Vital Conversations: An Interactive Conflict Resolution Training Session for Fourth-Year Medical Students.

Introduction: The AAMC has recognized the importance of effective teamwork and collaboration. One core Entrustable Professional Activity emphasizes creating a climate of mutual respect and trust and prioritizing team needs over personal needs, which leads to safe, timely, effective, efficient, and equitable patient care. Relationship conflicts, specifically, are associated with decreased productivity, complex information processing, and work satisfaction. Given the prevalence of conflict and its impact on health care workers, the lack of conflict resolution curricula in undergraduate medical education is surprising. We developed a curriculum formally introducing these skills and allowing practice in a simulated environment before students entered residency. Methods: Fourth-year medical students completed a conflict resolution exercise in a mandatory transition-to-residency course. Students completed online prework including reflection on teamwork and information on conflict resolution styles, participated in a simulated conflict with a standardized patient acting as a nurse, and afterward completed a self-evaluation with video review by the students' assigned coach and feedback on the session. Results: We collected complete responses from 108 students. We evaluated the curriculum for feasibility and acceptability by faculty and students. Most students agreed with faculty on their entrustment and milestone levels. Students found that the session prompted self-reflection and was a good review of conflict resolution. The standardized patient and faculty feedback was found to be the most useful by the students. Discussion: We successfully implemented a simulated but realistic conflict resolution exercise. Students found the exercise helpful in their preparation for residency.

L-Citrulline increases nitric oxide and improves control in obese asthmatics.

BACKGROUNDThe airways of obese asthmatics have been shown to be NO deficient, and this contributes to airway dysfunction and reduced response to inhaled corticosteroids. In cultured airway epithelial cells, L-citrulline, a precursor of L-arginine recycling and NO formation, has been shown to prevent asymmetric dimethyl arginine-mediated (ADMA-mediated) NO synthase (NOS2) uncoupling, restoring NO and reducing oxidative stress.METHODSIn a proof-of-concept, open-label pilot study in which participants were analyzed before and after treatment, we hypothesized that 15 g/d L-citrulline for 2 weeks would (a) increase the fractional excretion of NO (FeNO), (b) improve asthma control, and (c) improve lung function. To this end, we recruited obese (BMI >30) asthmatics on controller therapy, with a baseline FeNO of ≤30 ppb from the University of Colorado Medical Center and Duke University Health System.RESULTSA total of 41 subjects with an average FeNO of 17 ppb (95% CI, 15-19) and poorly controlled asthma (average asthma control questionnaire [ACQ] 1.5 [95% CI, 1.2-1.8]) completed the study. Compared with baseline, L-citrulline increased whereas ADMA and arginase concentration did not (values represent the mean Δ and 95% CI): plasma L-citrulline (190 µM, 84-297), plasma L-arginine (67 µM, 38-95), and plasma L-arginine/ADMA (ratio 117, 67-167). FeNO increased by 4.2 ppb (1.7-6.7 ppb); ACQ decreased by -0.46 (-0.67 to 0.27 points); the forced vital capacity and forced exhalation volume in 1 second, respectively, changed by 86 ml (10-161 ml) and 52 ml (-11 to 132 ml). In a secondary analysis, the greatest FEV1 increments occurred in those subjects with late-onset asthma (>12 years) (63 ml [95% CI, 1-137]), in females (80 ml [95% CI, 5-154]), with a greater change seen in late-onset females (100 ml, [95% CI, 2-177]). The changes in lung function or asthma control were not significantly associated with the changes before and after treatment in L-arginine/ADMA or FeNO.CONCLUSIONShort-term L-citrulline treatment improved asthma control and FeNO levels in obese asthmatics with low or normal FeNO. Larger FEV1 increments were observed in those with late-onset asthma and in females.TRIAL REGISTRATIONClinicalTrials.gov NCT01715844.FUNDINGNIH NHLBI R01 HL146542-01.

Fundamentals of asthma treatment / Os fundamentos do tratamento da asma

A asma é uma doença complexa. Sua característica cardial é a inflamação crônica que leva a hiper-responsividade brônquica. Como nenhum tratamento é capaz de modificar a história natural da asma, todas as abordagens terapêuticas disponíveis devem ser consideradas com a finalidade de se atingir o controle da asma e não sua cura. O principal objetivo do controle é o tratamento efetivo da inflamação da via aérea. Na maior parte dos casos, são necessáriosagentes farmacológicos para obter o controle. Os β2-agonistas de curta duração são os medicamentos preferidos para o alívio, graças a seu início rápido de ação. Os corticosteroides inalatórios são o tratamento mais efetivo para o controle dos sintomas asmáticos em longo prazo. Entretanto, em pacientes com asma persistente moderada a grave, é necessária terapia coadjuvante. Adicionar um β2-agonista de longa duração é mais efetivo na melhora dos sintomas do que agregar um antagonista dos receptores de leucotrienos. A teofilina continua a ter um papel específico em pacientes com pouca resposta aos corticosteroides inalatórios. O papel dos anticolinérgicos está evoluindo. Aproximadamente 10% dos asmáticos têm sintomas refratáriosmesmo com a combinação de tratamentos de controle. A imunoterapia surge como uma alternativa potencial no tratamento desse grupo heterogêneo de alto risco

Survival of acute myeloid leukemia cells requires PI3 kinase activation.

The mechanisms that regulate the growth and survival of acute myeloid leukemia (AML) cells are largely unknown. We hypothesized that constitutive activation of phosphatidyl-inositide 3 kinase (PI3 kinase) could regulate survival in primary cells from patients with AML. Here we demonstrate that Akt, a critical substrate of PI3 kinase, is activated in AML blasts. In a short-term culture system, most AML patient samples showed a dose-dependent decrease in survival after incubation with the PI3 kinase inhibitor LY294002. This decrease in survival was partially due to the induction of apoptosis. Furthermore, we have shown that p70 S6 kinase and 4EBP-1, downstream mediators of Akt signaling, also are phosphorylated in AML blasts. Phosphorylation of these proteins is inhibited by the mTOR inhibitor RAD001. Incubation of AML blasts with RAD001 induces only a small decrease in survival of the cells; however, when combined with Ara-C, RAD001 enhances the toxicity of Ara-C. These results demonstrate that constitutive activation of the PI3 kinase pathway is necessary for the survival of AML blasts and that targeting of this pathway with pharmacologic inhibitors may be of clinical benefit in treatment of AML.