually, that's what we define sleepwalking. And usually, the onset of a sleep disorder started really early at their age. Now, after that, we have about 958 subjects who screen positive of RenCB behavior disorder. And then we also did like two sensitivity of analysis to make sure that what we're seeing here are not compounded by other potential compounders. For instance, resist leg syndrome, which is also one of the sleep disorder that makes people make patients like move a little bit at night time. And also mental illness. All right. Now, social demagogically speaking, we didn't see any difference between ages, between groups. PRBD subjects, as we mentioned earlier in small clinical studies, we also see that they're more likely to be men and in a long-term relationship. PRBD participants are also more linked with lower socioeconomic statuses. They're more likely to tell us that you're retired due to health reasons. Now, sorry, I just wanted to make sure that we're clear for the presentation from here on. All the odds ratios that you will see here in the whole slides, they're all adjusted by age and sex already. And the PRBD negatives, screen negatives, will be referred them as healthy controls or PRBD negatives. And PRBD positive, we'll just call them PRBD positives here. Okay. All right. So for lifestyle-wise, we didn't see any difference between leisure time span on walking per week. Nor do we see any differences between frequencies and participating in social sports. Apologize to social activity. We didn't see any differences either here. But we see that subject-wise, when participants were asked, how do you feel about your health in general, your mental health or your physical health? You would see that participants are more likely to report that they are more concerned. They're less satisfied with their health. So that gives us a really good question of why do they think of it that way? Is it because they're already starting to show some neurological signs of perhaps movement disorders, symptoms or any other non-motor dysfunctions that we've seen in Parkinson's early stage Parkinson's patients? So moving on, because of what we see earlier from here for physical health and mental health, we're also looking into whether or not we will also see the similar effects on drinking patterns and smoking patterns that we've seen earlier in the small clinical sessions. So here we see that subject-wise, participants with PRBD, they won't rate themselves to be heavy drinkers comparing to healthy controls after adjustments. They're about the same, so subject-wise, they were not really concerned with their drinking behaviors. But if you take into objective measures, here we use the FDA's guidelines for heavy drinking, screening heavy drinkings, this will pick up mostly moderate or severe heavy drinkers. We see that participants are more likely to report that they drink more and after screening tools we'll also see that there are more likely to be heavy drinkers after adjusted by age and sex. Smoking is similar to what we found earlier in drinking. Participants are more likely to be smoking quite a bit. The smoking pack here is calculated by packs per day and time smoking, total smoking years. And we see that PRBD-positive subjects or participants are more likely to smoke more, just in general. Now, also we see that here that there are more likely to report that they smoke daily in the past or current or up until today they're still a daily smoker. Now this makes us really, sorry, all of these patterns and the health patterns like before that we showed here in the mental health and physical health here. Makes us ask the question of what happened to these subjects? Do they have any other non-motor symptoms? For instance, in early Parkinson's patients during prodromal stages, depression and anxiety are two of the common symptoms that we will see. So the questions that we want to ask here is do we also see the similar things in these participants? Now here, the first things that we did was using the Keeser psychological distress scale which is designed to screen for just general anxiety or depressive symptoms. We see that PRBD-positive participants are more likely to screen higher on the score and they're more likely to have at least moderate psychological distress. And here the screen towards itself defines that moderate as 24 and above and recommend participants can go see a psychiatrist because this may be a sign that they may be endorsing some sort of mental health issues. And we also see that these subjects are more likely to be using antidepressants which is parallel to what we've seen earlier in the psychological distress. Similarly to what we see earlier for mental illness here, most of the diagnosis here are based on self-report, whether or not you've been diagnosed by a physician with some sort of mental health issue. Here in mood disorder, anxiety disorder and depressive disorders, we see that participants are more likely to be saying that they have been diagnosed with some sort of this mental health issues. And we also see that there's strong connections between PRBD and post-traumatic stress disorders. This is screened by using the PCPDSD questionnaires. So overall our finding here is that we see that participants are more likely to be male and in a long-term relationship which can be caused by information bias because they're more likely to be told by their partner, that partner that they act up their dream. They are linked with lower socioeconomic statuses and they're more likely to endorse drinking and smoking behavior, more likely to report that they're retired because of health issues and use of antidepressant frequencies and rate increase, and also more likely to be screen positive or being diagnosed with some mental health issue. So the next question that we want to ask is whether or not after we adjust it by other factors in a big model, we'll also see these associations because remember here, we're talking about independent only one to one after adjustment by age and sex, one factor to one variable associations. So what we did here is that we just put the age and sex and income education, employment status, smoking, drinking and mental onness basically like most of the variables that we have here in point to regression model. What we see here is that after adjustment some of the factors disappear for instance like income disappear but this because it's confided by education these two usually go hand in hand with each other and also mental onness and antidepressant. Smoking also disappear as most of us know that drinking and smoking behaviors usually tie hand together people who drink more more likely to also have smoking behavior. Now retirement also disappear but overall our finding here is fairly similar to what we found earlier in some in small clinical trials and also cross-country multi-center clinical studies and so overall the take home message here is to let everyone know that without polysomography possible RBD participants share fairly similar risk factors or associated factors to what we found earlier in the part in in clinical study. Now one thing for researchers and physicians to be aware of is the mental onness issue because the mental onness issue can be either confounding our results here or it can be also just a sign of non-motor features common non-motor features in the poldromo stages of Parkinson's disease. So before I move on to the next chapter to the next part of a session I want to pause for five minutes to just taking questions. I guess I would just hand it to Carl. Thanks Tim. So the talk today is going to be in two parts so we thought we might pause at this first part and open it up to some questions. So if anybody has a question about the associated factors of rib and sleep behavior disorder go ahead and type it in now as we wait for a couple of those I'll I'll talk to Tim. Okay. So I'm assuming that you're you think that that may be mild sleep disorders that might not possibly be under that kind of gold standard you do believe that that may be linked with negative health consequences of bad health outcomes maybe not Parkinsonism but some kind of pardonable beginning of negative health consequences is that correct? Can you tell me more about what I think I'm not quite sure I understand. So I was just wondering if if you thought that mild or sleep disorders might possibly indicate negative health consequences. Right so um so there are a lot of different sleep disorders so some mild sleep disorders may potentially cause some of the things that we see here. There are some potential compounders for sure that can be influencing what we see in the results but remember like dream enactment behaviors are not common on if you have insomnia or REM sleep disorder which here we're talking about RBD. So in our screen tools like while we set up for this study we basically screen out um parasympathetic parasympathetic school maybe endorsing REM sleep parasonia which we define as early onset of dream enactment episodes and other like you know potential misdiagnosis or differential differentiated diagnosis such as um apnea and other symptoms and so what we see here are fairly similar to what we see in clinical settings so I would say that there definitely are some participants in there in in the study called in the in the PRBD screen positive groups are not PRBD screen positives but what's important to know is that like the patterns are fairly similar which means that there are probably a certain group of people in there are definitely like RBD, idiopathic RBD participants. Okay so maybe maybe a related question from from Margaret Fenstock. So how often is AFNI out required for the diagnosis of RBD? So kind of go back to that gold standard for the diagnosis. Right okay so um so go back to the gold standard diagnosis um basically um acting the frequency of actinology dreams can vary a lot for patients who are taking antidepressants um this has been shown before that antidepressant can trigger dream enactment episodes in both REM sleep and non REM sleep stages and it's been suggesting that it's possible that it's a gateway to show um the underlying neurological as our neurodegenerations um that's causing them economic dream um so it can be very like upon patients and if the patient you know be more stressed um we also know that stress um and mental illness are also um triggers for dream enactment so it can vary upon patients um yeah thank you. So Sarah asked have you considered protopathic bias to explain some of the findings? Right um so I that's a really good question so I have not considered that yet um right now what we're thinking of is that the longitudinal study is coming in um we're interested in to see whether or not some of the participants um that was being positive of RBD will later be diagnosed with Parkinson's disease or some neurologic defined neurological disorder that's linked with um pdrbd or rbd um in this case we'll be sure that okay what we've seen earlier maybe you know we'll be more comfortable like to say that these people probably actually have rbd um in early stages when we see in the at the baseline so we'll be more rely on um the the prospective data yeah that's okay thank you uh last question before we go ahead and with your second part of the talk from afton uh how do you explain different risk factors from Parkinson particularly smoking so I guess okay so that's actually a really interesting question so um like we know so far is that smoking is negative negatively associated with Parkinson's disease but in rbd even in clinic we see that they're positive associated with our with um smoking is possibly associated with rbd that's why I meant um one hypothesis that's been been out there um in clinic a lot is that when patients um when they feel converted into Parkinson's disease which means that they move from rbd into Parkinson's with a defined Parkinson's disease um their dopamine allergic neurons decrease to certain threshold and a threshold is sort of like um okay let's let's call it like um like a gate to open to close the door to any of the stimulations that can potentially trigger happiness or any addictive behavior so this can be a sign of like neurodegenerations because of dopamine allergic neurons um lose loss of dopamine allergic neurons that changes the behavior there's a really good study that's done by oxford um published I think it was in 2017 was talking about risky behaviors and um personality changes um between rbd and and Parkinson's disease it gives a really good detail into some potential hypothesis that that we have out there yeah okay so um Kara should I move on yeah yeah we'll go ahead and uh take the rest of the questions at the end but yeah go ahead for the second half thank you okay thank you all right thank you guys all right so for the second half we'll be talking about the global clinical features of possible rbd disorder now because the reason why we want to do this is because early on what we saw are some of the non-clinic non-motor features of um of Parkinson's that we see in the prodromo stages um in clinic now the next thing what we want to look at is the motor features and other features that we commonly would think of and associate with Parkinson's disease and we also want to see that whether or not we see similar um physical health patterns in this patient in these participants now before we move on to talk about our study I just want to go through some of the basic things um about rbd so right now it's estimated that the true irbd the idiopathic form of rbd which means that they don't have defined neurological disorders like Alzheimer's disease or Parkinson's disease is about one percent okay but what we see earlier in our study is that in a cruel like um in a cruel prevalence wise we have about 3.2 percent of prbd that means that as I mentioned earlier there is a group of people in their indoors potential indoors like true idiopathic form rbd but there's also another group of people or like majority of them are actually um non-rencid disorder patients or other Rencid disorder patients or other like sleep disorder patients or it can be just false positives so this is law 66 but I'm just going to go through a little bit really quick so remember like um when we talk about sensitivity and specificity a lot of times that we when we were talking about it a lot of times people are confusing between like positive predictive values to sensitivities um okay so here assuming that we have a new tool called rbd x y z q um as a sensitivity is and specificity that moves around okay but rbd prevalence is one percent you will see here that on this like you have even like actually even if you have a really perfect sensitivity and specificity the positive predictive value will still be slightly below 50 percent so that means that the screen pool no matter how much we improve there's just the screen tool itself it's not going to be able to perform so well as what we want this is like filtering a coin I have 10 patients in the clinic um probably five or then a half rbd um two when two of them come into um come into the clinic will just flip a coin maybe you know we'll find one of them with rbd and half of the time I may be right um so that's not really good um that's not a really good screen making methods that we want so what we want to do here is to talk about how do we improve it um just by um looking at some of the common clinical features that we have um this here is a cohort all right so before we define Parkinson's disease there's a program on stages um these stages can be up to 10 years to 20 years patients often a lot of these patients but one third of these patients may have were in cba disorders and oftentimes we'll also see that patients will have some sort of non-motor uh non-motor symptoms as we mentioned earlier depression is one of the common non-motor symptoms of Parkinson's disease now what we want to talk about next is some of the motor symptoms that we commonly see in Parkinson's disease and want to see if we also see that in among the prbd screen positives so in the whole COSA questionnaires one of the questionnaire is tender questionnaire now the questionnaire itself is is designed to spring Parkinson's especially motor symptoms in Parkinson's disease the questionnaire itself has um sorry the questionnaire itself includes certain like clinical features for instance resting tremor that's one of the um the first thing that will cross most of people's mind when they're thinking about Parkinson's disease micrographia which means that you sign to write really really small um microphonia means that sign to have soft and voice trouble buttoning button buttons it is the motor symptoms because of tremor or dyskinesia um gate freezing which is generally happened later in um Parkinson's disease stages patients will freeze when they're trying to turn um or when they're trying to move on to a different move physical movement um then we'll also have um other symptoms for instance like hypomemia which is um which in general we say poker face um the page Parkinson's patients they're face their facial expressions does not move too much it doesn't it doesn't change much and also try trouble rising from chair et cetera now out of all of the participants that we have in COSA um 958 participants screen positive on rbd and all of these participants when we see the cutoff at three and above for tenor questionnaires it's checking like just checking like yes or no yes or no questions so when participants answer at least three questions positive um three positives on this questionnaires we will we'll recruit them into tenor screen positive rbd group we have about 70 subjects now the positive control here which is pd we define it as Parkinson's patients who screen positive on tenor questionnaires or they've been um prescribed with levodopa um the reason is that if the patient is not using levodopa and does not have tenor screen um tenor um questionnaires um auto symptoms we'll be questioning whether or not the patient is not responding to levodopa or is it possible that it's a misdiagnosis or a patient just have a recall bias et cetera that's why we we exclude those subjects from the positive control groups now the control group here is defined as healthy controls who screen negative on the tenor questionnaires because we want to rule out some of the potential participants with vascular Parkinson's which are the patients who um probably have stroke or other symptoms that may mimic um Parkinson's symptoms so out of the subjects 70 people who screen positive on rbd and tenor questionnaire and to pd there's most of the features here that we see are fairly similar to each other except for some features are more predominant in the pd um page among pd patients um for instance gate freeze as i mentioned earlier gate freeze is more is mostly in later stages of Parkinson's disease so here we don't see we don't really see much here there's just um one or probably one or two patients here participants here screen positive on this one single item which is a good thing because that means that we're not we're not picking up participants here who screen positive on tenor and pd rbd in a later stage of Parkinson's disease microfonia here we see that both of in pd it's more predominant in pd and micrographia and resting chamber are more predominant in pd these are the common features that we'll see in Parkinson's disease patients and slightly less in this um this screen positive tenor positive rbd page um participants all right so what we see earlier here this is all subjective so subjective wise all the participants um this participants will show certain symptoms now the question that we want to ask is often time when patients have depressive disorders or anxiety disorders or certain traits of it and as we know like they're the common um prodromal clinical features of Parkinson's disease they will answer yes to many of those um many of the symptoms because they're more aware of things that happen to them so we want to see if we also see the similar things in objective measures so here we um use some of the um analysis some of the assessments that was um utilized in the co-hort which are the balance test um up in time up and go which is raise right ask the patient to um rise from chair and walk four meters come back and sit down and also grip strength now we see here that um in general the tenor positive prbd and pd page um participants they're more likely to take slightly longer time um for the balance and group strength their um performance were slightly worse compared to the healthy controls and prbd positives but tenor negative this which is this group now the next is talking about sleep earlier we I just already showed that like here earlier in the presentation we showed that there are certain clinical features that are associated with Parkinson's disease um and one of them is summoning which uses daytime sleepiness and this is one of the classic clinical features of non-ring of um a Parkinson's disease because patients you don't really sleep well at night so they in the daytime they get tired there are also other um clinical features that we also see are associated with um progenome stages of Parkinson's disease and Parkinson's patients for instance insomnia so that's why we decided to also take a look at the insomnia and also some commodity sleep disorders here we define insomnia disorders based on the dsm 5 and i i c s d3 um the international classification of please sleep disorders basically means that like whether or not um a patient um with sleep disorders issue um for instance um having trouble falling asleep within 30 minutes or stay asleep throughout the night for at least three times per week in the last three months um we can also find the items in the um in the c osa sleep questionnaires now here we see that prbd positive subjects are more likely to have onset insomnia um on the other hand for maintenance insomnia wise pd participants are more likely to have issues um compared to prbd negatives there are less but we didn't see any statistical significance after adjusted by agent sex and no difference in overall night overall time um patient and participants um spend and sleep but here all we see is that like i mentioned earlier in data insominance is one of the common podromal features of Parkinson's disease we also see that prbd tenor positives of participants are more likely to have issues with data insominance now as we know that in general if you don't sleep well the next day you feel like you're tired you feel like you're drug you just have hard time focused and so your cognitive performance are generally worse and over time um if you just if we all think about like back in the time we're trying to take sat exams or other like gre other or other exams we remember that back in the time when we're trying to take those exams we stay overnight and and over time we just realize that it gets harder and harder for us to memorize things because our we're lack of sleep um so our county performance are worse so here we also do the same thing we suspect that um some of these participants will also have cognitive performance issues because of um their sleep disorders um the consequences of their sleep disorders or neurodegeneration here we see that um out of all the tests um the um prbd tenor positive participants are more likely to perform worse on um on the stroke test and fast test and and animal fluency basically um fluency just verbal fluency tests and some of the um tests out for instance by persecuting memory tests they also perform slightly worse all right now moving on um earlier we see that they'll they already have a lot of clinical features that are similar to poldromal stages of Parkinson's pcs here we also want to take a look at this um psychiatric this um distressed levels and depressive disorders and anxiety disorders because we know that for this patient if we assume that the ones who screen negative on prbd positive but tenor negative participants are at the earlier stage of their poldromal stages those who screen positive on both questionnaires should be performed worse which means that here that they should have more psychological distress and generally worse mental health um just in general compared to other um other participants so here we see that it's fairly similar to what we see in clinic that prbd um tenor positive participants are more likely to have issues with their um mental health they're more likely to be stressed out in general and more likely to be depressed or anxious just in general so overall all we found here what I just want to recap is that even with the highest specificity or a high sensitivity if you have a really low prevalence um disorder which is like one percent in this case it's rvd the positive or due value will be low it's that's just the fact it is it's just going to be like that so one thing that we want to be aware is that when we're interpreting this data we need to be careful we want to make sure that we include other um objective measures or other measures to trying to make sure that what we're looking at is exactly what we expect or what we're saying which in this case is that the rvd that we're showing here are a group of these people maybe actually through rvd participants now of all the things that we show earlier it gives us an idea that a lot of these tenor positive rvd participants um share fairly similar clinical features that we see in early Parkinson's disease patients so the question that we have is are these participants are idiopathic rvd or are they at the phenol conversion stages as you know for instance they by the time that they come into um COSA um for for participants in the in in the study they already have some sort of um Parkinson's and they're probably at the stage that just not being diagnosed with Parkinson's disease yet so more is to be done um we're hoping that the prospective data will be able to answer these questions um which will be available next year we're quite excited about this all right so on that note that's basically my my presentation today i just wanted to thank all of my collaborators and my pis and um and funders for the um for this study yeah and i'll be taking questions now i'll give back to you well thank you very much and um i'd like to open it up for questions as a reminder your meeting remains on but you can enter your questions in the chat window the bottom right corner of the webx window anytime and i'll go ahead and read through them um so go back to kind of their first part of the conversation here we had another question from Jackie McDonald about risk factors did you consider hypertension as a risk factor right so hypertension um we don't really see that as risk factors in um in clinic at least um it's not associated with our um rbd or Parkinson's disease in general yeah it's more associated with stroke or patients with vascular Parkinson's okay and then i had a question about the risk factors so when you are going through the risk factors they all kind of kick off in your mind and you know making sense making sense but um there is the one about the living arrangement or long-term relationships did i catch that correctly that was with higher risk of of having rbd yes that is correct any any thoughts on that so um like our belief so far even in clinical settings is that it's an information bias as i mentioned again and again throughout the presentation that rbd part um patients in general they are not aware of them acting out their dream unless they accidentally injure themselves they punch the wall over they fall off their bed otherwise in general it later not aware of it unlike non-rescupial disorder participants um so usually it's associated with their partners telling them that you act out of your dream i can't sleep with you um at night time um i just want to have a good night's sleep and when they go to clinic that's usually what i refer to their um what they mentioned to their to their physicians that makes sense so do you do you think that maybe future work or you might be heading towards kind of looking at the cluster of risk factors to to really you know make the predictive ability of the screening questionnaires and things better with the logistical data is that fair to say that that's kind of where you're heading yeah so um that's uh yeah so for sure um one we're trying to explore um some of the possibilities um for potential i guess potential methods to improve the quality um cluster is definitely one thing that we were eager to give you to try we're actually trying now um so far um this is primary study like we haven't really let go of the details on it yet but um we see that there's a group of the participants that we cluster out based on the information in the baseline that look fairly similar to what we see in patients in clinic um we just basically use the data to match with each other um in between cohorts and we see that there's actually cruise participants are fairly similar so with the prospective coming in will it be will it be more comfortable to say whether or not this group are idiopathic would be possible idiopathic rbd participants and is there any specific disease or is there some some public health message to improve sleeper or improve the outcomes of kind of the late related things that have to do with rbd is there anything to change the the progression of these things so it's a lifestyle risk factors that you discussed right so um so far it's not clear um for prevented treatment for Parkinson's disease the answer is no um for treatment for rbd um in general um important decisions will prescribe patients with mental death pins or um or melatonin sometimes will work on patients but it doesn't really stop the patients from progressing to Parkinson's disease or Parkinson's disease it's very unfortunate but the good thing about rbd and our study is that we give a window um to potentially future clinical trials knowing that like you have at least 10 to 20 years of window if you can spring positive on these people with Parkinson's with for clinical state of Parkinson's disease um it really gives a whole perhaps there will be room for preventing medicines to come in in the future if it's developed early pharmaceutical intervention yes exactly very interesting so far that we know like like Alzheimer's disease um many of the treatments for Parkinson's disease are symptomatic treatments um the neural generation when you with to certain level it just it just makes it so hard for the medication to help to actually help out yeah well thank you very much if anybody has any further questions and feel free to go ahead type it into the chat menu so thank you uh thank you we we appreciate your time um i'd like to remind everyone to complete the survey located under the polling option if you have any questions or concerns that we can help you with for um working with the poll or anything else about the webinar series go ahead and write to us in the chat box and we'll help i'd like to remind everyone that clc data access requests applications are ongoing the next deadline for applications is on February 25th 2019 please visit the clsa website under data access to review available data further information and details about the application process uh remember that the clsa promotes this webinar series using the hashtag at clsa webinar and we invite you to follow us on twitter so finally i'd like to say that we have our next monthly webinar in january to join us for the new year we'll be talking about the availability and quality assessment of genome-wide genetic data on 9900 participants in the clsa so very exciting presentation to start us off for the new year our presenters will be doctors sprint richard and uh vince for gata so please join us registration for this upcoming webinar is now available so please go to the cl's website and register for our webinar for january and our webinar series soon and join us in december or january for this webinar so thank you again uh tin yow we appreciate your time for the clsa webinar series and thank you to everybody for attending today's presentation thank you thank you