Beyond the Individual: A Multidisciplinary Model for Critical Thinking in the Intensive Care Unit.

Health profession educators readily identify with the goal of fostering healthcare providers who are critical thinkers focused on quality patient care. In the following paper, we aim to delve into critical thinking at the team level and help educators begin the process of creating a shared mental model focusing on cognition to identify gaps and opportunities for growth in their trainees. We will distinguish between microcognition (an individual's own critical thinking process in a controlled environment), macrocognition (critical thinking process in a real-world environment), and team cognition (the interaction and relationship among team members to augment macrocognition). A common case example will be used to guide the discussion as well as provide a model framework to be used for clinician educators in the future.

Navigating biologic therapies in elderly asthma.

The prevalence of asthma among the elderly population has witnessed a notable rise, presenting unique challenges in diagnosis and management. Biologic therapies, such as omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab, and tezepelumab, have demonstrated efficacy in targeting specific pathways associated with severe asthma in elderly individuals. However, a significant research gap exists in the application of these therapies in elderly asthma patients. Despite the considerable size of the elderly asthma population and the social and economic burden that this specific demographic imposes on society, the available body of research catering to this group is limited. Notably, no RCTs have been expressly designed for the elderly across all asthma biologic therapies. Moreover, most RCTs have set upper age cutoffs, commonly 75 years old, and exclusion criteria for common comorbidities in the elderly, thus marginalizing this group from pivotal research. This underscores the crucial need for intentional inclusion of elderly participants in separately designed clinical trials and more researches, aiming to augment the generalizability of findings and enhance therapeutic outcomes. Given the distinct physiological changes associated with aging, there may be a concern regarding the efficacy and safety of biologic therapies in the elderly compared to non-elderly adults, posing a barrier to their use in this population. However, observational studies have shown similar benefits of these therapies in elderly individuals as seen in non-elderly adults. Other anticipated challenges related to initiating biologic therapy in elderly people with asthma including dosing consideration and monitoring strategies, which are important areas of investigation for optimizing asthma management will be discussed in this review. In summary, this review navigates the current landscape of biologic therapies for elderly asthma, offering valuable insights for various stakeholders, including researchers, healthcare providers, and policymakers, to advance asthma care in this vulnerable population. We propose that future research should concentrate on tailored, evidence-based approaches to address the undertreatment of elderly asthma patients.

Twelve Tips to Succeed as Health Profession Clinical Educator in Resource-Limited Settings.

Health professions education is one of the pillars of academic medicine; however, clinical educators often lack the appropriate resources to succeed in this field. Examples of these challenges include: lack of support for faculty development, mentorship, and high cost of resources, when available. In addition, challenges such as the Coronavirus disease (COVID-19) pandemic can affect healthcare personnel who are already struggling to provide adequate patient care while attempting to succeed in the role of educator and supervisor of trainees. Clinical educators face more challenges particularly in low-middle income countries as the limitations are more prominent and become key barriers to success. Similarly, due to COVID-19, these challenges can be far more evident in disadvantaged geographical, economic, and academic environments even in the United States. Herein, in this perspective paper, we define resource-limited settings in medical education, provide an overview of the most common barriers to career development as a clinical educator, and offer practical strategies to overcome some of these shortcomings.

Relationship Between Cognitive Load Theory, Intrinsic Motivation and Emotions in Healthcare Professions Education: A Perspective on the Missing Link.

Cognitive Load Theory (CLT) is one of the key cognitive theories that have been used to assess learners' information and working memory load. CLT has been applied to Simulation Based Education (SBE) and optimizing instructional design. However, a challenge that occurs is that these high-fidelity simulations and mannequins of critically ill patients can elicit negative emotions in learners which can unfavorably impact the learning process. There is also a potential for cognitive overload if the simulation is more authentic and requires more dynamic interactions and lead to high levels of anxiety due to a novel learning environment, which can also have detrimental effects on learning process. Hence, it is critical for health professional educators (HPE) to know how to minimize cognitive load to improve learning as a professional in a workplace setting. The literature on the role of emotions, intrinsic motivation, cognitive load is scarce in HPE literature. Specifically when not being studied together at once since they move dynamically together and affect the learning for the learner. Therefore, the purpose of this perspective paper is to cover the gap in the literature and propose a framework and recommendation for future HPE research.

Evaluation of tracheostomy suctioning procedure among nursing and respiratory therapy students: wearable manikin vs. standard manikin.

Introduction: This study aims to evaluate cognitive load (CL), emotional levels (EL), and stress levels (SL) of students when using a wearable manikin vs. a standard manikin for tracheostomy suctioning (TS). Methods: This study was approved by the Institutional Review Board. Subjects were recruited by email. Subjects completed a baseline demographics questionnaire, then they were randomized into two groups: wearable manikin group (WMG) or standard manikin group (SMG). For the WMG, an actor simulated a patient by wearing the device. In phase I, both groups were educated on how to perform TS by video and offered hands-on practice. Then I put through a tracheostomy suctioning clinical simulation and completed a post sim-survey. In phase II, the same survey was repeated after encountering a real patient as part of their clinical rotation. Results: A total of 30 subjects with a mean age 26.0 ± 5.5 years participated. 20 (66.7%) were respiratory care students and 10 (33.3%) were nursing students. In the WMG, the median stress level dropped significantly post phase II compared to post phase I [2(1,4) vs.3(1,5), p = 0.04]. There were no significant changes in median CL, confidence, and satisfaction levels between post phase II and post phase I (p > 0.05). In the SMG, the satisfaction level increased significantly post phase II compared to post phase I [5(4,5) vs.4(2,5), p = 0.004], but there were no significant changes in CL, SL, and confidence levels between post phase I and phase II. There was no significant difference in mean EL scores over time and these changes did not differ by group. Subjects in the WMG showed a higher mean competency score than those in the SMG (85.5 ± 13.6 vs. 78.5 ± 20.8, p = 0.14, Cohen's d = 0.4), yet not significant. Conclusion: Our results showed that the WMG is beneficial in helping bridge the gap of learning TS from the sim setting to the real-world clinical setting. More studies with higher sample size and use of other CL scales that assesses the different types of CL are needed to validate our findings.

A Cross-Sectional Survey of Pulmonologists Working at Non-ILD Centers in the United States.

The purpose of this cross-sectional short report study was to evaluate the perception of pulmonologist working in noninterstitial lung disease centers on challenges (COE) encountered in daily practice. Results of this survey revealed that only 40% of their patients are referred to an ILD COE, out of 69% who have access to an ILDCOE. Of these patients who were referred, the perceived benefits were rated high when it comes to having an accurate diagnosis.

Measurement and changes of exhaled nitric oxide fraction while vaping with a brief education intervention session.

A brief, 15-min education intervention session might be helpful to highlight the dangers of vaping and aid in cessation. In addition, post-washout period (15 min), F ENO levels increased significantly. https://bit.ly/3Xu4X5Y.

Kounis syndrome following multiple wasp stings: A case report.

This is a case of Kounis syndrome with chest tightness, lightheadedness, unconsciousness, and features of shock following multiple wasp stings. Despite cardiopulmonary resuscitation and management of allergic and cardiac symptoms, the patient died. Kounis syndrome should be suspected when a patient presents with allergic symptoms and acute coronary syndrome.

Asthma Care in the Elderly: Practical Guidance and Challenges for Clinical Management - A Framework of 5 "Ps".

Uncontrolled asthma in the elderly is a public health issue recognized in developed countries such as the United States and among the European Union, both from patient safety and economic perspectives. Variations in the cutoff, which defines elderly age, contribute to epidemiological study difficulties. Nonetheless, the relevance of elderly asthma from a socioeconomic perspective is inarguable. The projected growth of the enlarging geriatric population in the United States portends an impending national health burden that may or may not be preventable with pharmacologic and non-pharmacologic treatments. Asthma in the elderly might be a consequence of uncontrolled disease that is carried throughout a lifetime. Or elderly asthmatics could suffer from uncontrolled asthma, which overlaps with other ailments common with advancing ages that merit consideration, eg, COPD, heart disease, OSA, diabetes mellitus, and other comorbidities. Because of the heterogeneity of asthma phenotypes and other conditions that could mimic the symptoms of elderly asthma, further cohort studies are needed to elucidate the elderly asthmatic pathophysiology and management. More studies to characterize elderly asthma can help address these patients' unmet need for evidence-based guidelines. We introduce the 5 "Ps" (phenotypes, partnership, pharmacology, practice in acute exacerbations, and problems or barriers for the elderly asthmatics) that establish a framework approach for clinical practice.

Surgical mask wearing behaviour in COVID-19 pandemic and influenza seasons: a cross-sectional study on healthcare professional students and staff's perspective in Southern California.

OBJECTIVE: To investigate healthcare professional staff and students' perception of wearing surgical masks before and after their experience with the COVID-19 pandemic, and to evaluate the impact on mask wearing behaviour in future influenza seasons. DESIGN: Cross-sectional study using anonymous survey. SETTING AND PARTICIPANTS: Healthcare students and staff from a healthcare academic institution in Southern California participated in the mask survey study. Survey results were collected from June to November 2021. A total of 305 respondents responded to the survey, with 173 being healthcare students and 132 being working healthcare staff. OUTCOMES: The study examined respondents' perceptions and hospital mask wearing behaviour before and after their COVID-19 pandemic experience, as well as during previous and future influenza seasons. RESULTS: Two hundred and sixty-four (86.6%) respondents agreed that wearing a surgical mask reduces infection and limits transmission of infectious disease, yet prior to the pandemic, only a small proportion wore a mask in the hospital or during patient care. After experiencing the COVID-19 pandemic, more respondents indicated that they would continue to wear a mask when they are in a hospital in general (n=145, 47.5%), during patient care (n=262, 85.9%), during influenza seasons throughout the hospital (n=205, 67.2%) and during influenza seasons during patient care (n=270, 88.5%). CONCLUSION: The pandemic experience has greatly influenced the health prevention behaviours of healthcare students and staff. After the pandemic, many respondents will continue to practice surgical mask wearing behaviour in the hospital, especially during face-to-face patient care. This demonstrates a significant change in health prevention perceptions among the current and the future generation of healthcare professionals.

Anxiety level in severe asthmatics undergoing bronchial thermoplasty procedure: An observational study.

Bronchial thermoplasty (BT) is one of the novel approved modalities in treating severe asthmatics to overcome their exacerbating symptoms such as increased anxiety. The purpose of this study was to evaluate anxiety level among severe asthmatics while undergoing BT procedure. This was an observational study where subjects self-evaluated their overall anxiety level using the burns anxiety inventory (BAI) questionnaire at baseline and prior to each of three BT treatments (broncho thermoplasty procedure 1, broncho thermoplasty procedure 2, and broncho thermoplasty procedure 3). The BAI questionnaire consisted of three different categories with each category having specific symptoms. Categories were grouped as: Anxious feelings, Anxious thoughts, and Physical symptoms. Subjects' Asthma Control Tests were also collected for analysis before and after the BT procedure. A total of 17 subjects with a mean age of 55.9 ±â€…14.5 years participated in the study. Fifty three percent were females (n = 9) and 41.2% (n = 7) were on prescribed anxiety medications. There was a significant drop in the patients' overall BAI anxiety level over time, P < .0001, in Anxious feelings (P = .0001), anxious thoughts (P = .001), and physical symptoms (P = .025). When analyzing the change in anxiety level among those who were not on prescribed anxiety medications, significant drop in overall anxiety level and in the subcategories were also noted. (P < .05). In addition, ACT scores showed a significant improvement (post vs pre) (18.5 ±â€…4.0 vs 13.3 ±â€…6.3, P = .03; Cohen's d = 0.73). This study shows the effectiveness of BT in decreasing severe asthmatic anxiety levels from baseline to last BT treatment and this benefit was mostly noted in those who were not on any anxiety medications. A limitation of this study is that all subjects were recruited from a single center. Therefore, to further validate the study findings, a multi-center study needs to be conducted with a larger sample size.

Management of Uncontrolled Asthma: A Framework for Novel and Legacy Biologic Treatments.

Asthma continues to be a complex respiratory disease to control for many despite optimal standard inhaler therapy. The increased dependence on steroid-sparing biologic treatments in the 21st century has created a dilemma between identifying the patient's intrinsic biomarkers and their "life markers." With Tezepelumab being the most recent FDA-approved biologic for asthma, it is even more critical for asthma specialists to better understand and establish a framework to determine which biologic would work best for their patients. While cost and payor approvals limit access to certain asthma biologics, medical decisions on which biologic to select should be centered around shared decision-making, the rationale for biologic initiation, and critical biologic education to help achieve successful asthma control.

Asthma guidelines: comparison of the National Heart, Lung, and Blood Institute Expert Panel Report 4 with Global Initiative for Asthma 2021.

PURPOSE OF REVIEW: Asthma continues to be a prevalent respiratory disease that affects lives within the United States and worldwide. Clinical asthma guidelines based on scientific evidence on testing and therapeutic interventions are needed to control this disease better. To meet this need, the NAEPP (National Asthma Education and Prevention Program) and GINA (Global Initiative for Asthma) were formed to assist with best practice diagnosis and treatments for asthma. This paper reviews the subtle differences and similarities between the most recent recommendations put forth by NAEPP 2020 and GINA 2021, mainly examining the six selected topics, as well as methodology, guidance on emerging topics, and implementation. RECENT FINDINGS: In December 2020, the National Asthma Education and Prevention Program Coordinating Committee released their focused update on fraction of exhaled nitric oxide, indoor allergen mitigation, inhaled corticosteroids, long-acting muscarinic antagonists, allergen immunotherapy, and bronchial thermoplasty. The Global Initiative for Asthma comprehensive document is published annually as a framework for all nations. Therefore, it is timely to consider the National Asthma Education and Prevention Program Coordinating Committee 2020 in relation to the GINA 2021. SUMMARY: The comparison provides a better understanding of evidence-based recommendations for asthma. The NAEPP 2020 and GINA 2021 will equip providers with the knowledge to provide their patients with the best and most updated asthma care.

Randomised trial estimating length of endotracheal tube insertion using gestational age or nasal-tragus length in newborns: a study protocol.

INTRODUCTION: Endotracheal tube (ETT) insertion depth estimation is important for optimal placement of ETT tip and balanced ventilation of the lungs. Various methods are available to determine the ETT insertion depth. The Neonatal Resuscitation Programme recommends the gestational age and nasal-tragus length (NTL) methods for estimating ETT insertion depth during cardiopulmonary resuscitation. However, the prospective data comparing these two methods is lacking. METHODS AND ANALYSIS: This is an open-label multi-centre randomised controlled trial, where gestational age and NTL methods will be used to determine the initial ETT insertion depth in term and preterm infants that are less than 28 days old, requiring oral intubation in the delivery room or neonatal intensive care unit (NICU). SITES AND SAMPLE SIZE: The trial is aimed to recruit 454 infants over 3 years across tertiary level NICUs. OUTCOMES: The primary outcome includes an optimally positioned ETT, defined as an ETT tip between the upper border of the first thoracic vertebra and the lower border of the second thoracic vertebra. The outcome is assessed by a paediatric radiologist, who will be masked to the group assignment. Secondary outcomes are malpositioned ETT tips, pneumothorax, ETT repositioning, chronic lung disease, invasive ventilation days, and death. ANALYSIS: Data will be analysed using the intention-to-treat principle. The primary and categorical secondary outcomes will be compared using the χ2 test. Adjusted risk ratios of outcomes will be calculated along with 95% CIs through multivariable logistic regression analysis, including covariates deemed biologically to influence the outcomes. ETHICS AND DISSEMINATION: The study has been approved by the PNU Research Ethics Board (20-0148) and the respective ethical review boards of the participating centres. The results will be disseminated through conference meetings, social media platforms, and publications in scientific journals. TRIAL REGISTRATION NUMBER: NCT04393337.

Randomized, placebo controlled, double blinded pilot superiority phase 2 trial to evaluate the effect of curcumin in moderate to severe asthmatics.

BACKGROUND: Curcumin, a derivative of the spice turmeric, has been adopted by Eastern medicine for centuries as an adjunct to treat several medical conditions (e.g., anorexia and arthritis) because of its well-established anti-inflammatory properties. Studies have shown that the use of curcumin in mice models has led to reduction in several inflammatory markers as well as key inflammatory pathway enzymes. As a result, studies in Western medicine have developed to determine if this recognized benefit can be utilized for patients with inflammatory lung diseases, such as asthma. This study will seek to better understand if curcumin can be used as an adjunctive therapy for improving asthma control of patients with moderate to severe asthma; a finding we hope will allow for a more affordable treatment. METHODS: This study will utilize a randomized, placebo controlled, double blinded pilot superiority phase 2 trial at an outpatient pulmonary clinic in Southern California, USA. Subjects will be receiving Curcumin 1500 mg or matching placebo by mouth twice daily for the study period of 12 weeks. Subjects will be randomized to either a placebo or intervention Curcumin. Subjects will have 6 clinic visits: screening visit, a baseline visit, monthly clinic visits (weeks 4, 8, and 12), at weeks 4, 8, and a follow-up clinic visit or phone-call (week 16). Changes in asthma control test scores, number of days missed from school/work, FEV1 (% predicted), FEV1/FVC ratio, FVC (% predicted), blood eosinophil count, blood total IgE, and FeNO levels will be compared by group over time. DISCUSSION: The therapeutic effects of curcumin have been studied on a limited basis in asthmatics and has shown mixed results thus far. Our study hopes to further establish the benefits of curcumin, however, there are potential issues that may arise from our study design that we will address within this paper. Moreover, the onset of the COVID-19 pandemic has resulted in safety concerns that have delayed initiation of our study. This study will contribute to existing literature on curcumin's role in reducing lung inflammation as it presents in asthmatics as well as patients suffering from COVID-19. TRIAL REGISTRATION: This study protocol has been approved by the Institutional Review Board at Loma Linda University Health, (NCT04353310). IND# 145101 Registered April 20th, 2020. https://clinicaltrials.gov/ct2/show/NCT04353310 .

Designing a Clinical Education Tracking System: An Innovative Approach.

In clinical education, there is a need for constant evaluation, assessment, and at times immediate feedback for students to recognize areas of success, learning, and areas for improvement. The clinical educator is expected to manage the number of student evaluations and assess their performance, regularly, as needed, and over time. This allows appropriate and timely formative, as well as summative feedback to students and the program. Clinical programs face challenges in finding innovative and efficient methods to track and manage this large volume of seemingly disparate needed and required data. Traditional solutions entail paper-based systems or a paid proprietary clinical tracking system. However, both of these options have their own unique challenges. This perspective article proposes an innovative approach of collecting data electronically via online forms, processing and storing data in cloud-based databases and providing appropriate visualizations for the end users (i.e., students and educators) to analyze and assess the information. Migrating data to be collected in this manner allows for the integration of business intelligence (BI) techniques that provide data mining and machine learning in various user needed methods. This article presents a perspective and an innovative guide for clinical educators on how to develop and design a system that leads to positive sentiments and immediate student feedback regarding their progress to improve student outcomes.

Effects of smartphone addiction on children's lung function.

BACKGROUND: With an increase in smartphone usage, constant neck flexion can lead to improper posture, which may impact on lung function. Therefore, the purpose of this study was to examine and compare the craniovertebral angle (CVA) and lung function between addicted and non-addicted boys and girls aged between 8-13 years who use smartphones for long periods of time. METHODS: A cross-sectional study was conducted on 24 boys and 26 girls (mean age 10.5 ± 1.6 years and body mass index 18.6 ± 3.0 kg/m2) . Participants were assigned to two groups based on their scores on the Smartphone Addiction Scale-Short Version (SAS-SV) for Adolescents: addicted group (score > 32, n = 32) and non-addicted group (score ≤ 32, n = 18). The outcome variables were CVA, forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), peak expiratory flow (PEF), maximal voluntary ventilation (MVV), maximum inspiratory pressures (PImax), and maximum expiratory pressures (PEmax). RESULTS: There was a significant difference in mean CVA between addicted and non-addicted boys (49.4 ± 6.7 vs 55.5 ± 7.6, η2  = 0.9, P = 0.03) and girls (47.3 ± 6.3 vs 52.9 ± 6.1, η2  = 0.9, P = 0.02). Mean FVC, FEV1, and FEV6 were significantly lower in addicted versus non-addicted boys (P = 0.04, P = 0.05, and P = 0.02, respectively). PImax was significantly less in addicted compared to non-addicted girls (55.2 ± 16.4 vs 65.3 ± 13.8, η2  = 0.7, P = 0.05). CONCLUSION: Our findings showed that children addicted to smartphones (when using the SAS-SV as an indicator for addiction) revealed lower CVA and lung function results. Therefore, education on proper posture while holding smartphones is essential to the children's postural and lung function status.