Discussing and Teaching About Race and Health Inequities.

Health inequities are prevalent in our medical institutions and result in unfair access to and delivery of health care. Some of the most profound health disparities are related to race, which has erroneously been used to make biological inferences to explain disease states in medicine. Our profession continues to shift away from such race-based medical narratives, which do not examine how social determinants of health, social injustice, systemic racism, and existing power structures shape health outcomes toward a health equity mindset and race-conscious medicine. Clinician educators are responsible for teaching and engaging with learners around issues of inequity in medicine, although many may feel they lack the knowledge or skills to do so. Opportunities for conversations on health equity abound, either as a response to statements made by clinical peers or patients, or through direct clinical care of affected populations. In this paper, we focus our discussion of health equity around the topic of race corrections in spirometry, which is one of several salient areas of conversation in the field of pulmonary medicine undergoing reconciliation. We review basic definitions and concepts in health equity and apply three strategies to engage in conversations around equity with colleagues and learners: actively learning and reflecting on health inequities, recognizing and naming inequities, and consciously role-modeling equity-conscious language and care. We also will summarize strategies for implementing health equity concepts into the continuum of medical education and our clinical learning environments.

Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment.

Introduction: Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods: With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results: Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion: The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.

Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders.

Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.

Chronic Neuromuscular Respiratory Failure and Home Assisted Ventilation.

Chronic respiratory failure is a common, important complication of many types of neuromuscular and chest wall disorders. While the pathophysiology of each disease may be different, these disorders can variably affect all muscles involved in breathing, including inspiratory, expiratory, and bulbar muscles, ultimately leading to chronic respiratory failure and hypoventilation. The use of home assisted ventilation through noninvasive interfaces aims to improve the symptoms of hypoventilation, improve sleep quality, and, when possible, improve mortality. An increasing variety of interfaces has allowed for improved comfort and compliance. In a minority of scenarios, noninvasive ventilation is either not appropriate or no longer effective due to disease progression, and a transition to tracheal ventilation should be considered.

Impact of the COVID-19 Pandemic on U.S. Pulmonary and Critical Care Medicine Fellowship Training.

BACKGROUND: Although it is well known that the coronavirus disease (COVID-19) pandemic has had a profound effect on health care, its impact on fellowship training in Pulmonary and Critical Care Medicine (PCCM) has not been well described. OBJECTIVE: We conducted an anonymous survey of PCCM program directors (PDs) to assess the impact of the COVID-19 pandemic on PCCM fellowship training across the United States. METHODS: We developed a 30-question web-based survey that was distributed to U.S. PCCM PDs through the Association of Pulmonary and Critical Care Medicine Program Directors. RESULTS: The survey was sent to 242 PDs, of whom 28.5% responded. Most of the responses (76.8%) came from university-based programs. Almost universally, PDs reported a decrease in the number of pulmonary function tests (100%), outpatient visits (94.1%), and elective bronchoscopies (96%). Three-quarters (77.6%) of the PDs reported that their PCCM fellows spent more time in the intensive care unit than originally scheduled. CONCLUSION: The COVID-19 pandemic has had a variable impact on different aspects of fellowship training. PDs reported a significant decrease in the core components of pulmonary training, whereas certain aspects of critical care training increased. It is likely that targeted mitigation strategies will be needed to ensure no gaps in PCCM training while optimizing well-being.

Just-In-Time Tools for Training Non-Critical Care Providers. Troubleshooting Problems in the Ventilated Patient.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for non-intensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to managing complications that can arise in patients receiving invasive mechanical ventilation.

Just-In-Time Tools for Training Non-Critical Care Providers. Basics of Respiratory Failure.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for nonintensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to the evaluation and management of patients with hypoxemic respiratory failure and the basics of invasive mechanical ventilation.

Virtually Hosting a National Medical Society Conference. Lessons Learned from the 2020 Association of Pulmonary and Critical Care Medicine Program Directors Conference.

The coronavirus pandemic forced the Association of Pulmonary and Critical Care Medicine Program Directors to change the 2020 annual conference to a virtual format with relatively short notice. Using the experience of the planning committee and survey feedback from attendees, we describe the steps taken to implement a virtual conference and lessons learned in the process. The lessons described include frequent and concise communication, establishment of roles within a discrete production team, preparing speakers with a protocolized training session, active moderation of the chat box, using interactive polling and online documents to improve interactivity, a shorter agenda with more frequent breaks, encouraging "virtual happy hours" to connect with colleagues, and establishing facilitators for breakout rooms.

Síndrome de Kounis, a propósito de un caso / Kounis syndrome, apropos of a case

El síndrome de Kounis se caracteriza por un compromiso cardiaco que es secundario a una respuesta alérgica. Hay pocos datos acerca de la epidemiologia de esta enfermedad debido a su reciente descripción. Se presenta el caso de una paciente mujer de 46 años sin antecedentes de importancia que presentó dolor tipo cólico episódico en hipocondrio derecho de 4 días de tiempo de enfermedad, en la que se consideró el diagnóstico de cólico de origen biliar. Quince minutos luego de manejo sintomático (hiocsina/dipirona), la paciente presentó dolor torácico en región precordial de inicio súbito. La evaluación física mostró hipotensión, taquicardia, presencia de habones en todo el cuerpo y sibilantes a la auscultación pulmonar. El electrocardiograma mostro infradesnivel del segmento ST. Considerado como síndrome coronario agudo, se realizó el manejo con esteroides y soporte vital, y se indicó monitorización cardiovascular en unidad de cuidados intensivos. La paciente egresó sin complicación luego de unos días

Kounis syndrome is defined as an acute coronary syndrome secondary to an allergic response; and it is also known as allergic angina - acute myocardial infarction. There is little data on the epidemiology of this disease because of having been recently described. We present the case of a 46-year old woman who developed an episode of colicky abdominal pain in the right upper quadrant for 4 days, and a diagnosis of abdominal pain of biliary origin was considered. Fifteen minutes after symptomatic therapy was administered (hyoscine and metamizole), the patient developed sudden chest pain. Physical examination revealed hypotension, tachycardia, rash, and wheezing. The electrocardiogram showed ST segment depression. The case was managed as an acute coronary syndrome, vital support and steroids were part of its management, and the patient was admitted in the intensive care unit for coronary monitoring. A few days later, the patient was uneventfully discharged

Inclusion of an informant yields strong associations between cognitive complaint and longitudinal cognitive outcomes in non-demented elders.

BACKGROUND: The relation between the source of cognitive complaint and objective cognitive performance is not well understood. OBJECTIVE: Examine self and informant cognitive complaint as predictors of objective cognitive and functional trajectory in non-demented elders. METHODS: Participants from the National Alzheimer's Coordinating Center had a baseline diagnosis of normal cognition (NC; n = 6133, 72±8 years, 68% female) or mild cognitive impairment (MCI; n = 3010, 74±8 years, 55% female). Four independent groups defined cognitive complaint: no complaint, self-only complaint, informant-only complaint, or mutual complaint (both self and informant complaint). Linear mixed model regression analyses related complaint status (referent was no complaint) to cognitive and functional trajectories, adjusting for age, sex, race, education, and follow-up period. RESULTS: Among NC participants, mutual complaint related to faster decline in global cognition (p < 0.0001), language (all p-values <0.0001), processing speed (p = 0.0002), and executive functioning (p = 0.0006). Informant-only complaint related to faster decline in global cognition (p = 0.0001) and processing speed (p = 0.0001). Self-only complaint related to greater decline in immediate (p < 0.0001) and delayed (p = 0.0005) episodic memory. In MCI, mutual complaint related to faster decline in global cognition (p < 0.0001), verbal episodic memory (all p-values <0.0001), language (all p-values <0.0001), and processing speed(all p-values <0.0006). Informant-only or self-only complaint associations with cognitive trajectory did not survive correction factor for multiple comparisons.Conclusion: Cognitive complaint appears to have clinical significance, as it is related to declines in objective cognitive performance over time. Mutual complaint was associated with the worst cognitive trajectory in both NC and MCI elders, highlighting the importance of incorporating an informant into evaluation of elders whenever feasible.

Clinical research risk assessment among individuals with mild cognitive impairment.

OBJECTIVE: : To determine whether individuals with mild cognitive impairment (MCI) differ from cognitively normal (NC) elders on a risk assessment task and whether participants and their study partners evaluate risk and benefit similarly. DESIGN: : Cross-sectional. SETTING: : University medical setting. PARTICIPANTS: : Seventy-nine participants (NC, n = 40; MCI, n = 39), age 60-90 years (73 ± 7 years; 53% women), and 64 study partners (NC, n = 36; MCI, n = 28), age 38-84 years (68 ± 10 years; 67% women). MEASUREMENTS: : Participants and study partners completed a risk assessment task that involved ranking from least to most risk four hypothetical vignettes for memory loss research (brain autopsy, blood draw, oral medication, neurosurgery). Participants also completed decisional capacity for research and neuropsychological protocols. RESULTS: : MCI participants' risk rankings differed from NC risk rankings (p <0.001) with MCI participants ranking brain autopsy higher and an oral medication trial lower. Demographic, decisional capacity, and neuropsychological variables could not explain MCI participant performances. Participants and their study partners had comparable risk assessment performance (p = 1.0). MCI study partners performed similar to their MCI participant counterparts but were different from NC study partners (p = 0.002; i.e., ranking autopsy higher and oral medication lower). CONCLUSION: : Findings suggest that individuals with MCI assess risk differently than NC peers by overestimating the risk (or underestimating the benefit) of brain autopsy and underestimating the risk (or overestimating the benefit) of oral medication. Study partners display a similar pattern. These observations may be secondary to MCI participants' (and their study partners') personal connection to the potential benefits of an experimental medication for memory loss.