Effect of high-frequency chest wall oscillation on the central and peripheral distribution of aerosolized diethylene triamine penta-acetic acid as compared to standard chest physiotherapy in cystic fibrosis.

BACKGROUND AND OBJECTIVES: High-frequency chest wall oscillation (HFCWO) has been shown to be as effective as standard chest physiotherapy (SCPT) for removal of pulmonary secretions as well as increasing FEV(1) in cystic fibrosis (CF) patients. Patients using HFCWO often administer aerosolized medications simultaneously, reducing time required for daily care. While peripheral pulmonary distribution of tracer in normal subjects has been shown to be unaffected by HFCWO, this has not been studied in CF patients. We evaluated distribution of aerosolized (99m)Tc diethylene triamine penta-acetic acid (DTPA) administered simultaneously with HFCWO and compared this with DTPA aerosolized after SCPT. STUDY DESIGN: Ten CF patients, ages 22 to 38 years, with moderate-to-severe obstructive disease were studied in a crossover design after documentation of stable lung function. (133)Xe was administered to delineate total lung volume. DTPA was aerosolized (Pari LC Plus nebulizer and Pulmo-Aide compressor; Pari Respiratory Equipment Inc.; Richmond, VA) to delineate airway deposition. The central to peripheral deposition ratio (C/P ratio) of each lung was analyzed in each study group. Central regions were represented by the inner one third of the (133)Xe scan as demonstrated in previous research models. RESULTS: The mean C/P ratio (+/- SD) for both lungs was 1.45 +/- 0.31 with HFCWO and 1.46 +/- 0.28 following SCPT (p = not significant [NS]). Right lung mean C/P ratio was 1.74 +/- 0.43 with HFCWO and 1.85 +/- 0.63 after SCPT (p = NS). Left lung mean C/P ratio was 1.25 +/- 0.29 with HFCWO and 1.21 +/- 0.35 after SCPT (p = NS). There was no correlation between C/P ratio and FEV(1) or FVC. CONCLUSIONS: Use of HFCWO in combination with aerosolized DTPA did not result in increased central deposition as compared with aerosolized DTPA administered after SCPT. Further study is required to determine if combining HFCWO with aerosolized medications can be modified to improve peripheral deposition.

Pulmonary hypertension: new perspectives.

The World Health Organization symposium offers a new treatment-oriented classification of pulmonary hypertension based on an improved understanding of its pathophysiology. Regardless of the etiology, severe or unrelieved pulmonary hypertension leads to right heart failure. Symptoms and signs of pulmonary hypertension are often subtle and nonspecific. As a result, a significant delay between the onset of symptoms and the diagnosis of pulmonary hypertension is common. Echocardiography with Doppler flow is the most useful study to evaluate patients suspected of having pulmonary hypertension. The suspected diagnosis of pulmonary hypertension should then be confirmed by right heart catheterization. If present, further evaluation may include oxygen assessment, pulmonary function testing, high resolution computed tomography of the chest, and ventilation-perfusion lung scanning. Treatment of pulmonary hypertension requires uncommon expertise. General measures include correction of the underlying cause, reversal of hypoxemia and judicious use of diuretics. Advances in vasodilator therapy have increased treatment options beyond calcium channel blockers and intravenous epoprostenol. Lung transplantation remains an option for select patients with pulmonary hypertension not responding to medical management.

Quality improvement initiative to reduce deep vein thrombosis associated with peripherally inserted central catheters in adults with cystic fibrosis.

RATIONALE: Peripherally inserted central catheters (PICCs) are common in the treatment of patients with cystic fibrosis (CF). Previous reports suggest that patients with CF are at increased risk for PICC-associated deep vein thrombosis (DVT). OBJECTIVES: We assessed potential risk factors for symptomatic PICC-associated DVT with subsequent implementation of a quality improvement (QI) initiative to reduce PICC-associated DVT in patients with CF. METHODS: This was a 5-year retrospective cohort study with subsequent 21-month prospective observation following implementation of a QI intervention in adults (aged 18 yr or older) with CF. All patients with a PICC inserted from July 2006 to March 2013 at our CF Foundation-accredited center were included. Symptomatic DVT was diagnosed by Doppler ultrasound. PICC insertions were analyzed, and nine risk factors for DVT were analyzed to formulate a QI initiative to reduce risk of PICC-associated DVT. The QI program focused on staff education and included modification to PICC order entry with a 4 French (F) single-lumen (SL) catheter as standard for all patients with CF. MEASUREMENTS AND MAIN RESULTS: A total of 369 PICCs were analyzed in 117 unique patients for a total of 5,437 PICC-days of placement. Symptomatic DVT was diagnosed in 28 (7.6%) of the 369 PICCs analyzed. Using regression analysis, the strongest predictors for DVT occurrence were warfarin use (odds ratio [OR] = 9.2, P = 0.006) and history of PICC-associated DVT (OR = 2.97, P = 0.08). Insertion of a 4F SL PICC resulted in zero symptomatic DVT. Zero episodes of DVT associated with 4F PICC insertion prevented use of PICC size in regression analysis. However, univariate analysis revealed that insertion of a 4F SL PICC instead of either 5F double lumen or 6F triple lumen was associated with a reduction in PICC-associated DVT (P = 0.001). After the QI intervention, 4F SL catheter insertion substantially increased to 65.8% of all PICCs inserted, whereas 6F triple-lumen catheter insertion declined to 6.8% of PICCs inserted. The QI initiative resulted in an absolute risk reduction in DVT per PICC placed of 6.1% (P = 0.055). CONCLUSIONS: To reduce risk of PICC-associated DVT in patients with CF, QI strategies should focus on insertion of smaller-diameter 4F PICCs and reduction in PICC use in high-risk patients when possible.

Applying the milestones in an internal medicine residency program curriculum: a foundation for outcomes-based learner assessment under the next accreditation system.

In 2010, University of Kansas Medical Center internal medicine residency program leaders concluded that their competency-based curriculum and evaluation system was not sufficient to promote accurate assessment of learners' performance and needed revision to meet the requirements of the Accreditation Council for Graduate Medical Education (ACGME) Next Accreditation System (NAS). Evaluations of learners seldom referenced existing curricular goals and objectives and reflected an "everyone is exceptional, no one is satisfactory" view.The authors identified the American Board of Internal Medicine and ACGME's Developmental Milestones for Internal Medicine Residency Training as a published standard for resident development. They incorporated the milestones into templates, a format that could be modified for individual rotations. A milestones-based curriculum for each postgraduate year of training and every rotation was then created, with input from educational leaders within each division in the Department of Internal Medicine and with the support of the graduate medical education office.In this article, the authors share their implementation process, which took approximately one year, and discuss their current work to create a documentation system for direct observation of entrustable professional activities, with the aim of providing guidance to other programs challenged with developing an outcomes-based curriculum and assessment system within the time frame of the NAS.

Comparison and cross-validation of simple and multiple logistic regression models to predict USMLE step 1 performance.

BACKGROUND: Early identification of students who may have difficulty with the United States Medical Licensing Examination-Step 1 examination is important for medical schools and students. Numerous models that predict Step 1 performance have been identified, but few of these models have been cross-validated. PURPOSE: To cross-validate different prediction models of Step 1 performance. METHODS: The development sample was 686 students from a Midwestern medical school. The cross-validation sample was 147 different students. Logistic regression was used to develop the multiple model and Year 1 grade point average (GPA) and Year 2 Fall GPA were used as the simple models. Receiver Operating Characteristic graphs were used to select optimal cutoffs for each model. Kappa coefficients were used to determine level of agreement, and sensitivity and specificity were used to assess classification accuracy. RESULTS: The Year 1 GPA model had relatively poor agreement with actual Step 1 performance, but the other models evidenced fair agreement. The multiple and Year 1 GPA models demonstrated statistically significant loss of classification accuracy on cross-validation, whereas the Year 2 Fall GPA model did not. CONCLUSIONS: Cross-validation is necessary to determine the generalizability and overall utility of prediction models.