A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit.

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

DAPK-ZIPK-L13a axis constitutes a negative-feedback module regulating inflammatory gene expression.

Phosphorylation of ribosomal protein L13a is essential for translational repression of inflammatory genes by the interferon (IFN)-gamma-activated inhibitor of translation (GAIT) complex. Here we show that IFN-gamma activates a kinase cascade in which death-associated protein kinase-1 (DAPK) activates zipper-interacting protein kinase (ZIPK), culminating in L13a phosphorylation on Ser(77), L13a release from the ribosome, and translational silencing of GAIT element-bearing target mRNAs. Remarkably, both kinase mRNAs contain functional 3'UTR GAIT elements, and thus the same inhibitory pathway activated by the kinases is co-opted to suppress their expression. Inhibition of DAPK and ZIPK facilitates cell restoration to the basal state and allows renewed induction of GAIT target transcripts by repeated stimulation. Thus, the DAPK-ZIPK-L13a axis forms a unique regulatory module that first represses, then repermits inflammatory gene expression. We propose that the module presents an important checkpoint in the macrophage "resolution of inflammation" program, and that pathway defects may contribute to chronic inflammatory disorders.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice.

BACKGROUND: Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION: How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? STUDY DESIGN AND METHODS: This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS: We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION: Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Pulmonary Critical Care Fellows' Use of and Self-reported Barriers to Learning Bedside Ultrasound During Training: Results of a National Survey.

BACKGROUND: Competence in ultrasonography is essential for pulmonary and critical care medicine (PCCM) fellows, but little is known about fellow-reported barriers to acquiring this crucial skill during fellowship training. RESEARCH QUESTION: How do PCCM fellows acquire experience performing and interpreting ultrasonography during their training, what is their perspective on barriers to acquiring ultrasound expertise during fellowship, and what is their comfort with a range of ultrasound examinations? STUDY DESIGN AND METHODS: A 20-item survey including questions about procedural training and acquisition of ultrasound skills during PCCM fellowship was developed. The survey instrument was sent to PCCM fellowship program directors to distribute to their fellows at program directors' discretion. RESULTS: Four hundred seventy-five responses were received. The most common method of learning ultrasonography was performing it independently at the bedside. Fellows reported that the greatest barrier to acquiring ultrasound skills was the lack of trained faculty experts, followed by lack of a formal curriculum. Fellow comfort was greatest with thoracic ultrasound and least with advanced cardiac ultrasound. INTERPRETATION: Significant barriers to ultrasound training during PCCM fellowship exist, and future educational efforts should address these barriers at both program and institutional levels.

Learning without Borders: Asynchronous and Distance Learning in the Age of COVID-19 and Beyond.

The coronavirus disease (COVID-19) pandemic has disrupted not only clinical care but also medical education. Physical distancing and shift rearrangements for both trainees and faculty have led to abrupt cancelation of many in-person didactics. These have been replaced by distance learning options, which include both synchronous and asynchronous curricula. Unfortunately, many medical educators have been forced to quickly create distance-learning options for trainees with little prior experience. In this perspective, we review the evidence base for distance learning and discuss practical considerations for transitioning traditional in-person curricula to distance platforms. We review technical aspects of distance learning as well as educational principles essential for success. The goal is for medical educators to optimize distance learning not just during this COVID-19 pandemic but beyond this crisis as well.

Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship.

BACKGROUND: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale. OBJECTIVE: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in United States (US) PCCM training programs. METHODS: We administered a survey to a convenience sample of US PCCM fellows to elicit typical intubation practices in the medical ICU. RESULTS: 89 discrete US PCCM and Internal Medicine CCM training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was "always or almost always" designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was "rarely or never" the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator. CONCLUSION: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

Potentially inappropriate medications and adverse drug effects in elders in the ED.

The objective of this study was to examine the prevalence of potentially inappropriate medications (PIMs) and potential adverse drug effects (ADEs) in older adults presenting to the emergency department (ED). This was a prospective observational study of a convenience sample of adults 65 years and older presenting to the ED at an urban, tertiary care hospital. Potentially inappropriate medications were defined according to 2003 Beers criteria. Potential ADEs were defined as either (1) a potential drug-drug interaction, (2) alternative medication likely to cause toxicity or drug interactions, or (3) toxic doses of vitamins or minerals. Of 174 eligible patients, 124 were enrolled. The mean number of medications used per patient was 8.6 (range, 0-20). Thirty six patients (29%, 95% confidence interval, 27%-37%) presented to the ED with at least one PIM. Eight PIMs were prescribed in the ED, representing 16% of all prescriptions in the ED. Potential ADEs meeting the defined criteria were found in 26.6% of patients. A subanalysis of a random sample of charts revealed significant discordance between medication lists obtained by the research assistants and that of the health care providers. Older ED patients are at high risk for use of potentially inappropriate medications and ADEs. This problem may be magnified by inaccurate medication lists obtained by ED providers. A larger multicenter study may help to better define the scope of this problem.

An Unusual Cause of Pulmonary Nodules After Stem Cell Transplantation.

A man in his 20s with a history of classical Hodgkin's lymphoma was admitted with fever. His original lymphoma diagnosis was made 3 years prior, when he had presented with lymphadenopathy and a mediastinal mass. He had relapsed disease despite chemotherapy and radiation. As a result, he underwent autologous peripheral blood stem cell transplant (SCT) 6 months prior to current presentation and subsequently allogeneic SCT 2 months prior for added graft vs tumor effect.

Survival outcome according to KRAS mutation status in newly diagnosed patients with stage IV non-small cell lung cancer treated with platinum doublet chemotherapy.

INTRODUCTION: Mutations (MT) of the KRAS gene are the most common mutation in non-small cell lung cancer (NSCLC), seen in about 20-25% of all adenocarcinomas. Effect of KRAS MT on response to cytotoxic chemotherapy is unclear. METHODS: We undertook a single-institution retrospective analysis of 93 consecutive patients with stage IV NSCLC adenocarcinoma with known KRAS and EGFR MT status to determine the association of KRAS MT with survival. All patients were treated between January 1, 2008 and December 31, 2011 with standard platinum based chemotherapy at the University of Pennsylvania. Overall and progression free survival were analyzed using Kaplan-Meier and Cox proportional hazard methods. RESULTS: All patients in this series received platinum doublet chemotherapy, and 42 (45%) received bevacizumab. Overall survival and progression free survival for patients with KRAS MT was no worse than for patients with wild type KRAS. Median overall survival for patients with KRAS MT was 19 months (mo) vs. 15.6 mo for KRAS WT, p = 0.34, and progression-free survival was 6.2 mo in patients with KRAS MT vs. 7 mo in patients with KRAS WT, p = 0.51. In multivariable analysis including age, race, gender, and ECOG PS, KRAS MT was not associated with overall survival (HR 1.12, 95% CI 0.58-2.16, p = 0.74) or progression free survival (HR 0.80, 95% CI 0.48-1.34, p = 41). Of note, receipt of bevacizumab was associated with improved overall survival only in KRAS WT patients (HR 0.34, p = 0.01). CONCLUSIONS: KRAS MT are not associated with inferior progression-free and overall survival in advanced NSCLC patients treated with standard first-line platinum-based chemotherapy.

Race and intensity of post-remission therapy in acute myeloid leukemia.

BACKGROUND: In many cancers, including AML, blacks have poorer overall survival. We investigated whether differences in post-remission therapy (PRT) were a contributing factor. METHODS: We compared PRT cycle number and intensity and time to PRT in blacks and whites, among 460 patients with newly diagnosed AML. RESULTS: Blacks and whites had PRT of equal cycle intensity and number, but black patients experienced a significant delay in starting PRT (2.73 months in blacks vs. 1 month in whites, p=0.047). Overall survival was equivalent in blacks and whites. CONCLUSION: PRT is delayed in blacks but does not explain differences in survival.