Sleep Habits and Disturbances Among Tunisian Adults: A Cross-Sectional Online Survey.

Background: Sleep quality and disturbances have gained heightened scholarly attention due to their well-established association with both mental and physical health. This study aims to assess sleep-wake habits and disturbances in Tunisian adults. Methodology: This cross-sectional study employed an online questionnaire to assess 3074 adults ≥ 18 years. Primary outcomes, including sleep quality, daytime vigilance, mood, and subjective well-being, were measured using validated questionnaires [the Pittsburgh Sleep Quality Index (PSQI), the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale (ESS), the Patient Health Questionnaire (PHQ)-9, and the World Health Organisation-Five Well-Being Index (WHO-5)]. Results: Less than two-thirds (n= 1941; 63.1%) of participants were females and the mean age was 36.25±13.56. The prevalence of poor sleep quality was 53.8% when defined as a PSQI > 5. The prevalence of insomnia, short sleep duration, long sleep duration, EDS, severe depression, and poor well-being were 14.5%, 34.7%, 12.3%, 32.4%, 7.4%, and 40.2%, respectively. Some factors were associated with an increased likelihood of poor sleep quality, including female gender, chronic hypnotics use, internet use close to bedtime, daily time spent on the internet >3 hours, smoking, university- level education, nocturnal work, severe depression, impaired well-being status, insomnia, and EDS. Conclusion: The high prevalence of sleep-wake disturbances among Tunisian adults emphasizes the need for an appropriate screening strategy for high-risk groups. Individuals with unhealthy habits and routines were significantly more likely to experience these kinds of disturbances. Consequently, there is a pressing need for educational programs on sleep to foster healthier sleep patterns.

Sleep habits and quality among war and conflict-affected Palestinian adults in the Gaza strip.

OBJECTIVES/BACKGROUND: Sleep may be affected by traumatic experiences leading to an increased risk of poor quality of life and daily functioning. However, studies related to sleep habits and problems in conflict-affected areas are still sparse. The present study attended to describe sleep habits, estimate the prevalence rate of sleep disturbances, and identify associated factors in the Gaza strip. PATIENTS/METHODS: A population-based cross-sectional study including 1458 Palestinian adults aged ≥18 years living in the Gaza strip was carried out during the period between 18 February and March 31, 2022. An electronic survey through the free-of-charge Google Forms tool was used for data collection. A range of self-report measures related to sleep, mood, and subjective quality of life were used: the Pittsburgh Sleep Quality Index (PSQI), the World Health Organisation-Five Well-Being Index (WHO-5), the Epworth Sleepiness Scale (ESS), and the Patient Health Questionnaire (PHQ)-9. RESULTS: Three out of five of participants (n = 882, 60.5%) were females and the mean age was 34.8 ± 12.77 years. More than one-third of participants (n = 556, 38.1%) had poor well-being as assessed by the WHO-5 and 108 (7.4%) had a PHQ-9 score ≥ 20 indicating severe depression. The prevalence of poor sleep quality was 52.8% when defined as PSQI ≥ 6 and 30.5% when defined as PSQI ≥ 8. The prevalence of excessive daytime sleepiness (EDS), short sleep duration, severe depression, and poor well-being were 43.6%, 26.4%, 7.1%, and 38.1% respectively. Women and the youngest participants reached the highest prevalence rates for sleep and mood disturbance as well as for daytime dysfunction. Using multivariate binary logistic regression analysis, severe depression, being divorced, a history of psychological disease, poor well-being and previous war injuries were identified as the strongest predictors of poor sleep quality. CONCLUSION: Poor sleep quality, EDS, severe depression, and poor well-being in our sample were strikingly increased. Females and the youngest participants were the most affected. The conflict-affected situation in the Gaza strip combined with the high population density and worsening socio-economic conditions may play an important role in sleep disturbances, mainly because of a high prevalence of mood disturbances. Sleep and mood disturbances also adversely affect the quality of life.

Inspiratory muscle training, with or without concomitant pulmonary rehabilitation, for chronic obstructive pulmonary disease (COPD).

BACKGROUND: Inspiratory muscle training (IMT) aims to improve respiratory muscle strength and endurance. Clinical trials used various training protocols, devices and respiratory measurements to check the effectiveness of this intervention. The current guidelines reported a possible advantage of IMT, particularly in people with respiratory muscle weakness. However, it remains unclear to what extent IMT is clinically beneficial, especially when associated with pulmonary rehabilitation (PR).   OBJECTIVES: To assess the effect of inspiratory muscle training (IMT) on chronic obstructive pulmonary disease (COPD), as a stand-alone intervention and when combined with pulmonary rehabilitation (PR). SEARCH METHODS: We searched the Cochrane Airways trials register, CENTRAL, MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO, Physiotherapy Evidence Database (PEDro) ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 20 October 2021. We also checked reference lists of all primary studies and review articles. SELECTION CRITERIA: We included randomized controlled trials (RCTs) that compared IMT in combination with PR versus PR alone and IMT versus control/sham. We included different types of IMT irrespective of the mode of delivery. We excluded trials that used resistive devices without controlling the breathing pattern or a training load of less than 30% of maximal inspiratory pressure (PImax), or both. DATA COLLECTION AND ANALYSIS: We used standard methods recommended by Cochrane including assessment of risk of bias with RoB 2. Our primary outcomes were dyspnea, functional exercise capacity and health-related quality of life.  MAIN RESULTS: We included 55 RCTs in this review. Both IMT and PR protocols varied significantly across the trials, especially in training duration, loads, devices, number/ frequency of sessions and the PR programs. Only eight trials were at low risk of bias. PR+IMT versus PR We included 22 trials (1446 participants) in this comparison. Based on a minimal clinically important difference (MCID) of -1 unit, we did not find an improvement in dyspnea assessed with the Borg scale at submaximal exercise capacity (mean difference (MD) 0.19, 95% confidence interval (CI) -0.42 to 0.79; 2 RCTs, 202 participants; moderate-certainty evidence).   We also found no improvement in dyspnea assessed with themodified Medical Research Council dyspnea scale (mMRC) according to an MCID between -0.5 and -1 unit (MD -0.12, 95% CI -0.39 to 0.14; 2 RCTs, 204 participants; very low-certainty evidence).  Pooling evidence for the 6-minute walk distance (6MWD) showed an increase of 5.95 meters (95% CI -5.73 to 17.63; 12 RCTs, 1199 participants; very low-certainty evidence) and failed to reach the MCID of 26 meters. In subgroup analysis, we divided the RCTs according to the training duration and mean baseline PImax. The test for subgroup differences was not significant. Trials at low risk of bias (n = 3) demonstrated a larger effect estimate than the overall. The summary effect of the St George's Respiratory Questionnaire (SGRQ) revealed an overall total score below the MCID of 4 units (MD 0.13, 95% CI -0.93 to 1.20; 7 RCTs, 908 participants; low-certainty evidence).  The summary effect of COPD Assessment Test (CAT) did not show an improvement in the HRQoL (MD 0.13, 95% CI -0.80 to 1.06; 2 RCTs, 657 participants; very low-certainty evidence), according to an MCID of -1.6 units.  Pooling the RCTs that reported PImax showed an increase of 11.46 cmH2O (95% CI 7.42 to 15.50; 17 RCTs, 1329 participants; moderate-certainty evidence) but failed to reach the MCID of 17.2 cmH2O.  In subgroup analysis, we did not find a difference between different training durations and between studies judged with and without respiratory muscle weakness.  One abstract reported some adverse effects that were considered "minor and self-limited". IMT versus control/sham Thirty-seven RCTs with 1021 participants contributed to our second comparison. There was a trend towards an improvement when Borg was calculated at submaximal exercise capacity (MD -0.94, 95% CI -1.36 to -0.51; 6 RCTs, 144 participants; very low-certainty evidence). Only one trial was at a low risk of bias. Eight studies (nine arms) used the Baseline Dyspnea Index - Transition Dyspnea Index (BDI-TDI). Based on an MCID of +1 unit, they showed an improvement only with the 'total score' of the TDI (MD 2.98, 95% CI 2.07 to 3.89; 8 RCTs, 238 participants; very low-certainty evidence). We did not find a difference between studies classified as with and without respiratory muscle weakness. Only one trial was at low risk of bias. Four studies reported the mMRC, revealing a possible improvement in dyspnea in the IMT group (MD -0.59, 95% CI -0.76 to -0.43; 4 RCTs, 150 participants; low-certainty evidence). Two trials were at low risk of bias. Compared to control/sham, the MD in the 6MWD following IMT was 35.71 (95% CI 25.68 to 45.74; 16 RCTs, 501 participants; moderate-certainty evidence). Two studies were at low risk of bias. In subgroup analysis, we did not find a difference between different training durations and between studies judged with and without respiratory muscle weakness.  Six studies reported theSGRQ total score, showing a larger effect in the IMT group (MD -3.85, 95% CI -8.18 to 0.48; 6 RCTs, 182 participants; very low-certainty evidence). The lower limit of the 95% CI exceeded the MCID of -4 units. Only one study was at low risk of bias. There was an improvement in life quality with CAT (MD -2.97, 95% CI -3.85 to -2.10; 2 RCTs, 86 participants; moderate-certainty evidence). One trial was at low risk of bias. Thirty-two RCTs reported PImax, showing an improvement without reaching the MCID (MD 14.57 cmH2O, 95% CI 9.85 to 19.29; 32 RCTs, 916 participants; low-certainty evidence). In subgroup analysis, we did not find a difference between different training durations and between studies judged with and without respiratory muscle weakness.   None of the included RCTs reported adverse events. AUTHORS' CONCLUSIONS: IMT may not improve dyspnea, functional exercise capacity and life quality when associated with PR. However, IMT is likely to improve these outcomes when provided alone. For both interventions, a larger effect in participants with respiratory muscle weakness and with longer training durations is still to be confirmed.

Nonspecific interstitial pneumonia revealing an antisynthetase syndrome.

One of the most common interstitial lung diseases in antisynthetase syndrome is nonspecific interstitial pneumonia (NSIP). A 49-year-old woman presented with slow progression exertional dyspnea, myalgia, and arthralgia. The radiological findings indicated an NSIP pattern. Autoantibodies were found to be positive, but no lung biopsy was performed. Even though corticosteroid therapy significantly improved the patient's dyspnea, the patient developed mechanic's hands, the anti-synthetase antibody (PL12) became positive, and creatine phosphokinase (CPK) levels increased. As a result, the antisynthetase syndrome was established. The patient follow-up after three years revealed an improvement in symptoms under corticosteroid therapy.

Leser-Trélat syndrome secondary to non-small-cell lung carcinoma.

The syndrome of Leser-Trélat (LT) is a rare paraneoplastic syndrome. However, patients presenting with the sign of Leser-Trélat should be considered to harbor an occult malignancy or a progressive tumor disease until "proven" otherwise. Herein, we present two cases of non-small-cell lung carcinoma associated with LT syndrome.

Thromboembolic events in COVID-19 ambulatory patients: An observational study about incidence, and thromboprophylaxis outcomes.

INTRODUCTION: There are no clear data about the incidence and the prophylactic strategies of arterial and venous thromboembolic events (TE) in COVID-19 ambulatory patients. Thus, we conducted this study to analyze thromboembolic complications in this setting and to assess thromboprophylaxis management and outcomes in the real life. PATIENTS AND METHODS: This is an observational study including Covid-19 ambulatory patients. We assessed incidence of venous and arterial TE events as well as thromboprophylaxis outcomes and hemorrhagic complications. We defined high risk thrombo-embolic factor according to the Belgian guidelines which are the only guidelines that described thromboprophylaxis in COVID-19 ambulatory patients. RESULTS: We included 2089 patients with a mean age of 43±16 years. The incidence of 30 days venous and arterial TE complications in our cohort was 1%. Venous thromboembolic complications occurred in 0.8% and arterial thromboembolic complications occurred in 0.3%.We noted at least one high-risk TE factor in 18.5% of patients but thromboprophylaxis was prescribed in 22.5% of the cases, LMWH in 18.1%, and Rivaroxaban in 3.7%. Hemorrhagic events occurred in eight patients (0.3%): five patients showed minor hemorrhagic events and three patients showed major ones (0.14%). CONCLUSIONS: Our study showed that the incidence of thromboembolic complications is very low in COVID-19 ambulatory patients. Paradoxically, there is an over prescription of thrombo-prophylaxis in this population.

Oxidative stress in patients with asthma and its relation to uncontrolled asthma.

This study aims to evaluate markers of oxidative stress in Tunisian asthmatic patients and investigate whether their markers are correlated with uncontrolled asthma. This prospective cohort study was conducted on 48 healthy subjects and 60 patients with asthma (34 patients with controlled asthma and 26 patients with uncontrolled asthma). The levels of malondialdehyde (MDA), advanced oxidation protein products (AOPP), and glutathione (GSH), as well as the activities of glutathione peroxidase (GPx) and superoxide dismutase (SOD), were estimated in plasma by spectrophotometry. Asthmatic patients have significantly higher plasmatic levels of MDA and AOPP than healthy controls (p < 0.001). Lower GSH level and GPx activity were found in patients with asthma compared to controls (p < 0.001). In contrast, higher SOD activity was noted in asthmatic patients (p < 0.001). The comparison among the patients with controlled asthma and uncontrolled asthma revealed increased MDA and AOPP levels and SOD activity (p < 0.001) as well as a decreased GSH level and GPx activity (p = 0.004, p = 0.019) in patients with uncontrolled asthma. Spirometry level was significantly correlated with SOD activity (r = 0.447; p = 0.010), whereas no significant correlations were found with the other parameters (MDA, AOPP, GSH, and GPx). Asthmatic patients, especially those with uncontrolled asthma, suffer a high degree of reactive oxygen species (ROS) formation causing considerable oxidative stress. Increased MDA level and SOD activity and reduced GPx activity were predictors of poorly controlled asthma.

Accelerated silicosis and silico-tuberculosis: A difficult diagnosis.

It is well established that exposure to respirable crystalline silica is associated with higher mortality. Such exposures are associated with an increased risk of silico-tuberculosis, silicosis, and other respiratory morbidities. We report two cases of accelerated silicosis, complicated with pulmonary tuberculosis and pulmonary infection.

Characteristics of Obese Patients with Acute Hypercapnia Respiratory Failure Admitted in the Department of Pneumology: An Observational Study of a North African Population.

BACKGROUND: Acute hypercapnic respiratory failure (AHRF) is a common life-threatening event in patients with obesity hypoventilation syndrome (OHS). OBJECTIVES: To study the clinical pattern, noninvasive ventilatory support, as well as the short- and long-term outcomes of patients with OHS admitted in a ward because of AHRF. METHODS: We conducted a retrospective cohort study including all adults with OHS aged ≥ 18 - year - old, admitted in a 90-bed-ward for AHRF. RESULTS: A total of 44 patients were included. Fifteen (34.1%) and 29 (65.9%) patients were diagnosed with malignant OHS (mOHS) and nonmalignant OHS (non-mOHS), respectively, while 36 (81.8%) had coexisting obstructive sleep apnea hypopnea syndrome (OSAHS). Patients with mOHS had a significantly higher rate of heart failure (100% vs. 31%; p < 0.001), chronic renal insufficiency (CRI) (73.3% vs. 41.4%; p = 0.04), and dyslipidemia (66.7% vs. 34.5%; p = 0.04) than those with non-mOHS. The mean forced vital capacity (FVC) in our patients was of 59.5% ± 18.5 of the predicted value, lower than what is usually reported in stable patients with OHS. At hospital admission, more than two-thirds (n = 34, 77.3%) were misdiagnosed as having asthma exacerbation (n = 4, 4.9.1%), chronic obstructive pulmonary disease (COPD) exacerbation (n = 12, 27.3%) and/or heart failure (n = 29, 65.9%). Acute pulmonary oedema (ACPE) (n = 16, 36.4%) and acute viral bronchitis (n = 12, 27.3%) were the main identified causal factors, while no cause could be determined in 5 (11.4%) patients. Noninvasive positive pressure ventilation (NIPPV) using bilevel positive airway pressure (BIPAP) was very highly effective to treat AHRF, with only 2.27% of patients failing the modality. Median overall duration of ventilation was 9 hours per day (1.3-20) and was significantly longer in patients with mOHS than in those with non-mOHS (10 [6-18] vs. 8 [1.3-20], respectively; p = 0.01). Forty two of the forty-three patients discharged alive were treated with BIPAP or continuous positive airway pressure (CPAP) in 26 and 16 patients, respectively. The probability of survival was 90% at 12 months, while the probability of readmission for a new episode of AHRF was 56% at 6 months and 22% at 12 months, respectively. CONCLUSION: AHRF in OHS patients is a life-threatening event which can be successfully and safely treated with BIPAP, with a low long-term mortality even in patients with mOHS.

Chronic Pain in Patients with Chronic Obstructive Pulmonary Disease: A Cross Sectional Study.

Background: Many individuals with chronic obstructive pulmonary disease (COPD) report suffering from chronic pain, which affects their quality of life. This study aimed to determine the prevalence, characteristics and impact of chronic pain in patients with COPD, and to explore its possible predictive and aggravating factors. Materials and Methods: It was a cross-sectional study. Male individuals with COPD responded to a questionnaire, including mMRC, CAT, Brief Pain Inventory (BPI) (composed of Worst pain, Pain Severity Score (PSS) and Pain Interference Score (PIS)), and Hospital Anxiety and Depression Scale. Patients were divided into group 1 (G1) with chronic pain, and group 2 (G2) without chronic pain. Results: Sixty eight patients were included. The general prevalence of chronic pain was 72.1% (CI95%:10.7%). The most common site of pain was the chest (54.4%). Analgesics were used in 38.8%. Patients from G1 had more hospital admissions in the past (OR=6.4[1.7-23.4]). Three variables were associated to pain in the multivariate analysis: socio-economic level (OR=4.6[1.1-19.2]), hospital admissions (OR=0.087[0.017-0.45]), and CAT (OR=0.18[0.05-0.72]). Dyspnea was associated to PIS (p<0.005). A correlation was found between PSS and PIS (r=0.73). Six patients (8.8%) retired because of pain. Patients who had CAT≥10 were more in G1 (OR=4.9[1.6-15.7]). CAT was correlated to PIS (r=0.5). G1 demonstrated higher anxiety scores (p<0.05). There was a moderate positive correlation between depression symptoms and PIS (r=0.33). Conclusion: Pain should be systematically assessed in COPD patients, regarding its high prevalence. New guidelines should take into consideration pain management to ameliorate patients' quality of life.

Recurrent Haemoptysis Revealing Hughes-Stovin Syndrome.

Hughes-Stovin syndrome is a very rare condition with no defined diagnostic criteria. We present the case of a 26-year-old man who had haemoptysis revealing Hughes-Stovin syndrome. We will consider the aetiology, therapeutic and evolutionary aspects of this disease. LEARNING POINTS: Hughes-Stovin syndrome is a very rare disorder of unknown aetiology which can be fatal.It is considered a variant of Behcet's disease.Early diagnosis and treatment improve prognosis.

Clinico-radiological particularities of common pulmonary tuberculosis among smokers in Tunisia.

INRODUCTION: Smoking and tuberculosis are two major public health issues worldwide, particularly in emerging countries. Currently, the relationship between these two scourges is well established. AIM: Describe the clinical, radiological and progressive features of common pulmonary tuberculosis in smokers. METHODS: Comparative study, carried out at the Pneumology department of the Hédi Chaker in Sfax, Tunisia, including 120 patients hospitalized for common pulmonary tuberculosis  from January 2014 to December 2016 and who completed their follow-ups for a minimum period of 2 years . The patients were divided into 2 groups: Group1 (G1) consisting of 60 smoking patients and Group 2 (G2) consisting of 60 non-smoking patients. To assess the severity of radiological lesions, we used the International Labour Organization classification for simple pneumoconiosis and the Brouet classification. RESULTS: The mean age of the patients was comparable in the two groups with a predominance of male for G1 (91%) and female for G2 (70%). The smokers consulted later (113 days versus 60 days (p=0.023). Dyspnea, hemoptysis and chest pain were significantly more frequent in the smokers. The radiological lesions were more serious in smoking group. Bilateral lesions were more observed in smokers (58% vs 25% p = 0.004). A positive association was noted between the extent of radiological lesions, stage 3 and 4 according to the Brouet classification, and smoking status (p <0.001). Similarly for the International Labour Organization classification for simple pneumoconiosis , the radiological lesions were more severe (scores 6 - 15) in the smokers (p <0.001).Smoking was associated with poor adherence (p <0.008), prolonged anti-tuberculosis treatment (p <0.001), delayed RBK negativation in sputum (p <0.001), and more frequent reactivation of tuberculosis (p=0.001). After the diagnosis of CPT, 83% of patients continued to smoke at the same rate and only 7% of patients had quit smoking. CONCLUSION: Smoking worsens CPT by making the clinical picture noisier, radiological lesions more aggressive, negativation of BK in sputum later, and reactivation of CPT more frequent.

Nocturnal Continuous Positive Airway Pressure (nCPAP) Decreases High-Sensitivity C-Reactive Protein (hs-CRP) in Obstructive Sleep Apnea-Hypopnea Syndrome.

BACKGROUND: Systemic and airway inflammation has recently been linked to obstructive sleep apnea-hypopnea syndrome (OSAHS) and is considered to be a probable risk factor for OSAHS-induced cardiovascular damage. High-sensitivity C-reactive protein (hs-CRP), as an inflammatory mediator, may be useful for the prediction of the risk of cardiovascular disease (CVD) and assessment of nocturnal continuous positive airway pressure (nCPAP) therapy effect in OSAHS patients. METHODS: A prospective, controlled, cross-sectional study was conducted on 64 consecutive adult subjects with suspected sleep-disordered breathing (SDB). RESULTS: OSAHS was confirmed in 43 patients (24 normotensive and 19 hypertensive patients) and ruled out in 21 normotensive subjects (controls). The median plasma level of hs-CRP did not differ significantly between OSAHS patients and controls. It showed an unmarked rise with the severity of OSAHS (p = 0.20) and was not correlated with AHI (p = 0.067; r = 0.28). After adjusting for cervical perimeter (CP), waist-to-hip ratio (WHR), and blood sugar level, hs-CRP level of 1 mg/dL or greater was significantly more often observed in OSAHS patients compared with controls (p = 0.032; OR = 5.60) and was also significantly associated with AHI (p = 0.021). A significant decrease in the median plasma hs-CRP level was observed in CPAP compliant patients (p = 0.006). Of those, only normotensive patients showed a significant decrease in plasma hs-CRP level. In hypertensive ones, however, the hs-CRP level dropped but not significantly. Using a linear regression model, the change in hs-CRP level (Δhs-CRP) following a 6-month-nCPAP therapy was found to positively correlate with the baseline hs-CRP level for both hypertensive (p = 0.02; r = 0.68), and even more normotensive OSAHS patients (p < 0.0001; r = 0.89). CONCLUSION: nCPAP therapy may have a cardiovascular protective effect in OSAHS patients. hs-CRP level would be useful as a valuable predictor of success in OSAHS treatment monitoring.

Vitamin D supplementation to prevent COVID-19 in patients with COPD: a research perspective.

There is increased evidence that the massive release of pro-inflammatory cytokines leading to the cytokine storm syndrome shapes the evolution of COVID-19 and is responsible of the severity of COVID-19 in some patients. A recent review argued that vitamin D deficiency could have increased the COVID-19 outbreak and suggested vitamin D supplementation as a preventive action. In fact, many factors seem to be correlated both to low vitamin D levels and the importance of COVID-19 spreading and severity. It is also important to highlight that the lockdown, implemented in many countries, prevents people to go out and then increases the risk of vitamin D deficiency. COPD patients are particularly at risk to have low levels of vitamin D due to multiple risk factors. COPD may generate a systemic inflammatory process responsible of secondary extra-pulmonary impairments. Vitamin D deficiency could sustain and aggravate the systemic inflammation associated to COPD. Reports have also shown that vitamin D deficiency was associated to exacerbations and hospital admissions, as well as lung function. Recent research showed that vitamin D supplementation significantly reduced COPD exacerbations. Although vitamin D deficiency was not proved to be neither a risk factor of COVID-19, nor a determinant of its severity, vitamin D supplementation represents a preventive perspective that needs to be further studied.

Coexisting central and obstructive sleep apnea and mild diurnal hypoventilation associated with unilateral diaphragmatic dysfunction and brainstem lesion.

A 63-year old man was diagnosed with coexisting central (CSA) and obstructive (OSA) sleep apnea, crescendo-decrescendo (CD) periodic breathing (PB), frequent sustained desaturation hypoxemia events related to prolonged hypopnea and mild diurnal hypoventilation. Unilateral diaphragmatic dysfunction (DD) related to diabetic phrenic neuropathy was identified. Magnetic resonance imaging (MRI) scans of the head disclosed frontal-subcortical white matter (WM) lesions, while brainstem MRI found a small punctiform defect in the median area of the pons. Continuous positive airway pressure (CPAP) therapy was ineffective, while a one-month bi-level positive airway pressure (BIPAP) trial provided better outcomes.