W. Graham Carlos

Blastomycosis in Indiana: Digging up more cases

BACKGROUND The endemic region of blastomycosis historically has included the state of Indiana. However, few published reports of blastomycosis exist to substantiate this distinction. A surge of patients with blastomycosis in central Indiana (Indianapolis and surrounding counties) beginning in 2005 prompted us to review our local experience. We propose that this surge was related to major highway construction around Indianapolis. METHODS We reviewed all microbiologically confirmed cases from four hospitals serving central Indiana. Chart review was completed for adult patients, and data were collected on clinical presentations, methods of diagnosis, comorbidities, radiologic findings, treatment, and outcomes. We plotted patient residence addresses with sites of highway construction. RESULTS Fifty-nine patients were identified from laboratory results and physician referral. Interestingly, a surge of blastomycosis incidence occurred in 34 patients between 2005 and 2008 during which time major highway projects were under way around the Indianapolis metropolitan area. The majority of these patients presented acutely and with pulmonary involvement. Fungal culture and antigen testing were the most sensitive means to diagnosis. Antifungal therapy was highly effective. CONCLUSIONS This urban outbreak of blastomycosis in Indianapolis should prompt clinicians to consider blastomycosis in this highly endemic area of histoplasmosis.

Effectiveness of implementing a wake up and breathe program on sedation and delirium in the ICU.

Objectives:Mechanically ventilated critically ill patients receive significant amounts of sedatives and analgesics that increase their risk of developing coma and delirium. We evaluated the impact of a “Wake-up and Breathe Protocol” at our local ICU on sedation and delirium. Design:A pre/post implementation study design. Setting:A 22-bed mixed surgical and medical ICU. Patients:Seven hundred two consecutive mechanically ventilated ICU patients from June 2010 to January 2013. Interventions:Implementation of daily paired spontaneous awakening trials (daily sedation vacation plus spontaneous breathing trials) as a quality improvement project. Measurements and Main Results:After implementation of our program, there was an increase in the mean Richmond Agitation Sedation Scale scores on weekdays of 0.88 (p < 0.0001) and an increase in the mean Richmond Agitation Sedation Scale scores on weekends of 1.21 (p < 0.0001). After adjusting for age, race, gender, severity of illness, primary diagnosis, and ICU, the incidence and prevalence of delirium did not change post implementation of the protocol (incidence: 23% pre vs 19.6% post; p = 0.40; prevalence: 66.7% pre vs 55.3% post; p = 0.06). The combined prevalence of delirium/coma decreased from 90.8% pre protocol implementation to 85% postimplementation (odds ratio, 0.505; 95% CI, 0.299–0.853; p = 0.01). Conclusions:Implementing a “Wake Up and Breathe Program” resulted in reduced sedation among critically ill mechanically ventilated patients but did not change the incidence or prevalence of delirium.

The influence of the residency application process on the online social networking behavior of medical students: A single institutional study

Purpose To evaluate medical students’ behavior regarding online social networks (OSNs) in preparation for the residency matching process. The specific aims were to quantify the use of OSNs by students to determine whether and how these students were changing OSN profiles in preparation for the residency application process, and to determine attitudes toward residency directors using OSNs as a screening method to evaluate potential candidates. Method An e-mail survey was sent to 618 third- and fourth-year medical students at Indiana University School of Medicine over a three-week period in 2012. Statistical analysis was completed using nonparametric statistical tests. Results Of the 30.1% (183/608) who responded to the survey, 98.9% (181/183) of students reported using OSNs. More than half, or 60.1% (110/183), reported that they would (or did) alter their OSN profile before residency matching. Respondents’ opinions regarding the appropriateness of OSN screening by residency directors were mixed; however, most respondents did not feel that their online OSN profiles should be used in the residency application process. Conclusions The majority of respondents planned to (or did) alter their OSN profile in preparation for the residency match process. The majority believed that residency directors are screening OSN profiles during the matching process, although most did not believe their OSN profiles should be used in the residency application process. This study implies that the more medical students perceive that residency directors use social media in application screening processes, the more they will alter their online profiles to adapt to protect their professional persona.

Intrapulmonary Recombinant Factor VII as an Effective Treatment for Diffuse Alveolar Hemorrhage: A Case Series.

Background:The diffuse alveolar hemorrhage (DAH) syndrome is a life-threatening pulmonary complication related to systemic vasculitides, posthematopoietic stem cell transplantation, drugs, or toxins. Once DAH develops, the mortality rate is as high as 50% to 80%. Initial treatment consists of high-dose steroids and supportive measures, including mechanical ventilation. We present a case series of 6 patients treated with intrapulmonary recombinant factor VIIa (rFVIIa) to treat refractory DAH. Methods:Six patients with DAH were treated with intrapulmonary instillation of rFVIIa. Doses were divided equally between the right and the left lungs. Doses were 30, 50, or 60 mcg/kg and frequencies varied from a single administration to repeated doses on subsequent days on the basis of the clinical response. All patients received high-dose steroids, and 4 also received an aminocaproic acid infusion. Results:Intrapulmonary rVFIIa treated DAH effectively in 5 of 6 patients. Doses used were smaller and less frequent than those described previously. Conclusions:Intrapulmonary factor VII is an effective adjunctive treatment for DAH. We achieved treatment success with both smaller and less frequent doses than those described previously. This may be a good therapeutic option for DAH, particularly when standard therapies have failed or bleeding is immediately life threatening. It is possible that intrapulmonary rFVIIa could save costs, while improving the intensive care unit length of stay. Further prospective studies are needed to assess the optimal dose and frequency for adequate therapeutic efficacy.

Multicenter Validation of a Customizable Scoring Tool for Selection of Trainees for a Residency or Fellowship Program. The EAST-IST Study

Rationale: Few data have been published regarding scoring tools for selection of postgraduate medical trainee candidates that have wide applicability. Objectives: The authors present a novel scoring tool developed to assist postgraduate programs in generating an institution‐specific rank list derived from selected elements of the U.S. Electronic Residency Application System (ERAS) application. Methods: The authors developed and validated an ERAS and interview day scoring tool at five pulmonary and critical care fellowship programs: the ERAS Application Scoring Tool‐Interview Scoring Tool. This scoring tool was then tested for intrarater correlation versus subjective rankings of ERAS applications. The process for development of the tool was performed at four other institutions, and it was performed alongside and compared with the “traditional” ranking methods at the five programs and compared with the submitted National Residency Match Program rank list. Results: The ERAS Application Scoring Tool correlated highly with subjective faculty rankings at the primary institution (average Spearmans r = 0.77). The ERAS Application Scoring Tool‐Interview Scoring Tool method correlated well with traditional ranking methodology at all five institutions (Spearmans r = 0.54, 0.65, 0.72, 0.77, and 0.84). Conclusions: This study validates a process for selecting and weighting components of the ERAS application and interview day to create a customizable, institution‐specific tool for ranking candidates to postgraduate medical education programs. This scoring system can be used in future studies to compare the outcomes of fellowship training.

Intensive Care Unit Educators: A Multicenter Evaluation of Behaviors Residents Value in Attending Physicians

Rationale: It is important for attending physicians to know which behaviors influence learner perceptions. To date, two studies focusing on general medicine attending physicians have been published addressing internal medicine residents’ perceptions of attending physicians; there are no data on intensive care unit (ICU) attending physicians. Objectives: We sought to expand the evidence regarding this topic through a multicenter study at four geographically diverse academic medical centers. Our study focused on identifying the teaching behaviors of ICU physicians that learners observe in attending physicians who they value as effective educators. Methods: The study was conducted at Indiana University (Indianapolis, IN), Johns Hopkins University (Baltimore, MD), University of California‐San Francisco (San Francisco, CA), and University of Washington (Seattle, WA). Internal medicine residents completed an anonymous online survey rating the importance of behaviors of ICU attending physician role models. We created a 37‐item questionnaire derived from prior studies and from the Clinician Teaching Program from the Stanford Faculty Development Center for Medical Teachers. This questionnaire included behaviors, current and past, that residents observed in their ICU attending physicians. Results: A total of 260 of 605 residents responded to the survey (overall response rate of 43%). The five behaviors of attending physicians most commonly rated as “very important” to residents were: (1) enjoyment of teaching; (2) demonstrating empathy and compassion to patients and families; (3) ability to explain clinical reasoning and differential diagnoses; (4) treating nonphysician staff members respectfully; and (5) enthusiasm on rounds. Behaviors that trainees rated as less important were having numerous research publications, having served as chief resident, sharing personal life with residents, and organizing end‐of‐rotation social events. Conclusions: Our study provides new information to attending physicians striving to influence resident education. Although prior data demonstrated that learners valued attending physicians having served as chief resident and sharing personal information with learners, our study did not replicate this. We confirmed that learners appreciated teachers who are perceived to enjoy teaching. We discovered that behaviors, such as expression of empathy, explanation of clinical reasoning, and qualities of professionalism, were commonly seen in esteemed teaching attending physicians. Our study was limited by lack of correlation to objective performance metrics and a low response rate. Future work may include assessing the impact of faculty development on identified behaviors.

A pilot study: a teaching electronic medical record for educating and assessing residents in the care of patients

ABSTRACT Objective: We tested a novel, web-based teaching electronic medical record to teach and assess residents’ ability to enter appropriate admission orders for patients admitted to the intensive care unit. The primary objective was to determine if this tool could improve the learners’ ability to enter an evidence-based, comprehensive initial care plan for critically ill patients. Methods: The authors created three modules using de-identifed real patient data from selected patients that were admitted to the intensive care unit. All senior residents (113 total) were invited to participate in a dedicated two-hour educational session to complete the modules. Learner performance was graded against gold standard admission order sets created by study investigators based on the latest evidence-based medicine and guidelines. Results: The session was attended by 39 residents (34.5% of invitees). There was an average improvement of at least 20% in users’ scores across the three modules (Module 3-Module 1 mean difference 22.5%; p = 0.001 and Module 3-Module 2 mean difference 20.3%; p = 0.001). Diagnostic acumen improved in successive modules. Almost 90% of the residents reported the technology was an effective form of teaching and would use it autonomously if more modules were provided. Conclusions: In this pilot project, using a novel educational tool, users’ patient care performance scores improved with a high level of user satisfaction. These results identify a realistic and well-received way to supplement residents’ training and assessment on core clinical care and patient management in the face of duty hour restrictions.

Volcanic Eruptions and Threats to Respiratory Health

■ ■ Pregnancy People with known airway reactivity (such as asthma or COPD) may develop bronchospasm (tightening of airway muscles) that causes symptoms such as shortness of breath, wheezing, cough, and inflammation in the airways leading to swelling and mucus production, even with limited vog exposure. At high exposures, anyone (even healthy people with no lung disease) may develop breathing problems. Sustained levels of exposure have been associated with an increased risk of needing emergency room care. People, especially those at higher risk (listed above) should follow the health advisories listed in the Air Quality Index for particle pollution produced by the Environmental Protection Agency (Figure 1). For example, the Air Quality Index for Kona (about 40 miles or 64 km) northwest of the summit was at “orange” level on May 20th, 2018, and therefore was unhealthy for older individuals or those with preexisting heart or lung disease.

Bridging the gap for future clinician-educators

In contrast to the training required in the UK, opportunities for medical education training in the USA are limited. Resident‐as‐teacher programmes are typically insufficient to prepare trainees to be successful clinician‐educators, but few pursue formal education degrees. We sought to assess the need for, and feasibility of, a training pathway for subspecialty fellows in a large Department of Medicine that would prepare our trainees to become effective educators.

“Hole-hearted” Hemoptysis

A 77-year-old male with chronic trace hemoptysis presented with new submassive (z100 ml) hemoptysis. His history is significant for coronary artery bypass grafting with subsequent placement of an epicardial automated implantable cardioverter-defibrillator (AICD) via bilateral anterior thoracotomies 10 years later. No malformations or complications were noted at the time of these operations. Computed tomography of the chest, performed 12 years after AICD placement, demonstrated a broncho-atrial fistula with erosion of an epicardial patch into the right atrium and right upper lobe bronchus (Figure 1). Despite stable preoperative hemodynamics and successful repair of a 4 3 4 cm defect in the right atrial wall, he could not be weaned off of cardiopulmonary bypass and died. Early AICDs were placed surgically on the epicardium or pericardium via sternotomy or thoracotomy (1). Complications such as hemoptysis due to patch erosion causing fistula formation between the pericardium and lobar bronchi (1, 2), lead migration, infection (3, 4), and constrictive pericarditis have been described with surgically placed epicardial AICDs. Clinicians should have a high amount of suspicion for patch erosion when evaluating patients with recurrent unexplained hemoptysis who have surgically implanted AICDs.