Margaret M. Hayes

Pain is a common problem affecting clinical outcomes in adults with cystic fibrosis

BACKGROUND As the cystic fibrosis (CF) population has aged, many chronic health problems have emerged, including diabetes mellitus and osteoporosis. Previous studies have suggested that pain is common in patients with CF; however, little is known about the factors associated with it or its impact on clinical outcomes. We hypothesized that pain is common, is associated with psychologic distress, and adversely affects clinical outcomes. METHODS From February 1, 2008, to April 3, 2008, adults with CF from Johns Hopkins Hospital were surveyed about their pain. Outcomes were assessed for 12 months following survey completion. Bivariate analyses were performed using Wilcoxon log rank, Kruskal-Wallis tests, and Spearman correlations. Logistic regression models and Cox proportional hazard models were used to analyze clinical outcomes. RESULTS Eighty-three patients (61%) completed the survey. Eighty-two percent of patients reported pain within the past month, the most common sites being the head, sinuses, back, and chest. Pain frequently interfered with general activities (41.9%), mood (56.8%), and work (47.3%). Symptoms of depression and anxiety, as well as lower quality-of-life (QOL) scores, were associated with the presence of pain (P < .05 for each). The risk of pulmonary exacerbations was increased in patients with higher levels of pain, even after adjusting for FEV(1) and age (OR = 1.65; P = .038; 95% CI, 1.03-2.64). Additionally, the risk of death was higher in patients with higher average pain scores (HR = 2.28; P = .008; 95% CI = 1.2-4.2). CONCLUSIONS Pain is common in adults with CF, interferes with activities, and is associated with lower QOL and an increased risk of both exacerbations and death.

Preadolescent Methylphenidate versus Cocaine Treatment Differ in The Expression of Cocaine-Induced Locomotor Sensitization During Adolescence and Adulthood

BACKGROUND Methylphenidate (MPH), the most commonly prescribed medication for childhood attention-deficit/hyperactivity disorder (ADHD), shares chemical and mechanistic similarities to cocaine which has stimulated research to address the addiction liability following treatment. METHODS Utilizing locomotor sensitization we examined the consequences of recurrent MPH versus cocaine treatment during preadolescence in altering cocaine-induced locomotor behavior in adolescent and adult mice. Black Swiss Webster mice were treated with MPH, cocaine, or saline during preadolescence. To test whether MPH pretreatment during preadolescence contributed to an altered sensitivity to cocaine during adolescence, these mice were treated with recurrent cocaine or saline during adolescence. All mice were challenged with cocaine as adults. RESULTS Recurrent MPH treatment, unlike cocaine treatment in preadolescent mice, had no effect on locomotor sensitization to cocaine during adolescence or adulthood, as compared with saline controls. Furthermore, unlike cocaine, administration of MPH in adolescence did not augment the response to cocaine challenge. CONCLUSIONS MPH treatment during preadolescence does not increase subsequent sensitivity to cocaine, whereas cocaine treatment does. Thus, MPH treatment during preadolescence does not appear to persistently induce long-term adaptations, which may underlie an enhanced liability for subsequent drug abuse.

Interventional pulmonology procedures in the pediatric population

Advanced training in interventional pulmonology (IP) includes a multidisciplinary approach to a wide variety of pathologic conditions affecting different age groups. The role of the interventional pulmonologist in the pediatric patient population has not been described. We report our experience of the care of pediatric patients by IP at an academic institution.

A Quality Improvement Intervention to Reduce Indwelling Tunneled Pleural Catheter Infection Rates

RATIONALE The indwelling tunneled pleural catheter has altered the management of patients with dyspnea related to malignant pleural effusions. However, indwelling tunneled pleural catheter placement does not remain free from risk. The most commonly reported risk is infection. OBJECTIVES The aim of this paper is to describe our continuous quality improvement program for infection rate recognition, the process changes implemented for improvement, and subsequent outcomes. METHODS All patients undergoing indwelling tunneled pleural catheter placement at The Johns Hopkins Medical Institutions between May 2009 and April 2014 were identified. The primary outcome was the incidence of infection within the preintervention and intervention cohorts. Intervention was identified as use of preoperative antibiotics, full sterile draping, and limiting placement to a single defined location. MEASUREMENTS AND MAIN RESULTS A total of 225 indwelling tunneled pleural catheter placements were performed in 201 patients during the study period, and the overall infection rate was 5.8%. During the preintervention period, 134 placements were performed, and 91 placements occurred during the intervention period. A preintervention infection rate was identified as 8.2%, with a significant decrease to 2.2% (P = 0.049) within the intervention cohort. CONCLUSIONS The use of a continuous quality improvement program to review indwelling tunneled pleural catheter practices can result in the identification of infectious complications and lead to implementation of measures to improve patient outcomes.

Treatment of Acute Dyspnea with Morphine to Avert Respiratory Failure

Treatment of Acute Dyspnea with Morphine to Avert Respiratory Failure Morgan I. Soffler, Alexandra Rose, Margaret M. Hayes, Robert Banzett, and Richard M. Schwartzstein Massachusetts General Hospital and Beth Israel Deaconess Medical Center Combined Fellowship in Pulmonary and Critical Care Medicine, Harvard Medical School, Boston, Massachusetts; Division of Pulmonary Critical Care and Sleep Medicine, University of California San Diego, La Jolla, California; Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Carl J. Shapiro Institute for Education and Research at Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and Department of Medicine, Harvard Medical School, Boston, Massachusetts

Critical Thinking in Critical Care: Five Strategies to Improve Teaching and Learning in the Intensive Care Unit

&NA; Critical thinking, the capacity to be deliberate about thinking, is increasingly the focus of undergraduate medical education, but is not commonly addressed in graduate medical education. Without critical thinking, physicians, and particularly residents, are prone to cognitive errors, which can lead to diagnostic errors, especially in a high‐stakes environment such as the intensive care unit. Although challenging, critical thinking skills can be taught. At this time, there is a paucity of data to support an educational gold standard for teaching critical thinking, but we believe that five strategies, routed in cognitive theory and our personal teaching experiences, provide an effective framework to teach critical thinking in the intensive care unit. The five strategies are: make the thinking process explicit by helping learners understand that the brain uses two cognitive processes: type 1, an intuitive pattern‐recognizing process, and type 2, an analytic process; discuss cognitive biases, such as premature closure, and teach residents to minimize biases by expressing uncertainty and keeping differentials broad; model and teach inductive reasoning by utilizing concept and mechanism maps and explicitly teach how this reasoning differs from the more commonly used hypothetico‐deductive reasoning; use questions to stimulate critical thinking: “how” or “why” questions can be used to coach trainees and to uncover their thought processes; and assess and provide feedback on learners critical thinking. We believe these five strategies provide practical approaches for teaching critical thinking in the intensive care unit.

External beam radiation therapy combined with airway stenting leads to better survival in patients with malignant airway obstruction: Airway stenting versus EBRT in MAO

Malignant airway obstruction (MAO), a common complication of patients with advanced lung cancer, causes debilitating dyspnoea and poor quality of life. Two common interventions used in the treatment of MAO include bronchoscopy with airway stenting and external beam radiotherapy (EBRT). Data are limited regarding their clinical effectiveness and overall effect on survival.

Respiratory Sensations in Dynamic Hyperinflation: Physiological and Clinical Applications

Dynamic hyperinflation is a common cause of dyspnea and functional limitation in patients with emphysema. Dynamic hyperinflation occurs in individuals with air-flow limitation when expiratory time is decreased during periods of relative tachypnea (such as during exercise or agitation, for example). In this setting, patients with emphysema develop lung hyperinflation, impairment of inspiratory respiratory muscles, and an increase in work of breathing. The associated decrease in inspiratory capacity results in the stimulation of several receptors, including chemoreceptors and pulmonary receptors, which signal the brain to increase tidal volume. The inability of the respiratory system to respond to signals of increased demand (eg, by enlarging tidal volume and increasing inspiratory flow) results in a dissociation between afferent and efferent signaling thereby intensifying breathing discomfort, or what clinicians term dyspnea. A thorough understanding of the physiology of dyspnea and pathophysiology of dynamic hyperinflation informs the interventions used to mitigate sensations of dyspnea and the physiologic effects of dynamic hyperinflation, respectively. Pharmacotherapy, pulmonary rehabilitation, breathing techniques, positive airway pressure, and lung volume reduction are well-studied interventions that target pathways to dyspnea in patients with dynamic hyperinflation.

Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates

Effective communication between providers and patients and their surrogates in the intensive care unit (ICU) is crucial for delivery of high-quality care. Despite the identification of communication as a key education focus by the American Board of Internal Medicine, little emphasis is placed on teaching trainees how to effectively communicate in the ICU. Data are conflicting on the best way to teach residents, and institutions vary on their emphasis of communication as a key skill. There needs to be a cultural shift surrounding the education of medical residents in the ICU: communication must be treated with the same emphasis, precision, and importance as placing a central venous catheter in the ICU. We propose that high-stakes communications between physicians and patients or their surrogates must be viewed as a medical procedure that can be taught, assessed, and quality controlled. Medical residents require training, observation, and feedback in specific communication skill sets with the goal of achieving mastery. It is only through supervised training, practice in real time, observation, and feedback that medical residents can become skillful practitioners of communication in the ICU.

Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units

Gabriel T. Bosslet, Thaddeus M. Pope, Gordon D. Rubenfeld, Bernard Lo, Robert D. Truog, Cynda H. Rushton, J. Randall Curtis, Dee W. Ford, Molly Osborne, Cheryl Misak, David H. Au, Elie Azoulay, Baruch Brody, Brenda G. Fahy, Jesse B. Hall, Jozef Kesecioglu, Alexander A. Kon, Kathleen O. Lindell, and Douglas B. White; on behalf of The American Thoracic Society ad hoc Committee on Futile and Potentially Inappropriate Care