Hypertension develops in 10% of pregnancies. Snoring, a marker of obstructive sleep apnoea, is a newly identified risk factor for gestational hypertension. Moreover, obstructive sleep apnoea is an independent risk factor for incident hypertension in the non-pregnant population. The aim of the present study was to test the hypothesis that obstructive sleep apnoea is associated with new onset of hypertension among pregnant females.A case-control study was performed involving 17 pregnant females with gestational hypertension and 33 pregnant females without hypertension. Subjects were frequency-matched for gestational age and recruited in a tertiary obstetrical centre. Obstructive sleep apnoea was ascertained by polysomnography and defined by an apnoea/hypopnoea index (AHI) of o15 events?h -1 , without requirement for desaturation. The mean¡SD AHI for normotensive pregnant females was 18.2¡12.2 events?h -1 compared with 38.6¡36.7 events?h -1 for females with hypertensive pregnancies. The crude odds ratio for the presence of obstructive sleep apnoea given the presence of gestational hypertension was 5.6. The odds ratio was 7.5 (95% confidence interval 3.5-16.2), based on a logistic regression model with adjustment for maternal age, gestational age, pre-pregnancy body mass index, prior pregnancies, and previous live births.In conclusion, gestational hypertension appears to be strongly associated with the presence of obstructive sleep apnoea.

The rates of sustained use of continuous positive airway pressure (CPAP) therapy among adults with obstructive sleep apnea (OSA) appear consistently suboptimal, despite the efficacy of this treatment. Using semistructured interviews, this study identified facilitators and barriers toward CPAP therapy after treatment initiation among patients with OSA. A purposive sample of eight patients representing extreme differences in CPAP use was recruited from a multisite sleep disorders clinic at a tertiary health center. Perceived physical, psychological, and social factors were found to influence both CPAP use and nonuse. It was revealed that the way patients feel about themselves influences the ways in which they manage their OSA with or without CPAP. This study underlines the necessity of working with patients and their families to create social environments that are both accepting and supportive of patients with OSA.

Background: Ehlers-Danlos Syndromes (EDS) and Hypermobility Spectrum Disorders (HSD) are a heterogeneous group of heritable genetic connective tissue disorders with multiple characteristics including joint hypermobility, tissue fragility, and multiple organ dysfunction. Respiratory manifestations have been described in EDS patients, but have not been systematically characterized. A narrative review was undertaken to describe the respiratory presentations and management strategies of individuals with EDS and HSD. Methods: A broad literature search of Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL was undertaken from inception to November 2020 of all study types, evaluating EDS/ HSD and pulmonary conditions. This narrative review was limited to adult patients and publications in English. Results: Respiratory manifestations have generally been described in hypermobile EDS (hEDS), classical and vascular EDS subtypes. Depending on EDS subtype, they may include but are not limited to dyspnea, dysphonia, asthma, sleep apnea, and reduced respiratory muscle function, with hemothorax and pneumothorax often observed with vascular EDS. Respiratory manifestations in HSD have been less frequently characterized in the literature, but exertional dyspnea is the more common symptom described. Respiratory symptoms in EDS can have an adverse impact on quality of life. The respiratory management of EDS patients has followed standard approaches with thoracotomy tubes and pleurodesis for pleural manifestations, vocal cord strengthening exercises, continuous positive pressure support for sleep apnea, and exercise training. Reduced respiratory muscle function in hEDS patients responds to inspiratory muscle training. Conclusion: Respiratory symptoms and manifestations are described in EDS and HSD, and have generally been managed using conservative non-surgical strategies. Research into the prevalence, incidence and specific respiratory management strategies in EDS and HSD is needed to mitigate some of the associated morbidity.

Background With ongoing COVID-19 vaccination schedules and the popularity of cosmetic fillers, it is important to examine and record associated adverse reactions to a more general audience of health care professionals. Case reports exist in subspecialty journals outlining reactions after SARS-CoV-2 infection and vaccination. This is one of the first cases published in Canada, and it highlights priorities and challenges faced by physicians in assessing and managing patients presenting with adverse reactions post vaccination. Case Presentation We present a case of a 43 -year-old women with delayed type 4 hypersensitivity reaction to hyaluronic acid cosmetic filler triggered by COVID-19 mRNA vaccination. We outline the clinical presentation, diagnosis, complications, and treatment of a late inflammatory reaction to hyaluronic acid filler and highlight the treatment priorities for clinicians faced with similar presentations. Conclusion The differential diagnosis of delayed onset nodules formation post filler injection is broad and includes redistribution of fillers, inflammatory reaction to biofilm, and delayed hypersensitivity reaction. As result, in order to make the right diagnosis, administer the appropriate treatment and achieve great cosmetic results, we highly recommend seeking expert opinion from dermatologist, plastic surgeon and allergist immunologist in a timely manner.

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BACKGROUND Introduction: Dyspnea is a prevalent symptom for individuals with hypermobile Ehlers-Danlos Syndrome (hEDS) and generalized hypermobility spectrum disorder (G-HSD). The characteristics and contributors to dyspnea in hEDS/G-HSD have not been well elucidated. One known contributor to dyspnea is respiratory muscle weakness. The feasibility and effectiveness of inspiratory muscle training (IMT) in combination with standard of care rehabilitation (aerobic, resistance, neuromuscular stabilization, and balance and proprioception exercises) to improve respiratory muscle strength and related patient-reported outcomes in hEDS/G-HSD patients have not been evaluated. OBJECTIVE Objectives: 1) To evaluate dyspnea, respiratory muscle strength, and patient-reported outcome measures (PROMs) in hEDS/G-HSD compared to healthy controls, and 2) to assess the feasibility of a randomized control trial of IMT and standard of care rehabilitation to improve respiratory muscle strength, exercise capacity and PROMs compared to standard of care rehabilitation in hEDS/G-HSD. METHODS Methods: The study will include 34 hEDS/G-HSD participants from the EDS rehabilitation program at Toronto General Hospital and 17 healthy, age-sex matched controls for comparison of respiratory muscle structure and function and PROMs. After baseline assessments, hEDS/G-HSD participants will be randomized into IMT combined with EDS standard of care rehabilitation (intervention group) versus standard of care rehabilitation (usual care) for 8 weeks. The intervention group will be prescribed IMT in the home environment using the POWERbreathe®K5 IMT device. IMT will comprise of 2 daily sessions, 5 days per week of 30 breaths, with IMT progressing from 20% to 60% of baseline maximal inspiratory pressure (MIP) over an 8-week period. Feasibility will be assessed through rates of recruitment, attrition, adherence, and adverse events, as well as participant satisfaction. The primary pilot outcome will be MIP change over an 8-week period in hEDS/G-HSD. Secondary outcomes will include evaluation of dyspnea (Medical Research Council Scale and 18-point Qualitative Dyspnea Descriptors), diaphragmatic thickening fraction with ultrasound, respiratory muscle endurance, pulmonary function including oscillometry, pre-frontal cortical activity using functional near-infrared spectroscopy and aerobic capacity during cardiopulmonary exercise testing, quality of life (Short Form-36), and scores from the depression, anxiety and stress scale (DASS-21). These measures will also be performed once in healthy controls for comparison of normative values. Multivariable regression will be used to assess the contributors to dyspnea. Paired-t-tests will be utilized to assess the change in MIP and secondary measures with 8 weeks of IMT. RESULTS Results: Study recruitment began in August 2021, with several disruptions due to COVID-19, and is expected to be completed by December 2023. CONCLUSIONS Conclusion: This study will provide a better understanding of the factors associated with dyspnea and the feasibility and effectiveness of IMT combined with standard of care rehabilitation. IMT may be a novel therapeutic strategy to improve respiratory muscle function and patient reported outcomes in individuals with hEDS/G-HSD. CLINICALTRIAL ClinicalTrials.gov (NCT04972565)

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