Michael S Firstenberg

Complications of needle thoracostomy: A comprehensive clinical review

Needle thoracostomy (NT) is a valuable adjunct in the management of tension pneumothorax (tPTX), a life-threatening condition encountered mainly in trauma and critical care environments. Most commonly, needle thoracostomies are used in the prehospital setting and during acute trauma resuscitation to temporize the affected individuals prior to the placement of definitive tube thoracostomy (TT). Because it is both an invasive and emergent maneuver, NT can be associated with a number of potential complications, some of which may be life-threatening. Due to relatively common use of this procedure, it is important that healthcare providers are familiar, and ready to deal with, potential complications of NT.

Arterial Levels of Oxygen Stimulate Intimal Hyperplasia in Human Saphenous Veins via a ROS-Dependent Mechanism

Saphenous veins used as arterial grafts are exposed to arterial levels of oxygen partial pressure (pO2), which are much greater than what they experience in their native environment. The object of this study is to determine the impact of exposing human saphenous veins to arterial pO2. Saphenous veins and left internal mammary arteries from consenting patients undergoing coronary artery bypass grafting were cultured ex vivo for 2 weeks in the presence of arterial or venous pO2 using an established organ culture model. Saphenous veins cultured with arterial pO2 developed intimal hyperplasia as evidenced by 2.8-fold greater intimal area and 5.8-fold increase in cell proliferation compared to those freshly isolated. Saphenous veins cultured at venous pO2 or internal mammary arteries cultured at arterial pO2 did not develop intimal hyperplasia. Intimal hyperplasia was accompanied by two markers of elevated reactive oxygen species (ROS): increased dihydroethidium associated fluorescence (4-fold, p<0.05) and increased levels of the lipid peroxidation product, 4-hydroxynonenal (10-fold, p<0.05). A functional role of the increased ROS saphenous veins exposed to arterial pO2 is suggested by the observation that chronic exposure to tiron, a ROS scavenger, during the two-week culture period, blocked intimal hyperplasia. Electron paramagnetic resonance based oximetry revealed that the pO2 in the wall of the vessel tracked that of the atmosphere with a ~30 mmHg offset, thus the cells in the vessel wall were directly exposed to variations in pO2. Monolayer cultures of smooth muscle cells isolated from saphenous veins exhibited increased proliferation when exposed to arterial pO2 relative to those cultured at venous pO2. This increased proliferation was blocked by tiron. Taken together, these data suggest that exposure of human SV to arterial pO2 stimulates IH via a ROS-dependent pathway.

The American College of Academic International Medicine 2017 Consensus Statement on International Medical Programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms

The growth of academic international medicine (AIM) as a distinct field of expertise resulted in increasing participation by individual and institutional actors from both high-income and low-and-middle-income countries. This trend resulted in the gradual evolution of international medical programs (IMPs). With the growing number of students, residents, and educators who gravitate toward nontraditional forms of academic contribution, the need arose for a system of formalized metrics and quantitative assessment of AIM- and IMP-related efforts. Within this emerging paradigm, an institutions “return on investment” from faculty involvement in AIM and participation in IMPs can be measured by establishing equivalency between international work and various established academic activities that lead to greater institutional visibility and reputational impact. The goal of this consensus statement is to provide a basic framework for quantitative assessment and standardized metrics of professional effort attributable to active faculty engagement in AIM and participation in IMPs. Implicit to the current work is the understanding that the proposed system should be flexible and adaptable to the dynamically evolving landscape of AIM – an increasingly important subset of general academic medical activities.

Reflections on the ebola public health emergency of international concern, part 2: The unseen epidemic of posttraumatic stress among health-care personnel and survivors of the 2014–2016 Ebola outbreak

intRoduction Neither dramatic footage nor horrifying statistics from the most recent Ebola virus (EBOV) outbreak come close to reflecting the true impact of the EBOV disease (EVD) on affected countries, communities, patients, health-care workers, or their friends and families.[1,2] With focus squarely on containing the outbreak and dealing with the immensity of the task at hand, many fail to notice the associated emotional and psychological toll.[3,4] Posttraumatic stress disorder (PTSD) is defined by Diagnostic and Statistical Manual of Mental Disorders, 5th edition as a specified constellation of emotional and behavioral responses to traumatic events.[5] The affected person frequently reports an exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Within this context, one or more of the following are required to meet the diagnosis of PTSD: (a) direct exposure to trauma; (b) witnessing the traumatic act or event in person; (c) indirect involvement, by learning that a close relative or close friend was exposed to trauma; (d) if the event involved actual or threatened death, it must have been violent or accidental; and (e) repeated or extreme indirect exposure to aversive details of the event(s) has occurred, usually in the course of professional duties (e.g., first responders, collecting body parts, social workers repeatedly exposed to details of child abuse).[5] This does not include indirect nonprofessional exposure to above-mentioned events through electronic media, television, movies, or pictures. In this Editorial, we will discuss the very real and well-documented phenomenon of PTSD among EVD survivors, caretakers, and their immediate contacts.

What's new in critical illness and injury science? The role of a cranial computed tomography scoring tool in the care of older trauma patients

The increasing longevity of the general population has created a parallel aging of the trauma population. This change in demographics has also lead to a change in injury patterns with falls and traumatic brain injury becoming an increasing proportion of the trauma burden. Because the birth of trauma stems from military experience, much of the lexicon of literature focuses on young and healthy patients – patients who typically are without significant co‐morbidities. So the question arises, how do we predict the clinical course of older patients?

A comprehensive framework for international medical programs: A 2017 consensus statement from the American College of Academic International Medicine

The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIMs mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations.

Mission statement of the American College of Academic International Medicine

On July 23, 2016, the founding meeting of The American College of Academic International Medicine (ACAIM or “The College”) took place at St. Luke’s University Health Network in Bethlehem, Pennsylvania [Figure 1]. The meeting marked an important convergence in a decade‐long collaboration between academic physicians and educators dedicated to advancing the discipline of International Academic Medicine. Details of the proceedings can be found on the organization’s website [www.acaim.org].

The importance of identifying patients at risk of dexmedetomidine-associated hypotension

© 2016 International Journal of Critical Illness and Injury Science | Published by Wolters Kluwer Medknow The use of dexmedetomidine in the intensive care setting has risen dramatically in recent years, which can be attributed to the benefits of decreased ventilator dependence,[1] shortened Intensive Care Unit (ICU) stays, and decreased costs of hospitalization associated with these improvements.[2] However, the hypotension and bradycardia associated with dexmedetomidine administration is well documented and can limit its use in critically ill patients. To date, scant evidence is available to predict which patients will suffer these potentially life‐threatening effects. With increasing emphasis on cost‐effective healthcare delivery, determining the patient populations and characteristics that would most benefit from dexmedetomidine use is critical both for patient safety and optimal resource utilization.

Retained surgical items: Accurate reporting is critical to institutional protocols

To the Editor, Retained surgical items (RSIs) remain a challenging problem with significant patient, physician, and institutional consequences, especially financial and reputational.[1] As such, the accurate reporting of RSIs is critical to the understanding and potential elimination of the problem. Many institutions have implemented intraoperative protocols to address “incorrect” counts with the goal of eliminating RSIs. However, even with strict adherence to protocols, institutional reporting system in which the physician has no control over the integrity of the data may result in erroneous reporting.

Brain drain in academic medicine: Dealing with personnel departures and loss of talent

The phenomenon of “brain drain,” (BD) or the unanticipated and significant loss of skilled people and the talent they represent via voluntary turnover, continues to be a significant problem across many academic medical centers. This BD is a result of a multifactorial interplay between personal, professional, institutional, peer-driven, and socioeconomic factors and affects mainly academic healthcare organizations characterized by a specific set of leadership, economic, and competitive preconditions. Institutional impact of BD, both financial and nonfinancial, can be profound and is often underappreciated. Financial considerations of BD include loss of clinical and non-clinical income, contraction of institutional expertise, severance and recruitment expenses, as well as costs of onboarding new faculty. This article focuses on how to identify risk factors for BD at both institutional and personnel levels. Proposed steps for prevention and early intervention are outlined. The following core competencies are addressed in this article: Professionalism, Practice-based learning and improvement, Systems-based practice, Interpersonal skills, and Communication.