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Plasma-liquid interactions represent a growing interdisciplinary area of research involving plasma science, fluid dynamics, heat and mass transfer, photolysis, multiphase chemistry and aerosol science. This review provides an assessment of the state-of-the-art of this multidisciplinary area and identifies the key research challenges. The developments in diagnostics, modeling and further extensions of cross section and reaction rate databases that are necessary to address these challenges are discussed. The review focusses on non-equilibrium plasmas.

Introduction: Extrusion of maxillary lateral incisors during aligner treatment is a difficult movement to achieve accurately. Despite recommendations regarding attachment design, few studies and no prospective trials compare predictability among attachments. This study aimed to compare the efficacy between optimized and horizontal attachment designs for achieving maxillary lateral incisor extrusion during clear aligner treatment., Methods: The study included maxillary lateral incisors in 3 orthodontic practices requiring at least 0.3 mm of extrusion during the first series of 20-25 aligners in patients aged ≥16 years who were scheduled to begin clear aligner treatment (Invisalign; Align Technology, San Jose, Calif). Teeth were randomly assigned to receive optimized (O), rectangular horizontal nonbeveled (H), rectangular horizontal incisally-beveled (HIB), or rectangular horizontal gingivally-beveled (HGB) attachments. After the first series, a blinded evaluator measured extrusion using superimpositions with initial and predicted models. Linear models determined the difference in the predicted extrusion percentage achieved on the basis of attachment design. Other covariates were patient age, sex, number of trays, and self-reported compliance., Results: Forty patients (74 teeth) were enrolled, and 38 patients (71 teeth) completed the study. Intraexaminer and interexaminer reliability for extrusion measurements was high (intraclass correlation coefficient, 0.985 and 0.991, respectively). The achieved extrusion was significantly less than predicted (mean, 73%; P <0.0001). The average achieved extrusion was 62%, 79%, 78%, and 78% for O, H, HIB, and HGB attachments, respectively, with H significantly more effective than O (P = 0.0403). Horizontal attachments (H, HIB, and HGB combined) were significantly more effective than O attachments (P = 0.0060), with an average difference in achieved extrusion of 14% of the predicted amount (95% confidence interval, 4-23; estimated 76% vs 62%). Horizontal attachments were an estimated 22% more effective than O attachments for extruding maxillary lateral incisors., Conclusions: Horizontal attachments are more effective than O attachments for predicted maxillary lateral incisor extrusion between 0.3 and 2.5 mm. The 3 horizontal attachment designs evaluated performed similarly for achieving predicted extrusion., Trial Registration: This randomized clinical trial was registered and reported at clinicaltrials.gov (NCT04968353)., Protocol: The protocol was not published before trial commencement., Funding: This study was funded in part by the Alexander Fellowship of the Virginia Commonwealth University School of Dentistry, the Southern Association of Orthodontists, and the Virginia Orthodontic Education and Research Foundation. No funding source influenced the study design, the collection, analysis or interpretation of data, writing of the report, or the decision to submit the article for publication., (Copyright © 2023 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.)

The overarching goal of medical education is to train clinicians who achieve and maintain competence in patient care. Although the field of medical education research has acknowledged the importance of education on clinical practices and outcomes, most research endeavors continue to focus on learner-centered outcomes, such as knowledge and attitudes. The absence of clinical and patient-centered outcomes in pulmonary and critical care medicine medical education research has been attributed to barriers at multiple levels, including financial, methodological, and practical considerations. This Perspective explores clinical outcomes relevant to pulmonary and critical care medicine educational research and offers strategies and solutions that educators can use to accomplish what many consider the "prize" of medical education research: an understanding of how our educational initiatives impact the health of patients., (Copyright © 2024 by the American Thoracic Society.)

Lignin is the most abundant renewable feedstock to produce aromatic chemicals, however its depolymerisation involves the breaking of several C-O and C-C inter-unit linkages that connect smaller aromatic units that are present in lignin. Several strategies have been reported for the cleavage of the C-O inter-unit linkages in lignin. However, till today, only a few methodologies have been reported for the effective breaking or the conversion of the recalcitrant C-C inter unit linkages in lignin. Here we report the ruthenium ion catalysed oxidative methodology as an effective system to activate or convert the most recalcitrant inter unit linkages such as β-5 and 5-5' present in lignin. Initially, we used biphenyl as a model compound to study the effectiveness of the RICO methodology to activate the 5-5' C-C linkage. After 4 h reaction at 22 °C, we achieved a 30% conversion with 75% selectivity towards benzoic acid and phenyl glyoxal as the minor product. To the best of our knowledge this is the first ever oxidative activation of the C-C bond that connects the two phenyl rings in biphenyl. DFT calculation revealed that the RuO 4 forms a [3 + 2] adduct with one of the aromatic C-C bonds resulting in the opening of the phenyl ring. Biphenyl conversion could be increased by increasing the amount of oxidant; however, this is accompanied by a reduction in the carbon balance because of the formation of CO 2 and other unknown products. We extended this RICO methodology for the oxidative depolymerisation of lignin model hexamer containing β-5, 5-5' and β-O-4 linkages. Qualitative and quantitative analyses of the reaction mixture were done using 1 H, 13 C NMR spectroscopy methods along with GC-MS and Gel Permeation Chromatographic (GPC) methods. Advanced 2D NMR spectroscopic methods such as HSQC, HMBC and 31 P NMR spectroscopy after phosphitylation of the mixture were employed to quantitatively analyse the conversion of the β-5, 5-5' and β-O-4 linkages and to identify the products. After 30 min, >90% of the 5-5' and linkages and >80% of the β-5' are converted with this methodology. This is the first report on the conversion of the 5-5' linkage in lignin model hexamer., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Developing an effective therapy to overcome carbapenemase-positive Klebsiella pneumoniae (CPKp) is an important therapeutic challenge that must be addressed urgently. Here, we explored a Ca-EDTA combination with aztreonam or ceftazidime-avibactam in vitro and in vivo against diverse CPKp clinical isolates. The synergy testing of this study demonstrated that novel aztreonam-Ca-EDTA or ceftazidime-avibactam-Ca-EDTA combination was significantly effective in eliminating planktonic and mature biofilms in vitro , as well as eradicating CPKp infections in vivo . Both combinations revealed significant therapeutic efficacies in reducing bacterial load in internal organs and protecting treated mice from mortality. Conclusively, this is the first in vitro and in vivo study to demonstrate that novel aztreonam-Ca-EDTA or ceftazidime-avibactam-Ca-EDTA combinations provide favorable efficacy and safety for successful eradication of carbapenemase-producing Klebsiella pneumoniae planktonic and biofilm infections., Competing Interests: The authors declare no competing interests., (© 2023 The Author(s).)

The presence of antibiotic residues in water is linked to the emergence of antibiotic resistance globally and necessitates novel decontamination strategies to minimize antibiotic residue exposure in both the environment and food. A holistic assessment of cold atmospheric pressure plasma technology (CAPP) for β-lactam antibiotic residue removal is described in this study. CAPP operating parameters including plasma jet voltage, gas composition and treatment time were optimized, with highest β-lactam degradation efficiencies obtained for a helium jet operated at 6 kV. Main by-products detected indicate pH-driven peroxidation as a main mechanism of CAPP-induced decomposition of β-lactams. No in vitro hepatocytotoxicity was observed in HepG2 cells following exposure to treated samples, and E. coli exposed to CAPP-degraded β-lactams did not exhibit resistance development. In surface water, over 50% decrease in antibiotic levels was achieved after only 5 min of treatment. However, high dependence of treatment efficiency on residue concentration, pH and presence of polar macromolecules was observed.

Background: Producing scholarship in education is essential to the career development of a clinician-educator. Challenges to scholarly production include a lack of resources, time, expertise, and collaborators., Objective: To develop communities of practice for education scholarship through an international society to increase community and academic productivity., Methods: We developed multi-institutional scholarship pods within the American Thoracic Society through the creation of a working group (2017-2019). Pods met virtually, and meetings were goal focused to advance education scholarship within their area of interest. To understand the impact of these scholarship pods, we surveyed pod leaders and members in 2021 and analyzed the academic productivity of each pod via a survey of pod leaders and a review of the PubMed index., Results: Nine pods were created, each with an assigned educational topic. The survey had a response rate of 76.6%. The perceived benefits were the opportunity to meet colleagues with similar interests at other institutions, production of scholarly work, and engagement in new experiences. The main challenges were difficulty finding times to meet because of competing clinical demands and aligning times among pod members. Regarding academic productivity, eight publications, four conference presentations, and one webinar/podcast were produced by six of the nine pods., Conclusion: The development of communities of practice resulted in increased multi-site collaboration, with boosted academic productivity as well as an enhanced sense of belonging. Multiple challenges remain but can likely be overcome with accountability, early discussion of roles and expectations, and clear delegation of tasks and authorship., (Copyright © 2023 by the American Thoracic Society.)

Objectives: Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic., Design: Cross-sectional survey using four validated instruments., Setting: Sixty-two sites in Canada and the United States., Subjects: Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs., Intervention: None., Measurements and Main Results: We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures., Conclusions: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness., Competing Interests: Dr. Burns disclosed that the Canadian Critical Care Society (CCSS) paid for the statistical analyses. Dr. Lorens received funding from the CCCS. Drs. Lorens and Kerlin disclosed work for hire. Drs. Viglianti, Kohn, Peltan, and Schnapp received support for article research from the National Institutes of Health (NIH). Dr. Fox-Robichaud’s institution received funding from the Canadian Institutes of Health Research and Hamilton Academic Hospitals. Dr. Mathews’ institution received funding from the National Heart, Lung, and Blood Institute (NHLBI); he received funding from Roivant/Kinevant Sciences. Dr. Jain is supported by the National Institute on Aging (NIA) T32AG019134, the Pepper Scholar Award from Yale Claude D. Pepper Older American Independence Center (P30AG021342), NIA of the NIH GEMSSTAR Award (R03AG078942), Parker B. Francis Fellowship Award, and Yale Physician-Scientist Development Award. Drs. Akgun and Crothers disclosed government work. Dr. Gershengorn received funding from the American Thoracic Society (ATS), Gilead Sciences, and Southeastern Critical Care Summit. Dr. Martin’s institution received funding from BARDA; he received funding from Genetech. Dr. Stapleton disclosed that she is chair of DSMB for Altimmune and a member of the ATS Board of Directors 2019–2021 (elected to Chair the Critical Care Assembly which includes a position on the Board). Dr. Attia’s institution received funding from the NHBLI (NHLBI K23 HL129888 and R03 [pending]), the Centers for Aids Research, and Pediatric HIV/AIDS Cohort Study. Dr. Maddux’s institution received funding from the National Institute of Child Health and Human Development (K23HD096018) and the Francis Family Foundation. Dr. Bagshaw received funding from Baxter and Bioporto. Dr. Crothers’ institution received funding from the NIH and Veteran’s Affairs. Dr. Peltan’s institution received funding from Regeneron and Asahi Kasei Pharma; he received funding from the NIH (K23GM129661) and Janssen. Dr. Schnapp received funding from UptoDate and Elsevier. Dr. Kraft’s institution received funding from the NIH, the American Lung Association, Sanofi, and AstraZeneca Consulting; she received funding from Sanofi, Astra-Zeneca, Chiesi Speaking, and UptoDate; she disclosed she is a cofounder and Chief Medical Officer of RaeSedo LLC. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and Wolters Kluwer Health, Inc.)

Background: Remediation of struggling learners in pulmonary and critical care fellowship programs is a challenge, even for experienced medical educators., Objective: This evidence-based narrative review provides a framework program leaders may use to address fellows having difficulty achieving competency during fellowship training., Methods: The relevant evidence for approaches on the basis of each learner's needs is reviewed and interpreted in the context of fellowship training in pulmonary medicine and critical care. Issues addressed include bias in fellow assessments and remediation, the impacts of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, the specific challenges of pulmonary and critical care fellowship programs, a brief review of relevant legal issues, guidance on building and leveraging program resources, and a discussion of learner outcomes., Results: This results in a concise, evidence-based toolkit for program leaders based around four pillars: early identification, fellow assessment, collaborative intervention, and reassessment. Important concepts also include the need for documentation, clear and written communication, and fellow-directed approaches to the creation of achievable goals., Conclusion: Evidence-based remediation helps struggling learners in pulmonary and critical care fellowship to improve their ability to meet Accreditation Council for Graduate Medical Education (ACGME) milestones., (Copyright © 2022 by the American Thoracic Society.)

Care of the critically injured burn patient presents unique challenges to the intensivist. Certified burn centers are rare and geographically sparse, necessitating that much of the initial management of patients with severe burn injuries must happen in the pre-burn center setting. Severe burn injuries often lead to a wide range of complications that extend beyond the loss of skin integrity and require specialized care. As such, medical intensivists are often called on to stabilize these critically injured patients. This focused review outlines the clinical care of these medically complex patients, including airway management, postburn complications, volume resuscitation, nutrition, and end-of-life care.

Prerecorded video content in medical education has become more common. Increasingly accessible technology coupled with the COVID-19 pandemic and subsequent need for distanced learning has greatly increased the interest in and need for high-quality video content. The use of short educational videos to augment other teaching methods has been shown to improve learners' experiences, knowledge retention, and understanding of content. Multiple studies have demonstrated that video education can be a highly effective tool for learning, particularly for hard-to-visualize processes and for procedural education. Videos allow learners to view content at their own pace and revisit materials on demand. In addition, well-designed videos can be repurposed by educators, ultimately reducing time needed to create high-quality educational content. Currently available technology allows educators to create high-quality videos at minimal cost and with a modest investment of time. This article details practical tips for creating high-yield educational videos., (Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Time-reversible dynamical simulations of nonequilibrium systems exemplify both Loschmidt's and Zermélo's paradoxes. That is, computational time-reversible simulations invariably produce solutions consistent with the irreversible Second Law of Thermodynamics (Loschmidt's) as well as periodic in the time (Zermélo's, illustrating Poincaré recurrence). Understanding these paradoxical aspects of time-reversible systems is enhanced here by studying the simplest pair of such model systems. The first is time-reversible, but nevertheless dissipative and periodic, the piecewise-linear compressible Baker Map. The fractal properties of that two-dimensional map are mirrored by an even simpler example, the one-dimensional random walk, confined to the unit interval. As a further puzzle the two models yield ambiguities in determining the fractals' information dimensions. These puzzles, including the classical paradoxes, are reviewed and explored here.

The COVID-19 pandemic has changed the face of education for undergraduate and graduate medical trainees. Lectures, clinical clerkships, and testing have all been impacted significantly because of patient care needs and concern for the health and safety of trainees. While traditional teaching strategies have been upended, the challenges posed by the pandemic have also created unique opportunities for trainees. In this article, the authors summarize lessons trainees can learn from the ongoing pandemic in the following areas: public health, disaster preparedness, and resource allocation; reinventing professional and personal roles to meet the needs of the health care system; flexibility in navigating testing, licensure, and certification; appraising scientific evidence quickly and accurately; balancing a physician's call to duty with fear for personal safety; combating moral injury; interprofessional collaboration; and advocating for oneself and one's colleagues. Focusing on these lessons can help educators steer their efforts to better prepare future physicians for unforeseen challenges that may come up in their personal and professional lives as well as in society as a whole., (Copyright © 2020 by the Association of American Medical Colleges.)

Purpose: Accreditation Council for Graduate Medical Education (ACGME) milestones were implemented across medical subspecialties in 2015. Although milestones were proposed as a longitudinal assessment tool potentially providing opportunities for early implementation of individualized fellowship learning plans, the association of subspecialty fellowship ratings with prior residency ratings remains unclear. This study aimed to assess the relationship between internal medicine (IM) residency milestones and pulmonary and critical care medicine (PCCM) fellowship milestones., Method: A multicenter retrospective cohort analysis was conducted for all PCCM trainees in ACGME-accredited PCCM fellowship programs, 2017-2018, who had complete prior IM milestone ratings from 2014 to 2017. Only professionalism and interpersonal and communication skills (ICS) were included based on shared anchors between IM and PCCM milestones. Using a generalized estimating equations model, the association of PCCM milestones ≤ 2.5 during the first fellowship year with corresponding IM subcompetencies was assessed at each time point, nested by program. Statistical significance was determined using logistic regression., Results: The study included 354 unique PCCM fellows. For ICS and professionalism subcompetencies, fellows with higher IM ratings were less likely to obtain PCCM ratings ≤ 2.5 during the first fellowship year. Each ICS subcompetency was significantly associated with future lapses in fellowship (ICS01: β = -0.67, P = .003; ICS02: β = -0.70, P = .001; ICS03: β = -0.60, P = .004) at various residency time points. Similar associations were noted for PROF03 (β = -0.57, P = .007)., Conclusions: Findings demonstrated an association between IM milestone ratings and low milestone ratings during PCCM fellowship. IM trainees with low ratings in several professionalism and ICS subcompetencies were more likely to be rated ≤ 2.5 during the first PCCM fellowship year. This highlights a potential use of longitudinal milestones to target educational gaps at the beginning of PCCM fellowship., (Copyright © 2021 by the Association of American Medical Colleges.)

Background: Pulmonary and critical care societies, including the American Thoracic Society, the American College of Chest Physicians, and the Society of Critical Care Medicine have large memberships that gather at academic conference events, attracting thousands of attendees. Objective: With the growth of social media use among pulmonary and critical care clinicians, our goal was to examine the Twitter presence and digital footprint of these three major medical society conferences. Methods: We used Symplur Signals (Symplur, LLC) to track the tweets and most active participants of the 2017-2019 annual conferences of American Thoracic Society, American College of Chest Physicians, and the Society of Critical Care Medicine. Attendance records of participants were obtained from each society. Results: During the study period, there was growth in the number of tweets, participants, and impressions for all three society conferences. Across all conferences, the amount of original content generated was less than the retweets, which comprised 50-72% of all tweets. Individuals physically attending each conference were more likely to post original content than those not in attendance (53-68% vs. 32-47%). For each society and at each meeting, clinicians made up the largest group of participants (44-60%), and most (59-82%) were physicians. A small cohort of participants was responsible for a large share of the tweets, with more than half of the participants at each conference for each society tweeting only once and only between 5-8% of participants tweeting more than 10 times. Seventy-eight individuals tweeted more than 100 times at one or more of the conferences. There was significant overlap in this group, with 32 of these individual participants tweeting more than 100 times at two or more of these conferences. Conclusion: Growth in conference digital footprints is largely due to increased activity by a small group of prolific participants that attend conferences by multiple academic societies. Original content makes up the smallest proportion of posts, suggesting that amplification of content is more prevalent than posting of original content. In a postpandemic environment, engagement of users producing original content may be even more important for medical societies., (Copyright © 2021 by the American Thoracic Society.)

Background: Social media is ubiquitous as a tool for collaboration, networking, and dissemination. However, little is known about use of social media platforms by pulmonary and critical care medicine fellowship programs., Objective: We identify and characterize pulmonary and critical care fellowship programs using Twitter and Instagram, as well as the posting behaviors of their social media accounts., Methods: We identified all adult and pediatric pulmonary, critical care medicine (CCM), and combined pulmonary and critical care medicine (PCCM) programs in the United States using the Electronic Residency Application Service. We searched for Twitter profiles for each program between January 1, 2018, and September 30, 2018. Tweets and Twitter interactions were classified into the following three types: social, clinical, or medical education (MedEd) related. We collected data about content enhancements of tweets, including the use of pictures, graphics interchange format or videos, hashtags, links, and tagging other accounts. The types of tweets, content enhancement characteristics, and measures of engagement were analyzed for association with number of followers., Results: We assessed 341 programs, including 163 PCCM, 36 adult CCM, 20 adult pulmonary, 67 pediatric CCM, and 55 pediatric pulmonary programs. Thirty-three (10%) programs had Twitter accounts. Of 1,903 tweets by 33 of the 341 programs with Twitter accounts, 476 (25%) were MedEd related, 733 (39%) were clinical, and 694 (36%) were social. The median rate of tweets per month was 1.65 (interquartile range [IQR], 0.4-6.65), with 55% programs tweeting more than monthly. Accounts tweeting more often had significantly more followers than those tweeting less frequently (median, 240 followers; 25-75% IQR, 164-388 vs. median, 107 followers; 25-75% IQR, 13-188; P  = 0.006). Higher engagement with clinical and social Twitter interactions (tweets, retweets, likes, and comments) was associated with more followers but not for the MedEd-related Twitter interactions. All types of content enhancements (pictures, graphics interchange format/videos, links, and tagging) were associated with a higher number of followers, except for hashtags., Conclusion: Despite the steadily increasing use of social media in medicine, only 10% of the pulmonary and critical care fellowship programs in the United States have Twitter accounts. Social and clinical content appears to gain traction online; however, additional evaluation is needed on how to effectively engage audiences with MedEd content., (Copyright © 2021 by the American Thoracic Society.)

Background: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale., Objective: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in United States (US) PCCM training programs., Methods: We administered a survey to a convenience sample of US PCCM fellows to elicit typical intubation practices in the medical ICU., Results: 89 discrete US PCCM and Internal Medicine CCM training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was "always or almost always" designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was "rarely or never" the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator., Conclusion: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

Dynamic microtubules are essential for many processes in the lives of eukaryotic cells. To study and understand the mechanisms of microtubule dynamics and regulation, in vitro reconstitution with purified components has proven a vital approach. Imaging microtubule dynamics can be instructive for a given species, isoform composition, or biochemical modification. Here, we describe two methods that visualize microtubule dynamics at high speed and high contrast: (1) total internal reflection fluorescence microscopy and (2) label-free interference reflection microscopy. For complete details on the use and execution of this protocol, please refer to Hirst et al. (2020)., Competing Interests: The authors declare no competing interests., (© 2020 The Authors.)

Cytoplasmic extracts from unfertilized Xenopus eggs have made important contributions to our understanding of microtubule dynamics, spindle assembly, and scaling. Until recently, these in vitro studies relied on the use of heterologous tubulin. This protocol allows for the purification of physiologically relevant Xenopus tubulins in milligram yield, which are a complex mixture of isoforms with various post-translational modifications. The protocol is applicable to any cell or tissue of interest. For complete details on the use and execution of this protocol, please refer to Hirst et al. (2020)., Competing Interests: The authors declare no competing interests., (© 2020 The Authors.)

Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.

This is our current research perspective on models providing insight into statistical mechanics. It is necessarily personal, emphasizing our own interest in simulation as it developed from the National Laboratories' work to the worldwide explosion of computation of today. We contrast the past and present in atomistic simulations, emphasizing those simple models that best achieve reproducibility and promote understanding. Few-body models with pair forces have led to today's "realistic" simulations with billions of atoms and molecules. Rapid advances in computer technology have led to change. Theoretical formalisms have largely been replaced by simulations incorporating ingenious algorithm development. We choose to study particularly simple, yet relevant, models directed toward understanding general principles. Simplicity remains a worthy goal, as does relevance. We discuss hard-particle virial series, melting, thermostatted oscillators with and without heat conduction, chaotic dynamics, fractals, the connection of Lyapunov spectra to thermodynamics, and finally simple linear maps. Along the way, we mention directions in which additional modeling could provide more clarity and yet more interesting developments in the future.

Background: Interpersonal and communication skills are essential for physicians practicing in critical care settings. Accordingly, demonstration of these skills has been a core competency of the Accreditation Council for Graduate Medical Education since 2014. However, current practices regarding communication skills training in adult and pediatric critical care fellowships are not well described. Objective: To describe the current state of communication curricula and training methods in adult and pediatric critical care training programs as demonstrated by the published literature. Methods: We performed a systematic review of the published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three authors reviewed a comprehensive set of databases and independently selected articles on the basis of a predefined set of inclusion and exclusion criteria. Data were independently extracted from the selected articles. Results: The 23 publications meeting inclusion criteria fell into the following study classifications: intervention ( n  = 15), cross-sectional survey ( n  = 5), and instrument validation ( n  = 3). Most interventional studies assessed short-term and self-reported outcomes (e.g., learner attitudes and perspectives) only. Fifteen of 22 publications represented pediatric subspecialty programs. Conclusion: Opportunities exist to evaluate the influence of communication training programs on important outcomes, including measured learner behavior and patient and family outcomes, and the durability of skill retention., (Copyright © 2020 by the American Thoracic Society.)

Background: All applicants to accredited training programs must write a personal statement as part of the application process. This may provoke anxiety on the part of the applicant and can result in an impersonal product that does not enhance his or her application. Little has been written about what program directors are seeking in personal statements. Objective: To gain a better understanding of how pulmonary and critical care fellowship program directors view and interpret these essays and to help applicants create more effective personal statements and make the writing process less stressful. Methods: We surveyed the membership of the Association of Pulmonary and Critical Care Medicine Program Directors in 2018. Quantitative data were collected regarding the importance of the personal statement in the candidate selection process. Qualitative data exploring the characteristics of personal statements, what the personal statement reveals about applicants, and advice for writing them were also collected. Comparative analysis was used for coding and analysis of qualitative data. Results: Surveys were completed by 114 out of 344 possible respondents (33%). More than half of the respondents believed that the personal statement is at least moderately important when deciding to offer an interview, and 40% believed it is at least moderately important when deciding rank order. A qualitative analysis revealed consistent themes: communication skills, provision of information not found elsewhere, applicant characteristics, and things to avoid. Conclusion: The respondents view the personal statement as moderately important in the application process. They value succinct, quality writing that reveals personal details not noted elsewhere. The information presented may help reduce anxiety associated with writing the personal statement and result in making the personal statement a more meaningful part of the application., (Copyright © 2020 by the American Thoracic Society.)

The need for safe and quality food, free from the presence of hazardous contaminants such as mycotoxins is an on-going and complex challenge. Cold atmospheric pressure plasma (CAPP) has the potential to contribute to achieving this goal. Decontamination efficacy of CAPP against six of the most common mycotoxins found in foods and feedstuffs was assessed herein. Concentration reduction of up to 66% was achieved in maize for both aflatoxin B 1 and fumonisin B 1 . Degradation products were detected only in the case of aflatoxin B 1 and zearalenone and were tested on human hepatocarcinoma cells with no increase in cytotoxicity observed. Analysis of treated maize revealed substantial changes to small molecular mass components of the matrix. While CAPP shows promise in terms of mycotoxin detoxification important questions concerning potential changes to the nutritional and safety status of the food matrix require further investigations., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Guideline implementation tools are designed to improve uptake of guideline recommendations in clinical settings but do not uniformly accompany the clinical practice guideline documents. Performance measures are a type of guideline implementation tool with the potential to catalyze behavior change and greater adherence to clinical practice guidelines. However, many performance measures suffer from serious flaws in their design and application, prompting the American Thoracic Society (ATS) to define its own performance measure development standards in a previous workshop in 2012. This report summarizes the proceedings of a follow-up workshop convened to advance the ATS's work in performance measure development and guideline implementation. To illustrate the application of the ATS's performance measure development framework, we used the example of a low-tidal volume ventilation performance measure created de novo from the 2017 ATS/European Society of Intensive Care Medicine/Society of Critical Care Medicine mechanical ventilation in acute respiratory distress syndrome clinical practice guideline. We include a detailed explanation of the rationale for the specifications chosen, identification of areas in need of further validity testing, and a preliminary strategy for pilot testing of the performance measure. Pending additional resources and broader performance measure expertise, issuing "preliminary performance measures" and their specifications alongside an ATS clinical practice guideline offers a first step to further the ATS's guideline implementation agenda. We recommend selectively proceeding with full performance measure development for those measures with positive early user feedback and the greatest potential impact in accordance with ATS leadership guidance.

Lipopolysaccharide (LPS) is an endotoxin composed of a polysaccharide and lipid component. It is intrinsically responsible for the pathogenicity of Gram-negative bacteria and is involved in the development of bacterial sepsis. Atmospheric pressure non-thermal plasma is proposed as a potential new approach for the treatment of infected tissue such as chronic wounds, with both antibacterial and wound-healing activities extensively described. Using both the RAW264.7 murine macrophage cell line in vitro assays and the Galleria mellonella insect in vivo toxicity model, the effect non-thermal plasma exposure on LPS-mediated toxicity has been characterised. Short (60 s) non-thermal plasma exposures of Pseudomonas aeruginosa conditioned growth media, membrane lysates and purified P. aeruginosa LPS, resulted in a substantial detoxification and reduction of LPS-induced cytotoxicity in RAW264.7 murine macrophages. Non-thermal plasma exposure (60 s) of purified P. aeruginosa LPS led to a significant (p < 0.05) improvement in the G. mellonella health index (GHI) score, a measure of in vivo toxicity. These findings demonstrate the ability of short plasma exposures to significantly reduce LPS-induced cytotoxicity both in vitro and in vivo; attenuating the toxicity of this important virulence factor intrinsic to the pathogenicity of Gram-negative bacteria., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Management of mechanical ventilation (MV) is an important and complex aspect of caring for critically ill patients. Management strategies and technical operation of the ventilator are key skills for physicians in training, as lack of expertise can lead to substantial patient harm., Objective: We performed a narrative review of the literature describing MV education in graduate medical education (GME) and identified best practices for training and assessment methods., Methods: We searched MEDLINE, PubMed, and Google Scholar for English-language, peer-reviewed articles describing MV education and assessment. We included articles from 2000 through July 2018 pertaining to MV education or training in GME., Results: Fifteen articles met inclusion criteria. Studies related to MV training in anesthesiology, emergency medicine, general surgery, and internal medicine residency programs, as well as subspecialty training in critical care medicine, pediatric critical care medicine, and pulmonary and critical care medicine. Nearly half of trainees assessed were dissatisfied with their MV education. Six studies evaluated educational interventions, all employing simulation as an educational strategy, although there was considerable heterogeneity in content. Most outcomes were assessed with multiple-choice knowledge testing; only 2 studies evaluated the care of actual patients after an educational intervention., Conclusions: There is a paucity of information describing MV education in GME. The available literature demonstrates that trainees are generally dissatisfied with MV training. Best practices include establishing MV-specific learning objectives and incorporating simulation. Next research steps include developing competency standards and validity evidence for assessment tools that can be utilized across MV educational curricula., Competing Interests: Conflict of interest: Dr Ferreira reports receiving speaker fees from Medtronic (ended October 2017).

Ophthalmic disease encountered in the intensive care unit (ICU) has a wide spectrum of prevalence and severity. Prolonged exposure of the cornea is common and preventable. Trauma, glaucoma, infection, vascular disease, and burns are among the potential causes of vision loss. Patients are predisposed to ocular complications by the ICU environment and critical illness itself. Critically ill patients require prioritization of life-sustaining interventions, and less emphasis is placed on ophthalmic disease, leading to missed opportunities for vision-saving intervention. It is therefore imperative for intensivists, nurses, and other providers to have an increased awareness and understanding of the broad range of ocular conditions potentially seen in the ICU.

When life-sustaining treatments (LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient. Many studies have examined the frequency of limitations of LST in intensive care unit (ICU) settings in the past 30 years. This systematic review describes variation and patient characteristics associated with limitations of LST in critically ill patients in all types of ICUs in the United States. A comprehensive search of the literature was performed by a medical librarian between December 2014 and April 2017. A total of 1,882 unique titles and abstracts were reviewed, 113 were selected for article review, and 36 studies were fully reviewed. Patient factors associated with an increased likelihood of limiting LST included white race, older age, female sex, poor preadmission functional status, multiple comorbidities, and worse illness severity score. Based on several large, multicenter studies, there was a trend toward a higher frequency of limitation of LST over time. However, there is large variability between ICUs in the proportion of patients with limitations and on the proportion of deaths preceded by a limitation. Increases in the frequency of limitations of LST over time suggests changing attitudes about aggressive end-of-life-care. Limitations are more common for patients with worse premorbid health and greater ICU illness severity. While some differences in the frequency of limitations of LST may be explained by personal factors such as race, there is unexplained wide variability between units.

Acinetobacter baumannii is an intrinsically multidrug-resistant pathogen that, when existing as a biofilm, confers increased environmental tolerance to desiccation, nutrient starvation as well as increased tolerance to antimicrobials. Outbreaks of A. baumannii infections within the clinical setting are often associated with the biofilm phenotype. This study investigates the role of biofilm biomass in A. baumannii susceptibility to exposure to a kilohertz-driven, in-house-designed, cold plasma jet, through the examination of cold plasma treatment efficacy in A. baumannii biofilms grown over various times for up to 72 h. For biofilms grown for 24, 48 and 72 h, D values were 19·32 ± 2·71, 29·18 ± 3·15 and 24·70 ± 3·07 s respectively. Monitoring A. baumannii biofilm biomass over these time periods revealed that the greatest biomass was observed at 48 h with the lowest biofilm biomass at 24 h growth. Enumeration of viable biofilm colony counts at each time point was comparable. Scanning electron microscopy images of plasma-treated biofilms revealed extensive surface damage of A. baumannii cells. These results describe the role of biomass in mediating A. baumannii biofilm susceptibility to cold plasma treatment, implicating the biofilm matrix as a protective barrier to the antimicrobial effects of cold plasma. SIGNIFICANCE AND IMPACT OF THE STUDY: Acinetobacter baumannii biofilm formation results in increased environmental and antimicrobial tolerance and resistance compared to the planktonic phenotype. Cold plasma technology is increasingly investigated as a new tool for decontamination of biofilm-contaminated surfaces, especially those found in the clinical setting. This new technology presents a promising approach to the remediation of surfaces contaminated by biofilms. This study identifies the role played by A. baumannii biofilm biomass in mediating tolerance and susceptibility to cold plasma treatment. This work demonstrates that increased biofilm biomass reduces the efficacy of antimicrobial species generated by cold plasma, resulting in greater tolerance to plasma exposure., (© 2019 The Authors. Letters in Applied Microbiology published by John Wiley & Sons Ltd on behalf of Society for Applied Microbiology.)

Introduction: Point-of-care ultrasound is recognized as a safe and valuable diagnostic tool for patient evaluation. Hospitalists are prime candidates for advancing the point-of-care ultrasound field given their crucial role in inpatient medicine. Despite this, there is a notable lack of evidence-based ultrasound training for hospitalists. Most research focuses on diagnostic accuracy rather than the training required to achieve it. This study aims to improve hospitalists' point-of-care ultrasound knowledge and skills through a hands-on skills practicum., Methods: Four skill practicums were conducted with pre-course, post-course, and six-month evaluations and knowledge assessments., Results: The mean pre- vs. post-course knowledge assessment scores significantly improved, 41.7% vs. 75.9% (SD 16.1% and 12.7%, respectively, p  < 0.0001). The mean ultrasound skills confidence ratings on a 10-point Likert scale significantly increased post-course (2.60 ± 1.66 vs. 6.33 ± 1.63, p  < 0.0001), but decreased at six months (6.33 ± 1.63 vs. 4.10 ± 2.22, p  < 0.0001). The greatest limitations to usage pre-course and at six months were knowledge/skills and lack of machine access. While knowledge/skills decreased from pre-course (82.0%) as compared to six-months (64.3%), lack of machine access increased from pre-course (15.8%) to six-months (28.6%) ( p  = 0.28)., Conclusion: Hospitalists agree that point-of-care ultrasound has utility in the diagnostic and therapeutic management of patients, though the lack of training is a significant limitation. Our study demonstrated that a brief skills practicum significantly improves hospitalists' confidence and knowledge regarding ultrasound image acquisition and interpretation in the short term. Long-term confidence and usage wanes, which appears to be due to the lack of machine access.