Hypoglossal nerve stimulation over-titration.

This case report reviews worsening obstructive sleep apnea (OSA) events in a patient over-titrated with a hypoglossal nerve stimulator. A healthy 57-year-old man underwent hypoglossal nerve stimulator implantation for moderate OSA. During an in-laboratory hypoglossal nerve stimulator titration the patient had improvement of his OSA at 2.1 V. However, a further increase of voltage resulted in worsening of obstructive events. The pathophysiology behind this finding is unknown but may result from unfavorable changes in the upper anatomy due to higher energy delivered to the hypoglossal nerve and surrounding structures. This high energy may also lead to genioglossus muscle fatigue. This finding highlights the importance of hypoglossal nerve stimulation titration with a dedicated sleep study. CITATION: Chang M, Moore V, Eng K, Ryden A, Zeidler M. Hypoglossal nerve stimulation over-titration. J Clin Sleep Med. 2024;20(6):999-1001.

Obstructive sleep apnea due to oromandibular dystonia and treated with botulinum toxin.

None: Abnormalities of the upper airway anatomy are an underrecognized cause of obstructive sleep apnea. We present a unique case of a 51-year-old man with episodic sleep-maintenance insomnia and oromandibular dystonia requiring botulinum toxin injections of the temporalis and masseter muscles. He underwent multiple sleep studies and was found to have obstructive sleep apnea temporally associated with the severity of dystonia symptoms and dosing of botulinum toxin.

Corticosteroids in the Management of Severe Coccidioidomycosis.

BACKGROUND: There is limited data suggesting that recovery from severe pulmonary infection with Coccidioides may be hastened by the addition of systemic corticosteroids. METHODS: We present a case report of 2 patients with persistent and progressive coccidioidomycosis who demonstrated a dramatic response to adjunctive corticosteroid therapy. RESULTS: Both patients had Coccidioides immitis cultured from respiratory samples. One was a 69-year-old man who had been treated with combination fluconazole and liposomal amphotericin for over 6 weeks, with persistent fever and pneumonia. The other was a 61-year-old man treated with fluconazole and then amphotericin for 3 weeks, with progression to acute respiratory distress syndrome and shock. Both received short courses of intravenous methylprednisolone and recovered to be discharged home. CONCLUSIONS: As opposed to associated hypersensitivity, corticosteroid treatment in these cases was directed at modulating the ongoing destructive effects of unchecked inflammation. Rapid improvement was noted in both cases and raises the possibility that the addition of systemic corticosteroids may hasten recovery in patients with severe coccidioidomycosis.

Case Report: Pulmonary Papillomatosis in a Patient Presenting with Cough and Hemoptysis.

A previously healthy patient was seen in the Emergency Department for evaluation of a one-month history of cough and one-day history of hemoptysis. A computed tomography scan of the thorax found a mass on the right lower pulmonary lobe and a mass on the left upper lobe. A biopsy specimen of the right lobe lung mass, obtained during bronchoscopy, demonstrated papilloma. This case report, from a pulmonologist's perspective, includes a comprehensive review of the patient's clinical presentation and outcome, as well as a discussion of recurrent respiratory papillomatosis.

Risks from Catheter Ablation of Atrial Fibrillation: A Review of Methods, Efficacy, and Safety.

Atrial fibrillation (AF) is the most common arrhythmia and is a significant burden to healthcare cost. AF causes congestive heart failure, thromboembolic events such as stroke and intolerable symptoms in some patients. With the advances and increasing experience in catheter ablation, there is now an established role for catheter ablation in patients with atrial fibrillation. The risks, complications and patient features associated with it are increasingly recognized. A recent worldwide survey has shown an increasing number of medical centers that are practicing catheter ablation of atrial fibrillation, predominantly with pulmonary vein isolation techniques. However, catheter ablation is an invasive therapy in AF and is associated with a few major complications. Patient selection, ablation technique, and catheter energy source all influence the efficacy and safety of the procedure. Finally, while several randomized control trials have compared the efficacy of catheter ablation versus antiarrhythmic drug therapy, a number of trials are on the horizon to explore its role as a first line therapy for atrial fibrillation. New energy catheter energy sources are also being explored.