Rosemary Adamson

Epidemiology and Burden of Hepatitis A, Malaria, and Typhoid in New York City Associated With Travel: Implications for Public Health Policy

We examined New York City Department of Health and Mental Hygiene surveillance data on hepatitis A, malaria, and typhoid to determine the proportion of these diseases related to travel and their geographic distribution. We found that 61% of hepatitis A cases, 100% of malaria cases, and 78% of typhoid cases were travel related and that cases clustered in specific populations and neighborhoods at which public health interventions could be targeted. High-risk groups include Hispanics (for hepatitis A), West Africans living in the Bronx (for malaria), and South Asians (for typhoid).

Fatal acute necrotizing eosinophilic myocarditis temporally related to use of adalimumab in a patient with relapsing polychondritis.

Tumor necrosis factor α (TNF-α) antagonists are being increasingly used as maintenance therapies for rheumatic diseases, and therefore knowledge of their adverse effects is important. We report a case of fatal acute necrotizing eosinophilic myocarditis temporally related to use of a second course of the TNF-α antagonist, adalimumab. A 51-year-old woman with relapsing polychondritis took adalimumab 2 weeks before presenting with acute myocarditis. Within hours of presentation to the emergency department, she had cardiac arrest due to fulminant heart failure. Autopsy demonstrated necrotizing eosinophilic myocarditis. This is a rare cause of fulminant heart failure. This is the first report of a TNF-α antagonist potentially associated with acute necrotizing eosinophilic myocarditis.

Training the Teachers. The Clinician-Educator Track of the University of Washington Pulmonary and Critical Care Medicine Fellowship Program

The University of Washington was the first pulmonary and critical care medicine fellowship training program accredited by the Accreditation Council for Graduate Medical Education to create a dedicated clinician-educator fellowship track that has its own National Residency Matching Program number. This track was created in response to increasing demand for focused training in medical education in pulmonary and critical care. Through the Veterans Health Administration we obtained a stipend for a clinician-educator fellow to dedicate 12 months to training in medical education. This takes place predominantly in the second year of fellowship and is composed of several core activities: fellows complete the University of Washingtons Teaching Scholars Program, a professional development program designed to train leaders in medical education; they teach in a variety of settings and receive feedback on their work from clinician-educator faculty and the learners; and they engage in scholarly activity, which may take the form of scholarship of teaching, integration, or investigation. Fellows are guided throughout this process by a primary mentor and a mentoring committee. Since funding became available in 2009, two of the three graduates to date have successfully secured clinician-educator faculty positions. Graduates uniformly believe that the clinician-educator track met their training goals better than the research-based track would have.

Tophus Causing Bronchial Obstruction

A 56-year-old man with a history of chronic obstructive pulmonary disease and alcohol abuse was admitted to the medical ICU with septic shock and hypoxic respiratory failure requiring intubation. Imaging demonstratedmultifocal consolidation including complete consolidation of the right lower lobe (Figure 1) and blood cultures grew Streptococcus pneumoniae. He was treated with appropriate antibiotics and improved after 6 days but developed recurrent fevers and purulent airway secretions on Day 9. We performed bronchoscopy to evaluate for ventilator-associated pneumonia. A foreign body was found in the right lower lobe bronchus (Figure 2). It could not be removed using flexible bronchoscopy techniques and was later extracted using rigid bronchoscopy. Histopathologic examination revealed an acellular material (Figure 3) with crystalline structure which demonstrated strong negative birefringence under polarized light (Figure 4) consistent with urate crystals. There have been a number of case reports of gout affecting the larynx but to our knowledge this is the first report of a tophus in the lower airways (1, 2). The patient had no known history of gout or any signs of arthritis or external tophi on physical examination. No laryngeal abnormalities were noted during intubation.

ICU Emergencies Simulation Curriculum for Critical Care Fellows: The Difficult Airway

Introduction Management of airway emergencies is a core skill for critical care fellows. There is no standardized training mechanism for difficult airway management among critical care fellowships, although fellows frequently cite management of airway catastrophes as an area of educational need. Methods Three simulation cases that are each approximately 15 minutes in length are presented. The cases represent airway emergencies encountered in the intensive care unit consisting of angioedema, endotracheal tube dislodgement, and endotracheal tube occlusion. Incorporated into the scenarios are planned incidents of interpersonal conflict requiring negotiation by the learner during a crisis event. The case descriptions are complete, with learning objectives and critical actions as well as all necessary personnel briefs and required equipment. Results The cases were completed over multiple simulation sessions on different days by 11 first-year critical care fellows during the 2016–2017 academic year. All participants demonstrated improvement in self-perceived confidence in airway management skills. Discussion The cases were felt to be realistic and beneficial and led to perceived improvement in management of airway emergencies and leadership during crisis scenarios.

Acetazolamide Use in Severe Chronic Obstructive Pulmonary Disease. Pros and Cons

&NA; Acetazolamide is a carbonic anhydrase (CA) inhibitor sometimes used as a respiratory stimulant for patients with chronic obstructive pulmonary disease (COPD) with the goal of improving oxygenation, reducing carbon dioxide retention, and aiding liberation from mechanical ventilation and/or attempting to correct a metabolic alkalosis. However, the net effect of CA inhibition is multifactorial and complex, because CA is inhibited in many tissues that may negatively affect the patient with lung disease. The full impact of acetazolamide and other CA inhibitors depends critically on dosing, age, and pulmonary, renal, hepatic, hematological, and respiratory muscle function and reserves. This review examines the literature and indications for acetazolamide use in patients with COPD dating back to its initial release 6 decades ago. There are very few studies specifically designed to address the population with severe COPD, as such patients were frequently excluded from trials. We therefore discuss the complexity of CA inhibition and its potential benefits and dangers and describe ways in which the pathophysiology of patients with severe COPD puts them at considerable risk for serious adverse consequences. We offer guidance on the careful and rational use of acetazolamide in patients with respiratory disorders.

ATS Core Curriculum 2016. Part IV. Adult Pulmonary Medicine Core Curriculum.

Gaëtane C. Michaud, Colleen L. Channick, Anica C. Law, Jessica B. McCannon, MaryEllen Antkowiak, Garth Garrison, David Sayah, Richard H. Huynh, Anna K. Brady, Rosemary Adamson, Hilary DuBrock, Praveen Akuthota, Chad Marion, Charles Dela Cruz, James A. Town, Başak Çoruh, and Carey C. Thomson Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, New York, New York; Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Pulmonary and Critical Care Medicine, University of Vermont College of Medicine, Burlington, Vermont; Pulmonary and Critical Care Medicine, University of California, Los Angeles, Los Angeles, California; Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington; Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut; and Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Harvard Medical School, Boston, Massachusetts