Chronic obstructive pulmonary disease (COPD) causes respiratory muscle weakness that leads to disabling dyspnea and poor functional performance. Therapies are often geared to improve inspiratory muscle performance. Yoga has been shown to improve exercise capacity, quality of life, and some pulmonary function measures in COPD, but little research has examined the effects of yoga training on inspiratory muscle performance. The purpose of this study was to investigate the effects of yoga training on inspiratory muscle performance in military veterans using the Test of Incremental Respiratory Endurance (TIRE). A prospective pilot study examined a 6-week yoga training program consisting of asana (poses) and pranayama (controlled breathing). Subjects had baseline inspiratory muscle weakness. The TIRE measured inspiratory muscle performance via the PrO2 device, providing maximal inspiratory pressure, sustained maximal inspiratory pressure, and inspiratory duration. Secondary measures included 6-minute walk distance, St. George Respiratory Questionnaire, Hospital Anxiety and Depression Scale, and spirometry. Mean age and BMI of subjects were 67 ± 3.6 years and 20.7 ± 3.3, respectively. The majority of subjects had severe (28.7%) or very severe (57.1%) COPD. Statistically significant improve m e n t s were seen in maximal inspiratory pressure (39.0 ± 14.1 cmH2O to 56.4 ± 20.6 cmH2O) and sustained maximal inspiratory pressure (244.1 ± 100.6 PTU to 308.1 ± 121.2 PTU). No statistically significant improvements we re observed in 6-minute walk distance, St. George Respiratory Questionnaire, Hospital Anxiety and Depression Scale, or spirometry. Yoga training has the potential in improve inspiratory muscle performance in veterans with severe to very severe COPD who present with inspiratory muscle weakness. This is of importance because improving inspira-tory muscle performance has been shown to improve COPD outcomes.

Coronavirus disease 2019 (COVID-19) continues to be fatal despite advances in the understanding of characteristics of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), global prevention strategies, new anti-viral treatments, and worldwide vaccination programs. The exact underlying mechanism through which SARS-CoV-2 leads to acute respiratory distress syndrome (ARDS) resulting in intensive care unit admission, mechanical ventilation, and eventually death remains elusive. Cytokine storm is one of the most favorable mechanisms that scientists show remarkable interest to target in randomized clinical trials with promising outcomes. Macrophage activation syndrome (MAS), the most serious form of cytokine storm, requires early recognition and treatment regardless of etiology. Here, we report a 59-year-old gentleman with a COVID-19 infection complicated by MAS. Our aim is to increase awareness of this condition among health care providers as it necessitates prompt diagnosis and treatment due to an extremely poor prognosis.

Background: Implantable cardioverter-defibrillators (ICDs) are endorsed by the current American Heart Association (AHA) Guidelines as the cornerstone in the primary prevention of mortality in patients with reduced ejection fraction (EF) (≤35%). The timing for ICD therapy in non-ischemic cardiomyopathy (NICM) is not specified in the current guidelines. The objective of this study was to determine the timing for ICD insertion for patients with NICM versus ICM in the real-world population. Methods: Retrospective design study of patients with ICDs implantation from 2019 to 2022 at our community hospital. Data was obtained via the Device Implant Registry. All eligible participants had confirmed diagnosis of ICM and NICM on chart review; while confirmed EF≤35% on echocardiography. Categorical predictors and clinical outcomes were analyzed using Pearson’s chi-square test or Fisher’s exact test. Quantitative predictors and clinical outcomes were analyzed using Student's t-test or the Wilcoxon rank sum test. Results: Our cohort included 62 patients undergoing ICD placement for primary prevention. There was no statistical significance between patients based on age, sex, race, and EF. Average time to ICD placement was 134 days for patients with ICM and 274 days for patients with NICM, a difference that favoured NICM; p =0.009 ( p <0.05). In the majority of patients, 64.5%, ICD implantation was deferred for at least 90 days compared to 35.5% patients who had an ICD placed by 90 days; p =0.001 ( p <0.05). The mortality in our study was 13% over a median of 2 years, with a predominance of ICM as compared to NICM, 75% versus 25%, respectably. Logistics regression demonstrated that timing to ICD implantation was not an independent variable of mortality. The mean overall survival was 274.4 days (SD +/- 50) in NICM compared to 134.3 days (SD +/- 21) in the ICM group, p =0.007 ( p <0.05). Conclusions: In a real-world population, time to ICD implantation was statistically different in ICM compared to NICM. ICM remains a significant risk of all-cause mortality despite the progress made in both medical and procedural treatments. Further studies are necessary to determine the appropriate time to ICD implantation in patients with NICM and reduced EF.

Introduction: The positive impact of resident-driven synthesis of assessment data has been associated with increased intrinsic motivation to learn and create an individualized strategy to improve performance. The objective of the study was to incorporate residents' recommendations for restructuring the self-assessment metric into a tool that will promote a well-organized and effective self-improvement plan.Materials and methods: Residents and faculty collaborated on pre-and post-intervention questionnaires to assess the barriers to the timely completion of the current self-evaluation form and gather information on the tool's ability to stimulate the formation of concrete goals. The residents were also invited to provide their recommendations on the structure of the new tool and the educational domains that were assessed by the tool. The post-survey also evaluated the capacity of the proposed tool to guide residents in establishing specific goals.Results: The new form is concise and more precise in assisting the learner in developing short-term and long-term goals and the strategies and resources to achieve them. Discussion: Collaborating with the learners created an opportunity to address the faculty's and residents' most important concerns about the effectiveness of the metric. Conclusion:In a learner-centered model, resident participation is critical in designing/redesigning a practical self-assessment tool for residents in Internal Medicine.

Although melanoma starts as a local disease, it can metastasize to other sites of the body including the lung, brain, liver, and intestines. However, pleural involvement is a rare presentation. Here, we present a case of a 57-year-old man with a history of stage IIA cutaneous melanoma, that relapsed 3 years after cutaneous resection, presenting with a non-resolving pleural effusion. Pleural fluid analysis was consistent with an exudative effusion, and pleural biopsy confirmed metastatic melanoma. The patient was treated with dual therapy of ipilimumab and nivolumab, as per National Comprehensive Cancer Network guidelines, with good response. Thus, we recommend having a high index of clinical suspicion for metastatic pleural melanoma when a patient with a history of cutaneous melanoma presents with a non-resolving pleural effusion.