Work Related Post Traumatic Stress Disorder in Medicine Residents.

OBJECTIVE: This study sought to screen for the burden of work-related posttraumatic stress disorder (PTSD) symptoms in internal medicine residents. METHODS: A cross-sectional survey of internal medicine residents from three academic institutions was conducted using the PCL-5 screening tool. RESULTS: Off all residents surveyed, 5.2% screened positive for PTSD symptoms (N = 194). 86.1% of all trainees identified stressors during training. Positive PTSD screens were significantly higher in PGY3 residents (X2 = 15.24, p = 0.0005). Of all PGY3 residents, 9.8% (N = 4) and 14.6% (N = 6) of residents screened positive for PTSD symptoms based on absolute and cluster score criteria, respectively. Verbal/physical assault by patients/families/colleagues were triggers for the most cases of positive screens. CONCLUSIONS: Self-reported stressors are highly prevalent in internal medicine trainees. Verbal/physical assault by patients and families appear to be the triggering event for most positive screens. These observations will help with future study designs to quantify the burden of work related PTSD in internal medicine trainee physicians so that appropriate supportive measures can be provided.

FGF23 Induction of O-Linked N-Acetylglucosamine Regulates IL-6 Secretion in Human Bronchial Epithelial Cells.

The hexosamine biosynthetic pathway (HBP) generates the substrate for the O-linked ß-N-acetylglucosamine (O-GlcNAc) modification of proteins. The HBP also serves as a stress sensor and has been reported to be involved with nuclear factor of activated T-cells (NFAT) activation, which can contribute to multiple cellular processes including cell metabolism, proliferation, and inflammation. In our previously published report, Fibroblast Growth Factor (FGF) 23, an important endocrine pro-inflammatory mediator, was shown to activate the FGFR4/phospholipase Cγ (PLCγ)/nuclear factor of activated T-cells (NFAT) signaling in chronic inflammatory airway diseases such as cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD). Here, we demonstrate that FGF23 increased the O-GlcNAc modification of proteins in HBECs. Furthermore, the increase in O-GlcNAc levels by FGF23 stimulation resulted in the downstream activation of NFAT and secretion of interleukin-6 (IL-6). Conversely, inhibition of FGF23 signaling and/or O-GlcNAc transferase (OGT)/O-GlcNAc reversed these effects. Collectively, these data suggest that FGF23 induced IL-6 upregulation and secretion is, at least, partially mediated via the activation of the HBP and O-GlcNAc levels in HBECs. These findings identify a novel link whereby FGF23 and the augmentation of O-GlcNAc levels regulate airway inflammation through NFAT activation and IL-6 upregulation in HBECs. The crosstalk between these signaling pathways may contribute to the pathogenesis of chronic inflammatory airway diseases such as COPD and CF as well as metabolic syndromes, including diabetes.

Change in Diaphragmatic Thickness During the Respiratory Cycle Predicts Extubation Success at Various Levels of Pressure Support Ventilation.

PURPOSE: Ultrasonographic assessment of diaphragm function with patients on low levels of pressure support (PS) predicts extubation outcomes, but similar information regarding extubation success under other conditions is lacking. The purpose of this study was to determine whether ultrasound (US) measurements of the diaphragm made on various levels of PS can predict time until successful extubation. METHODS: Fifty-six intubated patients underwent ultrasound of the right hemidiaphragm during a PS wean at varying levels of pressure support (PS 5/5 cm of H2O, 10/5 cm of H2O, and 15/5 cm of H2O). The diaphragm was visualized using a 7.5-10 mHz transducer in the zone of apposition of the diaphragm to the lower rib cage. The percent change in diaphragm thickness between end-expiration and end-inspiration (∆tdi%) was calculated at each level of PS. RESULTS: ∆tdi% >20 is a robust predictor of extubation success within 48 h of US at PS 5/5 cm of H2O and 10/5 cm of H2O (sensitivity 84.6 and 88.9 % and specificity 79.0 and 75.0 %, respectively). At PS greater than 10/5 cm of H2O, its predictive power was greatly diminished. Of nine patients who were extubated with ∆tdi% below the cutoff, 66.6 % required emergent reintubation in the next two days. CONCLUSIONS: Diaphragm US is a valid predictor of extubation success at some but not all PS settings. Using a ∆tdi% of 20 % on PS levels up to 10/5 cm of H2O may reduce both unnecessarily prolonged intubations and prevent emergent reintubations.