Obstructive sleep apnea (OSA) is a highly prevalent disorder that has profound implications on the outcomes of patients with chronic lung disease. The hallmark of OSA is a collapse of the oropharynx resulting in a transient reduction in airflow, large intrathoracic pressure swings, and intermittent hypoxia and hypercapnia. The subsequent cytokine-mediated inflammatory cascade, coupled with tractional lung injury, damages the lungs and may worsen several conditions, including chronic obstructive pulmonary disease, asthma, interstitial lung disease, and pulmonary hypertension. Further complicating this is the sleep fragmentation and deterioration of sleep quality that occurs because of OSA, which can compound the fatigue and physical exhaustion often experienced by patients due to their chronic lung disease. For patients with many pulmonary disorders, the available evidence suggests that the prompt recognition and treatment of sleep-disordered breathing improves their quality of life and may also alter the course of their illness. However, more robust studies are needed to truly understand this relationship and the impacts of confounding comorbidities such as obesity and gastroesophageal reflux disease. Clinicians taking care of patients with chronic pulmonary disease should screen and treat patients for OSA, given the complex bidirectional relationship OSA has with chronic lung disease.

Background: Immersive virtual reality (VR) is a promising therapy to improve the experience of patients with critical illness and may help avoid postdischarge functional impairments. However, the determinants of interest and usability may vary locally and reports of uptake in the literature are variable. Objective: The aim of this mixed methods feasibility study was to assess the acceptability and potential utility of immersive VR in critically ill patients at a single institution. Methods: Adults without delirium who were admitted to 1 of 2 intensive care units were offered the opportunity to participate in 5-15 minutes of immersive VR delivered by a VR headset. Patient vital signs, heart rate variability, mood, and pain were assessed before and after the VR experience. Pre-post comparisons were performed using paired 2-sided t tests. A semistructured interview was administered after the VR experience. Patient descriptions of the experience, issues, and potential uses were summarized with thematic analysis. Results: Of the 35 patients offered the chance to participate, 20 (57%) agreed to partake in the immersive VR experience, with no difference in participation rate by age. Improvements were observed in overall mood (mean difference 1.8 points, 95% CI 0.6-3.0; P=.002), anxiety (difference of 1.7 points, 95% CI 0.8-2.7; P=.001), and pain (difference of 1.3 points, 95% CI 0.5-2.1; P=.003) assessed on 1-10 scales. The heart rate changed by a mean of –1.1 (95% CI –0.3 to –1.9; P=.008) beats per minute (bpm) from a baseline of 86.1 (SD 11.8) bpm and heart rate variability, assessed by the stress index (SI), changed by a mean of –5.0 (95% CI –1.5 to –8.5; P=.004) seconds–2 from a baseline SI of 40.0 (SD 23) seconds–2. Patients commented on the potential for the therapy to address pain, lessen anxiety, and facilitate calmness. Technical challenges were minimal and there were no adverse effects observed. Conclusions: Patient acceptance of immersive VR was high in a mostly medical intensive care population with little prior VR experience. Patients commented on the potential of immersive VR to ameliorate cognitive and emotional symptoms. Investigators can consider integrating minimally modified commercial VR headsets into the existing intensive care unit workflow to further assess VR’s efficacy for a variety of endpoints.

Objective: To provide medical kit recommendations for short mountain wilderness recreation trips (hiking, trekking, backpacking, mountaineering etc.) based on the epidemiology of injury and illness sustained and best treatment guidelines. Additionally, to compare these recommendations to the medical kit contents of mountain climbers in Colorado. Methods: A primary literature review concerning the epidemiology of injury and illness in mountain wilderness settings was performed. This information and literature on the efficacy of given treatments were used to derive recommendations for an evidence-based medical kit. The contents of 158 medical kits and the most likely demographics to carry them were compiled from surveys obtained from mountain climbers on 11 of Colorado’s 14 000-foot peaks. Results: Musculoskeletal trauma, strains, sprains and skin wounds were the most common medical issues reported in the 11 studies, which met inclusion criteria. Adhesive bandages (Band-Aids) were the most common item and non-steroidal anti-inflammatory drugs were the most common medication carried in medical kits in Colorado. More than 100 distinct items were reported overall. Conclusion: Mountain climbing epidemiology and current clinical guidelines suggest that a basic mountain medical kit should include items for body substance isolation, materials for immobilization, pain medications, wound care supplies, and medications for gastrointestinal upset and flu-like illness. The medical kits of Colorado mountain climbers varied considerable and often lacked essential items such as medical gloves. This suggests a need for increased guidance. Similar methodology could be used to inform medical kits for other outdoor activities, mountain rescue personnel, and travel to areas with limited formal medical care.

Article Citation: Marja Anton, Josephine Wright, Matthew Braithwaite, Greg Sturgeon, Brian Locke, Caroline Milne, and Aaron Crosby (2020) Creating a COVID-19 Action Plan for GME Programs. Journal of Graduate Medical Education In-Press. https://doi.org/10.4300/JGME-D-20-00206.1