Rehabilitation in obstructive sleep apnea: an ignored treatment adjunct.

Patients with obstructive sleep apnea (OSA) remain physically inactive during the day, are deconditioned, and have an impaired health-related quality of life (HRQoL). The role of rehabilitation is not yet defined in OSA, despite proven effective modalities for chronic illnesses like chronic obstructive pulmonary disease. In this prospective study, over a period of one year, 30 individuals with sleep-disordered breathing were included. Before recruitment, every patient was receiving continuous positive airway pressure treatment for at least 4 weeks. A statistically significant negative correlation was seen between the apnea hypopnea index and reductions in 6-minute walk distance, energy, and general health, which signified that patients with greater levels of daytime sleepiness have poor quality of life and are more deconditioned. Enrolled patients in the study underwent a 20-session rehabilitation program (with a minimum of 2 sessions per week). The patient received resistance and endurance exercises, dietary guidance, and counseling at each session. Before and after rehabilitation, target parameters such as 6MWD, HRQoL domains, Epworth sleepiness scale (ESS), and body mass index (BMI) were recorded. All 8 HRQoL domains showed improvement post-rehabilitation. Along with improvements in ESS and BMI, the 6MWD was also improved. No adverse event such as cardio-respiratory distress occurred in individuals undergoing rehabilitation. To conclude, rehabilitation is a safe and efficacious modality as an adjunct to positive airway pressure therapy in OSA patients.

Accidental breakage of needle tip during endobronchial ultrasound-guided transbronchial needle aspiration: A case report and review of literature.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly recommended for the diagnosis of mediastinal lymphadenopathy with malignant and nonmalignant etiology. EBUS-TBNA has been preferred over mediastinoscopy because of several advantages such as comparable diagnostic accuracy, safety, cost-effectiveness, and less invasiveness. Hemorrhage, mediastinitis, pneumonia, mediastinal abscess, empyema, lung abscess, pericarditis, and pneumothorax have been reported as major complications of EBUS-TBNA. Equipment malfunction has been observed mostly in the form of breakage of EBUS scope parts such as working channel, optical fibers, and ultrasound probe. Needle malfunction either involving assembly leading to inability to retract the needle within the sheath or accidental breakage of the needle tip has also been reported but the evidence is still limited. We encountered an accidental breakage of needle tip while performing EBUS-TBNA procedure in a 58-year-old male having subcarinal lymphadenopathy suspected to have lung cancer. We were able to successfully retrieve the broken fragment bronchoscopically without any complications.

Developing a pediatric ophthalmology telemedicine program in the COVID-19 crisis.

PURPOSE: To describe our methodology for implementing synchronous telemedicine during the 2019 novel coronavirus (COVID-19) pandemic. METHODS: A retrospective review of outpatient records at a single children's hospital from March 21 to April 10, 2020, was carried out to determine the outcome of already-scheduled face-to-face outpatient appointments. The week leading up to the March 21, all appointments in the study period were categorized as follows: (1) requiring an in-person visit, (2) face-to-face visit that could be postponed, and (3) consultation required but could be virtual. Teams of administrators, schedulers, and ophthalmic technicians used defined scripts and standardized emails to communicate results of categorization to patients. Flowcharts were devised to schedule and implement telemedicine visits. Informational videos were made accessible on social media to prepare patients for the telemedicine experience. Simultaneously our children's hospital launched a pediatric on-demand e-consult service, the data analytics of which could be used to determine how many visits were eye related. RESULTS: A total of 237 virtual ophthalmology consult visits were offered during the study period: 212 were scheduled, and 206 were completed, of which 43 were with new patients and 163 with returning patients. Following the initial virtual visit, another was required on average in 4 weeks by 21 patients; in-person follow-up was required for 170 patients on average 4.6 months after the initial virtual visit. None needed review within 72 hours. The pediatric on-demand service completed 290 visits, of which 25 had eye complaints. CONCLUSIONS: With proper materials, technology, and staffing, a telemedicine strategy based on three patient categories can be rapidly implemented to provide continued patient care during pandemic conditions. In our study cohort, the scheduled clinic e-visits had a low no-show rate (3%), and 8% of the on-demand virtual access for pediatric care was eye related.

High flow nasal cannula in acute hypercapnic exacerbation of chronic obstructive pulmonary disease: an emerging utility.

High flow nasal cannula (HFNC) provides warmed and humidified air with flow rates up to 60 liters/min with relatively fixed oxygen content (FiO2). It has been extensively evaluated for hypoxemic respiratory failure and has been used in mild acute respiratory distress syndrome, pre-intubation, bronchoscopy and pediatric obstructive sleep apnea. Recent data has suggested a role in stable hypercapnic chronic obstructive pulmonary disease (COPD) and even in acute exacerbations, though, the use has not been advocated by any guidelines yet. We present a case of acute hypercapnic exacerbation of COPD, intolerant to non-invasive ventilation, showing response and improvement on use of HFNC. This case highlights this potential mechanisms and prospects for the same.

An uncommon cause of diffuse alveolar hemorrhage in a young male.

It is uncommon for Systemic lupus erythematosus (SLE) to present with diffuse alveolar hemorrhage (DAH) as the initial presentation. To diagnose this in a young male with no renal involvement is further uncommon. We report a case of a 16-year-old boy, who presented with hemoptysis and was eventually diagnosed as DAH with underlying SLE. Treatment with steroids and immunosuppressant helped in rapid recovery from this potentially life-threatening condition. This case highlights the need of defining diagnostic criteria for SLE in patients presenting as DAH and formulating guidelines for treatment of the same, especially in absence of co-existing lupus nephritis.

Macrophage activation syndrome in a patient with systemic onset of the juvenile idiopathic arthritis.

Systemic onset juvenile idiopathic arthritis (sJIA) is defined as arthritis affecting one or more joint usually in the juvenile age group (< 16 years of age) with or preceded by fever of at least 2 weeks duration that is documented to be daily ("quotidian") for at least 3 days which may be associated with evanescent (non-fixed) erythematous rash or generalized lymph node enlargement or hepatomegaly/splenomegaly/both or serositis. Macrophage activation syndrome (MAS) is a life-threatening complication of sJIA marked by sudden onset of non-remitting high fever, profound depression in all three blood cell lines (i.e. leukopenia, anemia, and thrombocytopenia), hepatosplenomegaly, lymphadenopathy, and elevated serum liver enzyme levels. In children with systemic juvenile idiopathic arthritis, the clinical picture may mimic sepsis or an exacerbation of the underlying disease. We report a case of a 16-year-old female patient presenting with high grade fever with joint pains and generalized weakness which proved to be systemic onset juvenile idiopathic arthritis with macrophage activation syndrome after ruling out all other differential diagnoses and responded well to intravenous steroids.