Impact of Novel Multiinstitutional Curriculum on Critical Care Fellow Ventilator Knowledge.

Management of mechanical ventilation (MV) is a curricular milestone for trainees in pulmonary critical care medicine (PCCM) and critical care medicine (CCM) fellowships. Though recognition of ventilator waveform abnormalities that could result in patient complications is an important part of management, it is unclear how well fellows recognize these abnormalities. To study proficiency of ventilator waveform analysis among first-year fellows enrolled in a MV course compared with that of traditionally trained fellows.

Assessing Nephrology Fellows' Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News.

Rationale & Objective: Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy.

Study Design: Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy.

An Exploratory Assessment of Sleep Patterns, Burnout and Perceived Stress of a Cohort of Active Duty Military Physicians.

This article was migrated. The article was marked as recommended. Physician well-being is crucial and has the potential to impact patient safety.

Determining the Suitability of Registries for Embedding Clinical Trials in the United States: A Project of the Clinical Trials Transformation Initiative.

Background: Patient registries are organized systems that use observational methods to collect uniform data on specified outcomes in a population defined by a particular disease, condition, or exposure. Data collected in registries often coincide with data that could support clinical trials. Integrating clinical trials within registries to create registry-embedded clinical trials offers opportunities to reduce duplicative data collection, identify and recruit patients more efficiently, decrease time to database lock, accelerate time to regulatory decision-making, and reduce clinical trial costs.

Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline.

Clinical Question: What is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.

Current Practice: Gastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.

Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings.

Introduction: There is a need for educational resources supporting the practice and assessment of the complex processes of clinical reasoning in the inpatient setting along a continuum of physician experience levels.

Methods: Using participatory design, we created a scenario-based simulation integrating diagnostic ambiguity, contextual factors, and rising patient acuity to increase complexity. Resources include an open-ended written exercise and think-aloud reflection protocol to elicit diagnostic and management reasoning and reflection on that reasoning.

Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program.

Introduction: In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula.

Clinical Reasoning in the Primary Care Setting: Two Scenario-Based Simulations for Residents and Attendings.

Introduction: We describe the development and implementation of tools medical educators or researchers can use for developing or analyzing residents' through attending physicians' clinical reasoning in an outpatient clinic setting. The resource includes two scenario-based simulations (i.e.

Beneficial effect of combined spironolactone and quinapril treatment on thrombosis and hemostasis in 2K1C hypertensive rats.

A strong correlation between raised aldosterone levels and increased risk of thrombotic disorders has been provided. Clinical studies have demonstrated the benefits of the addition of the aldosterone receptor antagonist to the standard therapy with angiotensin-converting enzyme inhibitor in the reduction of cardiovascular events in patients. We suggest that the benefits of this dual renin-angiotensin-aldosterone system (RAAS) blockade may be related to the drug's effects on the hemostatic and oxidative balance.

The Impact of Deployment on the Practice of the Military Internist: A Needs Assessment for Post-Deployment Refresher Training.

Introduction: U.S. Army internists serve in a variety of provider roles during deployment, many of which vary from the traditional responsibilities of a general internist or internal medicine subspecialist.

Informed consent in clinical research: Consensus recommendations for reform identified by an expert interview panel.

Background: Informed consent is the cornerstone for protection of human subjects in clinical trials. However, a growing body of evidence suggests that reform of the informed consent process in the United States is needed.

Methods: The Clinical Trials Transformation Initiative conducted interviews with 25 experienced observers of the informed consent process to identify limitations and actionable recommendations for change.

Clinical Data for Informed Medication Use in Pregnancy: Strengths, Limitations, Gaps, and a Need to Continue Moving Forward.

The objective of this paper is to explore the strengths, weaknesses, gaps, and needs in research on medication use in pregnancy, where opportunities have been bypassed to develop standards and collaborations for collecting data to better understand how medications can impact clinical outcomes in pregnant women and developing fetuses. The availability of existing data and the methods of its capture are reviewed, including registries, claims and health record databases, and meta-analyses. The paper focuses on why these efforts have not fundamentally provided benefit-risk information and clinical treatment algorithms for medication use in pregnant women.

A Proposed Framework to Address Needs of Clinical Data for Informed Medication Use in Pregnancy.

The objective of this paper is to communicate a proposed framework for addressing research limitations and communication barriers that contribute to a lack of data for making clinical treatment decisions about medication use in pregnancy. To address this global public health concern, a cross-stakeholder coalition composed of several workstreams is proposed. The intent is to foster collaborative discussion regarding potential solutions to address gaps in communication, engagement, and data generation and collection.

The Central Simulation Committee (CSC): a model for centralization and standardization of simulation-based medical education in the U.S. Army healthcare system.

In this report, we describe the organizational framework, operations and current status of the Central Simulation Committee (CSC). The CSC was established in 2007 with the goals of standardizing simulation-based training in Army graduate medical education programs, assisting in redeployment training of physicians returning from war, and improving patient safety within the Army Medical Department. Presently, the CSC oversees 10 Simulation Centers, controls over 21,000 sq ft of simulation center space, and provides specialty-specific training in 14 medical specialties.

Does difficult mask ventilation predict obstructive sleep apnea? A prospective pilot study to identify the prevalence of osa in patients with difficult mask ventilation under general anesthesia.

Background: Given the pathogenesis of obstructive sleep apnea (OSA), anesthesiologists may be in a unique position to rapidly identify patients who are at risk for undiagnosed OSA in the perioperative period. Identification is the first step in prompt diagnosis and potential prevention of OSA related comorbidities. Patients who exhibit unanticipated difficult mask ventilation (DMV) during induction of general anesthesia may be at risk of having undiagnosed OSA.

An uncommon cause of chest pain in the deployed soldier.

Chest pain is a common complaint at medical treatment facilities during combat operations. The initial evaluation focuses on potentially life-threatening conditions (acute coronary syndrome, aortic dissection, pulmonary embolus), in addition to pericarditis and benign musculoskeletal conditions such as costochondritis. Pulmonary arteriovenous malformation is a rare condition, but an important diagnostic consideration in soldiers who present with chest pain and/or hypoxia and in whom other life-threatening conditions, such as cardiovascular disasters and pulmonary embolus, are excluded.

Altered M1/M2 activation patterns of monocytes in severe relapsing experimental rat model of multiple sclerosis. Amelioration of clinical status by M2 activated monocyte administration.

Objectives: We investigated proinflammatory M1 and immunomodulatory M2 activation profiles of circulating monocytes in relapsing experimental autoimmune encephalomyelitis (EAE) model of multiple sclerosis, and tested whether altered M1/M2 equilibrium promotes CNS inflammation.

Results: Approaches of MRI macrophage tracking with USPIO nanoparticles and expression patterns of M1/M2 macrophages and microglia in brain and M1/M2 monocytes in blood samples at various disease stages revealed that M1/M2 equilibrium in blood and CNS favors mild EAE, while imbalance towards M1 promotes relapsing EAE. We consequently investigated whether M2 activated monocyte restoration in peripheral blood could cure acute clinical EAE disease.

Type 3 deiodinase expression in inflammatory spinal cord lesions in rat experimental autoimmune encephalomyelitis.

Background: We have shown substantial expression of type 3 deiodinase (D3, a major enzyme involved in the inactivation of thyroid hormone) in infiltrating leukocytes in several models of inflammation. Recently, thyroid hormone has been shown to improve remyelination in experimental autoimmune encephalomyelitis (EAE), an animal model of multiple sclerosis. As induction of D3 may play an important role in decreasing local bioavailability of thyroid hormone at inflammation sites, we hypothesized that D3 is induced in spinal cord inflammatory lesions in EAE.

Clinical and lung-function variables associated with vocal cord dysfunction.

Background: Vocal cord dysfunction (VCD) is difficult to diagnose. Laryngoscopy while the patient is symptomatic is the accepted standard method to establish a diagnosis of VCD, but patient characteristics and spirometry values are thought to be useful for predicting VCD. We sought to identify clinical and spirometric variables that suggest VCD.

[Local thrombolysis in the treatment of peripheral arterial vascular diseases].

While atherosclerosis develops in a progressive manner, acute arterial thrombosis and embolism are characterized by fulminant occlusion of vessels. Special localisation of atherosclerotic plaques might result in severe and life threatening clinical symptoms. Multidisciplinary consultations of angiologist, radiologist and surgeon are necessary to identify the most proper diagnosis, and urgent intervention should be taken which nowadays involves local thrombolysis, too.

Vocal cord dysfunction.

A case of vocal cord dysfunction (VCD) is presented, followed by a discussion of the clinical characteristics, pathogenesis, diagnosis, and management of this disorder. Special emphasis is given to clinical pearls and pitfalls for the practicing allergist. VCD is a common condition that mimics asthma.

[Peripheral arterial disease].

The peripheral arterial disease (PAD) accounts for very significant medical issue in the world. Various clinical disorders due to coronary, cerebrovascular, abdominal and obliterative arteriosclerosis of extremities can be classified as the most important medical challenges. This review summarises the etiopathogenesis of this systemic problem including the function of endothelium as well as the anatomic, physiologic relevance, and major risk factors of atherosclerosis (diabetes mellitus, hypertension, obesity, smoking etc.

High levels of medical utilization by ambulatory patients with vocal cord dysfunction as compared to age- and gender-matched asthmatics.

Study Objectives: To evaluate medical utilization by ambulatory patients with vocal cord dysfunction (VCD).

Design: Retrospective, case-control study.

Setting: Pulmonary disease clinic at an army tertiary-care center.

Allergic bronchopulmonary aspergillosis.

A case of allergic bronchopulmonary aspergillosis (ABPA) is presented, followed by a discussion of the clinical characteristics, pathogenesis, diagnosis, and management of this disease. Special emphasis is given to clinical pearls and pitfalls for the practicing allergist. ABPA is a hypersensitivity response to Aspergillus antigens in the lung and is distinct from other forms of Aspergillus pulmonary disease.