♪ Too easy? No, I think it teaches something that we need to know. I think the question's great. I think the commentary needs to be expanded. Okay. The problem I have is that you don't even need the image or the story. I mean, you're basically asking people to define an arousal, and the image is irrelevant. Yeah, but images are cool for the board, so I think you ought to leave it in there. Yeah, so I was trying to get someone to say it's a leg movement or that it's REM sleep with a leg movement, right? So it's a little bit of trying to add a distractor because scoring questions can be challenging without a... Ooh, actually, you know what? Dee, I have an issue with, now that I think about it. If you go to the ASM manual, you consider... And there is a reference for it. I just don't know it offhand. A leg movement before, after, or... Right, you associate leg movements with an arousal if they're before, after, or during the arousal. They're considered... Actually, I'll defer to Lynn Marie. But I don't think that's an absolute criteria to score an arousal. No, but for an association with the limb movement, I think. 0.5 seconds. Oh, so say the arousal is because of a leg movement. I'll defer to one of the neurologists, but I'm pretty sure that's what ASM says. No, I think what you're pointing out, Anissa, is true, but it's a different point than what the question is asking. So the question isn't asking when is the leg movement associated with the arousal. It's saying, how does this meet the criteria for an arousal itself? So the leg movement's not relevant to it. The leg movement's not relevant. So maybe spell that out a bit in the commentary. Yeah, because I would have gotten it wrong because of that. I mean, because I teach that, that before, during, or after, you still consider it associated. Because you're right. At least say D stand alone is correct. The arousal is associated with the increase in leg EMG because, and this is a criteria, however, that's not why it meets criteria for an arousal is what you're trying to say. Right, so that's what we're trying to point out here. It's maybe equivalent to like a respiratory event related to an arousal as well, where you still score the arousal and it still meets criteria for an arousal, but it's associated with the respiratory event. It's not really what the question's asking. That's the way I look at the leg movement as well. It's firstly for the arousal, and then you'd look back to see is it spontaneous, for instance, or is it related to respiratory event or a PLM? And then that's when the rules about where the leg is in relation to the arousal is stated. Maybe that could be explained in the commentary. So I guess you're also saying, The question is actually is not the cost for arousals, is the actual criteria. The criteria. So if that's the case, I will leave the graph because it has a visual effects and a context. So when someone is reading this, they can look at the tracing and what they're talking about. The other way you could do it, you know, because I kind of agree with David, just you don't need, you know, pictures are great. Don't get me wrong. But it does, you know, it doesn't focus. I don't think it focuses the reader on the question. What I would suggest is maybe taking the picture and putting it as part of the discussion. And in the discussion, that's your the commentary. That's where it has some ability. And if you wanted to, if you're going to comment on, you know, a little bit about Raman was talking about PLM with an arousal, you could have an example image of that. So you've got two images, you know, that are instructive to the reader. So, all right. Something in the chat here, Anissa is saying that CND need to not say the arousal, it needs to say the event, but I already say it's an arousal. So let's, the verbiage is a separate issue. So, but I think that the Peter and what, what Fashil just said about moving the picture to the, to the discussion, to me that makes a lot of sense. Okay. Because you're really asking for people of the deaf about the, we'll work about the verbiage in a minute. I don't want to ignore it because Anissa had a good point, but I, I really like what the two of them just kind of put together, is that you can reword the question. Basically, so we can know which of their following is true of a, you know, a polysomnographic scored arousal. And no, you have to say, because then D would be correct. If you phrased it that way. Which of the following is required, is required, maybe. Okay. Is required to score an arousal. Okay. Which of the following is required? But, but then David, I feel like D isn't, if you choose it that way, then D is, no one's going to say you have to have, well, maybe they will, who knows. Which of the following is required to score an arousal? Move the picture to the discussion. What if you get rid, what if you get rid of leg? What if you get rid of leg? Arousal must be associated with an increase in chin EMG. That I have to say what stage of sleep it is. And you could say an arousal from N3, like from, It doesn't, it's not required though, right? You need an abrupt shift in EMG frequency. For REM, for REM it's required though. REM, arousal in REM. But you can score an arousal without having an increase in chin EMG. Doesn't have to be, right? You're not saying in the stem. And in fact, that's one of the things you could say in discussion, you know, answer choice D would have been correct. Had we stipulated that this was a REM sleep arousal, but it is not required for arousals from other stages of sleep. Okay. All right. I think I got it. So we want to move the picture to the discussion in the stem, say which of the following is required to score an arousal from sleep and then make D an increase in chin EMG and then in the discussion point out that that's for stage R and not necessary for N1, N2 or N3. Is that everything? Can I make another comment? Sorry. Which is just the imbalance in the length of the different distractors, right? So like one of them, the right answer basically gives you the entire definition of an arousal and then B is only slightly different from that, but then C and D are much shorter. Like I sort of feel like good test taking is going to point you in the direction of it's either A or B. So I wonder if it makes sense to move the abrupt shift in EEG frequency to the discussion and then have A be, I don't know, proceeded by 10 seconds of stable sleep, B be something else that's short that's wrong. And then there it's less, I think less obvious just from the length of the answer. What if you, Lin-Marie, what if you move it to the stem? In addition to an abrupt shift in EEG frequency, which of the following is required to score a polysomnographic arousal? A, it's preceded by 10 seconds of stable sleep. B, it's preceded and followed by 10 seconds. C, it's followed by stage wake. D, it's associated increase in chin EMG. Perfect. Love it. Okay. The increase in chin EMG is also, I mean, I guess the point is that it could be a REM related arousal. So that is also correct. No, it's not required. I'm going to, you know, again, it's a good distractor because it's not required. A is required. It must be preceded by 10 seconds of stable sleep. An increase in chin EMG is not required. It is required during certain stages of sleep, but it's not required. Is it a subtle distinction? Maybe, but I think it's one that most people should be able to make. I get where everyone's coming. Personally, I like, I would prefer to say a non-REM sleep. I almost think we should just vote, like, get a quick poll of that because I think we're not testing the question. We're testing, are you good at figuring out if we're talking about non-REM versus REM? Because I would sit there and spend an extra five minutes on a board question, be like, what the hell? What the heck? Sorry. Are they talking about non-REM or REM? So in general, how many people are uncomfortable with the fact that you do require an increase in chin tone in REM sleep? Raise your hand. I mean, as an arousal? Yeah, using this as a distractor, like, it makes me a little uncomfortable. And if it's really just three of us, maybe it's fine. Like, I think that saying that, I just think that saying an arousal associated with an increase in chin EMG would be, is not a fair distractor because what we're testing is, well, we didn't say REM, non-REM could be. So I don't know. I just, I would, I would clarify it with non-REM and just say non-REM in the STEM. Now, since the increase in leg EMG is not required for either non-REM or REM arousal, you could say like the, you know, the choices were, you know, with the, and they just include that and say that it is required that there should be an increase in leg EMG. So that is a distractor. Well, we're talking about chin, so I'm just. Okay. Let's go back. It looks like the chat that we've got some votes for specifying and REM. Yeah. Are you guys cool with that? So we just say, which of the following? Yeah. With, yeah. Okay. Caroline, you want to get that? Yeah. So I have to add non-REM to the, all right. Okay. So the STEM is going to be, which of the following is required to score an arousal from non-REM sleep? Then make D an increase in chin EMG and put more about that in the discussion. Move an abrupt shift in EEG frequency to the STEM, and then shorten the A and B answers so that they all sort of look like the same length. And then I was going to also add Carol Rosen put on the chat something about subcortical arousals, also put a couple sentences in the commentary about subcortical arousals and leg movements that occur with those. Yeah. I think the discussion, yeah. They're just adding that and the commentary, the distinction between REM and non-REM arousals. I think that's a nice way to bulk up the commentary. Please also get rid of as required in choice C, since that's by definition. That's part of the question. And then maybe use the term arousal in A, B, C, and D, just so that they're all parallel. I don't think you need it in any of them. Or take it out. Either way, have them parallel. Shorter is better. Yep. You can say it. It. Okay.

scoring arousal from sleep

leg movement

chin EMG

REM sleep

non-REM sleep