Development and evaluation of the Indian Sleepiness Scale to assess excessive daytime sleepiness in patients with Obstructive Sleep Apnea.

Background: Excessive daytime sleepiness (EDS), a cardinal symptom of obstructive sleep apnea (OSA) is assessed using Epworth Sleepiness Scale (ESS). Some limitations of ESS include graded responses, inapplicable situations and equal scores for active and passive situations. To overcome these limitations, we developed a novel sleepiness scale and evaluated its performance in patients with OSA. Methods: The study was executed in multiple phases. After determining applicability of items in the ESS, a 6-item questionnaire was developed comprising OSA symptoms and self-reported 'sleepy' situations, dichotomized responses and weighted scoring. After content and face validation by experts, the scale was tested for applicability and its performance was compared with ESS in patients with suspected OSA. Results: In phase I, applicability of ESS was tested in 189 participants, of whom 98 (51.8 %) participants found multiple items inapplicable.In phase II, 34 self-reported sleepy situations from 200 participants were narrowed down to a 6-item questionnaire, based on expert validation. This scale was named the Indian Sleepiness Scale (ISS) and was tested for applicability in phase III in 226 participants from diverse literacy backgrounds, who found all situations applicable.In phase IV, ISS and ESS were administered to 335 patients with suspected OSA. OSA was confirmed on polysomnography in 294 (87.7 %) patients. A cut-off score of ≥6 was derived for ISS; at this cut-off score, the ISS which was more sensitive than ESS (71.1 % vs 43.2 %). Conclusions: The Indian Sleepiness Scale was found to be widely applicable and more sensitive than ESS for sleepiness evaluation in patients with OSA.

Mediastinal hematoma following thrombolysis for acute pulmonary thromboembolism.

Massive pulmonary thromboembolism (PE) is a cardiorespiratory emergency and can be fatal if left untreated. The recommended treatment for PE in the presence of right ventricular dysfunction and hemodynamic instability is thrombolysis. However, the latter is a double-edged sword as life-threatening bleeding manifestations can occur post-thrombolysis. Timely identification and management of these complications can prevent a catastrophic outcome. We report a case of mediastinal hematoma with new onset hemodynamic compromise following thrombolysis for acute massive pulmonary embolism. Clinico-radiological features and Point of Care Ultrasound (POCUS) findings helped in the identification of the bleeding site in our case. Despite early diagnosis and timely intervention, the patient succumbed to secondary complications.

Identifying phenotypes of obstructive sleep apnea using cluster analysis.

PURPOSE: Over the last decade, advances in understanding the pathophysiology, clinical presentation, systemic consequences and treatment responses in obstructive sleep apnea (OSA) have made individualised OSA management plausible. As the first step in this direction, this study was undertaken to identify OSA phenotypes. METHODS: Patients diagnosed with OSA on level 1 polysomnography (PSG) were included. Clinical and co-morbidity profile, anthropometry and sleepiness scores were compiled. On PSG, apnea-hypopnea index, positional indices, sleep stages and desaturation indices (T90) were tabulated. Cluster analysis was performed to identify distinct phenotypes among included patients with OSA. RESULTS: One hundred patients (66 males) with a mean age of 49.5 ± 13.3 years were included. Snoring was reported by 94% subjects, and 50% were excessively sleepy. Two-thirds of subjects had co-morbidities, the most frequent being hypertension (55%) and dyslipidemia (53%). Severe OSA was diagnosed on PSG in 42%, while 29% each had mild and moderate OSA, respectively. On cluster analysis, 3 distinct clusters emerged. Cluster 1 consisted of older, obese subjects with no gender predilection, higher neck circumference, severe OSA with more co-morbidities and higher T90. Cluster 2 comprised of younger, less obese males with snoring, witnessed apnea, moderate and supine predominant OSA. Cluster 3 consisted of middle-aged, obese males with lesser co-morbidities, mild OSA and lower T90. CONCLUSIONS: This study revealed three OSA clusters with distinct demographic, anthropometric and PSG features. Further research with bigger sample size and additional parameters may pave the way for characterising distinct phenotypes and individualising OSA management.

Missing the Forest for the Trees - A Rare Cause of Pleural Effusion.

Neurofibromatosis type 1 (NF-1) is a genetic disorder associated with dermatological, musculoskeletal, and neurological features. Apart from these, knowledge of other uncommon manifestations, including intrathoracic and pulmonary involvement, is crucial for early diagnosis and treatment. These patients are predisposed to various sarcomatous and non-sarcomatous malignancies. We report the case of an elderly lady with NF-1 who presented with pleural effusion related to the genetic disorder, which was missed, and elaborate on the diagnostic workup done to reach a diagnosis.

Case of melioidosis misdiagnosed as pulmonary tuberculosis.

Melioidosis is an endemic infection caused by Burkholderia pseudomallei predominantly reported in the coastal parts of India. A 19-year-old male student with no comorbidities presented with features suggestive of pneumonia. He was initiated on antitubercular treatment empirically elsewhere. However, due to lack of response to therapy diagnosis was revisited. Microbiological investigations were unyielding initially. Despite antitubercular treatment, he presented with complications of pneumonia and was diagnosed to have melioidosis. He was initiated on appropriate antibiotics for the intensive and eradication phase. Obtaining microbiological confirmation is of utmost importance to prevent misdiagnosis and undue morbidity and mortality due to these uncommon infections.

A simple x-ray scoring system for the diagnosis of chronic pulmonary aspergillosis.

BACKGROUND: Chronic pulmonary aspergillosis (CPA) is a severe form of post-tuberculosis lung disease (PTBLD). Considering the high burden of TB in India, it can be concluded that the prevalence of CPA is also high. Chest x-ray though most feasible, interpretation is subjective. Therefore, decision on evaluation for CPA cannot be based on x-ray alone. OBJECTIVE: Present study evaluated an x-ray score as a marker for extent of lung damage in patients with PTBLD presenting with haemoptysis and its utility to predict Aspergillus serum IgG levels. METHODS: We used a modified scoring system developed by Anna Ralph et al X-ray score cut-offs of >71 and 40, with or without history of massive haemoptysis, were compared with serum IgG levels. RESULTS: With a chest x-ray score cut-off of 71, specificity was 88%. With an x-ray score of >71 combined with history of massive haemoptysis, 86% cases were found to be IgG positive. The specificity of this combination was 96%. CONCLUSION: This study concluded that a simple chest x-ray scoring system in addition to the symptom of massive haemoptysis helped in the decision on further evaluation of the subject for CPA, especially in resource constrained settings.

The effect of CPAP therapy on excessive daytime sleepiness and quality of life in subjects with obstructive sleep apnoea: an AB design study.

BACKGROUND: Obstructive sleep apnoea (OSA) is a disorder characterized by apnoeas and hypopnoeas due to repetitive upper airway collapse during sleep. So far, there are no published data regarding quality of life (QoL) and adherence to CPAP among patients with OSA in India. This study aims to measure sleepiness and QoL of patients before and after effective CPAP use in patients with OSA. METHOD: Newly diagnosed subjects with OSA were included, and socio-demographic risk factors and anthropomorphic measures were collected. Epworth sleepiness scale (ESS) and short sleep apnoea quality of life index (SAQLI) were administered before and after a minimum of 4 weeks of domiciliary CPAP use. While short SAQLI is a disease-specific questionnaire, ESS measures excessive daytime sleepiness. RESULTS: In 92 subjects age range was 28-74 years, mean age 49.7 ± 11.3 years, and male:female ratio was 70:22. Mean BMI was 32.1 ± 6.4 kg/sq.m; mean neck circumference was 39.4 ± 3.4 cm; 56 subjects had Mallampati score of 3 or 4. One-month follow-up was completed by 34 subjects who reported a mean of 5.8 ± 1.1 hours/night usage of CPAP. Mean ESS score was 11.31 ± 5.6 at baseline vs 6.9 ± 3.3 after 1 month (p = 0.02), and baseline short SAQLI score was at 2.54 ± 1.26 vs 1.38 ± 0.87 after 1 month (p = 0.0001). CONCLUSIONS: Subjects reported adequate compliance with CPAP at 1 month, and both ESS and short SAQLI showed a significant improvement in these patients. CPAP compliance improved both QoL and sleepiness in patients with OSA.

E-cigarettes: Out of the frying pan into the fire?

Electronic nicotine delivery systems were developed over a decade ago to simulate the experience of smoking, although with a lower exposure to toxins than in conventional smoking. However, they have their own unique profile of side effects, some of which can be life threatening. We report the case of a young male, who in a desperate bid to de-addict himself from smoking developed a serious adverse effect related to the e-cigarettes.