Diagnosis and Management of Acute Respiratory Failure.

Acute hypoxemic respiratory failure is defined by Pao2 less than 60 mm Hg or SaO2 less than 88% and may result from V/Q mismatch, shunt, hypoventilation, diffusion limitation, or low inspired oxygen tension. Acute hypercapnic respiratory failure is defined by Paco2 ≥ 45 mm Hg and pH less than 7.35 and may result from alveolar hypoventilation, increased fraction of dead space, or increased production of carbon dioxide. Early diagnostic maneuvers, such as measurement of SpO2 and arterial blood gas, can differentiate the type of respiratory failure and guide next steps in evaluation and management.

Barriers to Timely Lung Cancer Care in Early Stage Non-Small Cell Lung Cancer and Impact on Patient Outcomes.

BACKGROUND: Optimal time to treatment for early-stage lung cancer is uncertain. We examined causes of delays in care for Veterans who presented with early-stage non-small cell lung cancer (NSCLC) and whether workup time was associated with increased upstaging or all-cause mortality. METHODS: We performed a retrospective analysis of Veterans referred to our facility with radiographic stage I or II NSCLC between January 2013 to December 2017, with follow-up through October 2021. Patient demographics, tumor characteristics, time intervals of care, and reasons for delays were collected. Guideline concordance (GC) was defined as treatment within 14 weeks of abnormal image. Multivariable analyses were performed to determine association between delays in care, survival, and upstaging. RESULTS: Data from 203 Veterans were analyzed. Median time between abnormal imaging to treatment was 17.7 weeks (IQR 12.7-26.6). Only 33% of Veterans received GC care. Most common patient-related delays were: intercurrent hospitalization/comorbidity (23%), no-shows (16%) and inability to reach Veteran (17%). Most common system-related delay: lack of scheduling availability (25%). Delays associated with upstaging: transportation issues, request for coordination of appointments, and unforeseen appointment changes. Rates of upstaging did not differ between GC and discordant groups (P = .6). GC care was not an independent predictor of mortality. Post-hoc, treatment within 8 weeks was associated with lower rates of upstaging (P = .05). CONCLUSION: Although GC care did not impact survival or upstaging for early-stage NSCLC, shorter timeframes may be beneficial. Modifiable delays in care exist which may be addressed at an institutional level to improve timeliness of care.

Sources of Joy In Medical Educators as Described by the PERMA Model.

Phenomenon: Burnout is prevalent amongst long-practicing physicians. For medical educators, it has deleterious effects not only on the educator themselves, but also the students they are teaching. Though significant research has focused on factors associated with burnout, there is limited understanding of its counter: how physicians, particularly medical educators, derive joy from their work. Approach: This qualitative study included 15 highly-rated clinician educators in Internal Medicine who took part in individual semi-structured interviews. Participants were invited to discuss their sources of professional joy. After transcription, we used thematic content analysis: 50 themes were identified. Themes were then coded using the domains of the PERMA (Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment) model of positive psychology, assigning each theme a best fit domain. Forty-five themes were mapped into the PERMA model. Findings: When describing professional joy, highly-rated clinician educators displayed high levels of overlap with all domains of the PERMA model. Interaction with the learner was a prominent source of professional joy, particularly within Positive Emotion, Engagement, and Relationship domains. Insights: Our findings indicate that the PERMA model appropriately defines the sources of professional joy for these educators. Future research could employ this model to identify targets for interventions aimed at amplifying joy at work for this group.

Comparison of clinical outcomes following minimally invasive lateral interbody fusion stratified by preoperative diagnosis.

PURPOSE: Lumbar fusion has been shown to be effective in treating a variety of degenerative spinal conditions, though significant differences exist in the magnitude of clinical improvement across different surgical diagnoses. With modern, minimally disruptive approaches for fusion, diagnosis-specific differences in clinical improvement may be reduced. The purpose of this study is to report and compare interim clinical improvements in patients treated with XLIF for various degenerative lumbar conditions. METHODS: 160 patients underwent XLIF for either degenerative spondylolisthesis (n = 68), degenerative disc disease (n = 20), adjacent segment disease (n = 26), or post-laminectomy syndrome (n = 46). Average age was 61 years and 66 % were female. Mean BMI was 28.9 kg/m(2). 37 % were smokers, 23 % had diabetes mellitus, 22 % had depression. Mean age was highest for ASD patients (66 years) and lowest for DDD patients (48 years) (p < 0.001). There were no other baseline demographic differences between groups. Patient-reported clinical outcomes measures were collected at baseline and prospectively at standard intervals. Interim results at an average of 19 months follow-up are reported here. RESULTS: In total, 197 levels were treated with XLIF (mean 1.2 per patient). There were no cases of symptomatic pseudoarthrosis or implant/instrument failure. Overall, 1 patient (0.6 %) had a major complication and 12 % had a minor complication. Approach-related anterolateral thigh/groin sensory changes were present in 14 % and hip flexion weakness in 9 %. At last follow-up, overall ODI decreased 47 % (44.1-23.5), VAS LBP decreased 59 % (6.9-2.8), VAS LP decreased 56 % (7.1-3.1), and SF-36 PCS improved 40 % (30.9-43.2) (all p < 0.001). Baseline ODI was significantly lower for DDD patients (p = 0.052). At last follow-up, mean percent improvements on all outcomes were highest for DSP group, though not all differences were significant. Improvements between diagnostic groups were statistically different for LBP (p = 0.021), but were similar for all other clinical outcomes. Percentage of patients reaching MCID and SCB thresholds ranged from 60 to 95 % in clinical outcomes. Patient satisfaction for the entire group was 93 % when asked whether satisfied with surgical outcome. CONCLUSIONS: XLIF has been demonstrated in the current series to lead to significant improvements in clinical outcomes and high rates of MCID and SCB and reduce the discrepancy in outcomes between well accepted and technically challenging indications compared to traditional open approaches for IBF. Complication rates were low, with only one patient in the series experiencing a major complication. Further investigation with larger cohorts and longer follow-up is warranted.