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Because of the coronavirus disease (COVID-19) pandemic, graduate medical education programs adopted virtual interviews (VIs) as the default modality for the 2020 recruitment season. It is unknown whether VIs allowed applicants to effectively evaluate programs, and the best interview format for the future is unclear.ToAfter the National Residency Matching Program medical subspecialty match, an electronic survey was sent to 1,067 applicants to pulmonary and critical care medicine programs asking them to compare their fellowship VI experience with their residency in-person interview (IPI) experience.Three hundred six (29%) applicants responded to the survey, and 289 completed it (27%). There were 117 (40%) women and 146 (51%) White individuals. Most respondents believed that VIs hindered their ability to evaluate programs' culture, faculty-fellow relationships, location, facilities, and their own fit within the program. They believed they were able to evaluate the clinical experience, curriculum, and potential for academic development equally well compared with IPIs. The most helpful elements of VIs were the interview with the program director, meetings with the fellows, and interviews with faculty members. Less helpful elements included conference access, prerecorded program director presentations, virtual hospital and city tours, and video testimonials. One hundred twenty-three respondents (43%) chose VIs with an optional visit as their preferred future interview format, 85 (29%) chose IPIs, 54 (19%) wanted a choice between VIs and IPIs, and 27 (9%) chose VIs only.Most pulmonary and critical care medicine applicants preferred future interviews to include both VIs and the option of an in-person visit or interview. This study can assist programs in designing their future interview formats in a trainee-centric fashion.

Supported by the National Health and Medical Research Council Centre of Research Excellence in Pulmonary Fibrosis (GNT1116371), and by foundation partner, Boehringer Ingelheim, and program partners, Roche and Galapagos. Rationale : The interstitial lung disease (ILD) multidisciplinary meetings (MDM), composed of pulmonologists, radiologists, and pathologists, is integral to the rendering of an accurate ILD diagnosis. However, there is significant heterogeneity in the conduct of ILD MDMs, and questions regarding their best practices remain unanswered. Objectives : To achieve consensus among ILD experts on essential components of an ILD MDM. Methods : Using a Delphi methodology, semi-structured interviews with ILD experts were used to identify key themes and features of ILD MDMs. These items informed two subsequent rounds of online questionnaires that were used to achieve consensus among a broader, international panel of ILD experts. Experts were asked to rate their level of agreement on a five-point Likert scale. An a priori threshold for consensus was set at a median score 4 or 5 with an interquartile range of 0. Results : We interviewed 15 ILD experts, and 102 ILD experts participated in the online questionnaires. Five items and two exploratory statements achieved consensus on being essential for an ILD MDM following two questionnaire rounds. There was consensus that the presence of at least one radiologist, a quiet setting with a visual projection system, a high-quality chest high-resolution computed tomography, and a standardized template summarizing collated patient data are essential components of an ILD MDM. Experts also agreed that it would be useful for ILD MDMs to undergo an annual benchmarking process and a validation process by fulfilling a minimum number of cases annually. Twenty-seven additional features were considered to be either highly desirable or desirable features based on the degree of consensus. Although our findings on desirable features are similar to the current literature, several of these remain controversial and warrant further research. The study also showed an agreement among participants on several future concepts to improve the ILD MDM, such as performing regular self-assessments and conducting research into shared practices to develop an international expert guideline statement on ILD MDMs. Conclusions : This Delphi study showed consensus among international ILD experts on essential and desirable features of an ILD MDM. Our data represent an important step toward potential collaborative research into future standardization of ILD MDMs. Postprint

Outside sleep laboratory settings, peripheral arterial tonometry (PAT, eg, WatchPat) represents a validated modality for diagnosing obstructive sleep apnea (OSA). We have shown before that the accuracy of home sleep apnea testing by WatchPat 200 devices in diagnosing OSA is suboptimal (50%–70%). In order to improve its diagnostic performance, we built several models that predict the main functional parameter of polysomnography (PSG), Apnea Hypopnea Index (AHI). Participants were recruited in our Sleep Center and underwent concurrent in-laboratory PSG and PAT recordings. Statistical models were then developed to predict AHI by using robust functional parameters from PAT-based testing, in concert with available demographic and anthropometric data, and their performance was confirmed in a random validation subgroup of the cohort. Five hundred synchronous PSG and WatchPat sets were analyzed. Mean diagnostic accuracy of PAT was improved to 67%, 81% and 85% in mild, moderate-severe or no OSA, respectively, by several models that included participants’ age, gender, neck circumference, body mass index and the number of 4% desaturations/hour. WatchPat had an overall accuracy of 85.7% and a positive predictive value of 87.3% in diagnosing OSA (by predicted AHI above 5). In this large cohort of patients with high pretest probability of OSA, we built several models based on 4% oxygen desaturations, neck circumference, body mass index and several other variables. These simple models can be used at the point-of-care, in order to improve the diagnostic accuracy of the PAT-based testing, thus ameliorating the high rates of misclassification for OSA presence or disease severity.

Study Objectives:Peripheral arterial tonometry (PAT)–based technology represents a validated portable monitoring modality for the diagnosis of OSA. We assessed the diagnostic accuracy of PAT-based ...

Citation:Allam JS, Ioachimescu OC. Pulse Arterial Tonometry Evaluation of Reliability study. J Clin Sleep Med. 2021;17(6):1331–1332.

A 22-year-old woman presented to the ED following several days of worsening shortness of breath and chest tightness associated with tachypnea and palpitations. Her past medical history was significant for several months of nausea and vomiting, crampy abdominal pain, intermittent loose stool, and weight loss. Severe gastritis and pyloric ulcers were discovered during an upper endoscopy approximately 1 month prior; she was treated with a proton pump inhibitor and sucralfate. She had previously been healthy and did not have a history of alcohol consumption, smoking, or intake of nonsteroidal antiinflammatory drugs. Her initial chest radiograph and chest CT scan are shown in Figures 1 and ​and2.2. She denied frequent respiratory illness as a child. Figure 1. Posteroanterior chest radiograph demonstrates upper lobe predominant scarring, architectural distortion, and subtle cystic and cylindrical bronchiectasis. Contour deformity of the right upper mediastinum with silhouetting of the ascending aortic contour ... Figure 2. A, Representative axial CT image displayed with lung window settings demonstrates architectural distortion and bilateral cystic and cylindrical bronchiectasis in the upper lobes and superior portion of the lower lobes. B, Mediastinal window demonstrates ... Physical Examination Findings On physical examination the patient was afebrile, with a heart rate of 113 beats/min, BP of 101/65 mm Hg, respiratory rate of 22 breaths/min, and oxygen saturation of 99% on room air. Neck examination revealed no thyromegaly, jugular venous distention, or cervical lymphadenopathy. Cardiac examination was notable for tachycardia. Bilateral inspiratory crackles were noted on lung auscultation. On abdominal examination she had diffuse mild tenderness to palpation without organomegaly. The rest of the physical examination was unremarkable. Laboratory Findings Laboratory findings showed a normal chemistry panel and normocytic anemia (hemoglobin=10.4 g/dL). Thyrotropin and free T4 levels were normal. Serum immunoglobulin levels showed IgG 354 mg/dL (normal, 694-1,698 mg/dL), IgA 40 mg/dL (normal, 63-378 mg/dL), and IgM 19 mg/dL (normal, 60-263 mg/dL). HIV test was negative. A bronchoscopy with BAL and transbronchial biopsy did not isolate any organisms and showed normal lung parenchyma. What is the next diagnostic step? What is the probable diagnosis? Next diagnostic step: Biopsy of the mediastinal mass Diagnosis: Good syndrome

Sleep is defined as a reversible state of reduced responsiveness to environmental stimuli. It roughly occupies one third of a human life. The science of sleep has greatly evolved over the past century. From a state of passive inactivity, sleep has come to be regarded as a complex physiologic state, with characteristic brain activity.The neurobiology of sleep is complex. Transection studies have led to the description of the ascending reticular activating system as responsible for the awake state, with the main neurotransmitters involved being acetylcholine, norepinephrine, glutamate, serotonin, dopamine, histamine and orexin. Similarly, specific brain regions have been involved in the active generation of sleep. Non rapid eye movement (NREM) sleep is generated in the basal forebrain and anterior hypothalamus, containing the neurotransmitters gamma amino butyric acid (GABA) and galanin. These areas send inhibitory signaling to the excitatory regions of the brain. Rapid eye movement sleep (REM) is generated in the caudal pons and rostral mesencephalon area. It consists of several features, divided into tonic and phasic phases. Each of these is produced by a specific group of neurons. Acetylcholine is one of the major neurotransmitters in REM sleep. Sleep has been described in the developing human fetus as early as 28 weeks of gestation. At birth, the human infant sleeps up to 16-18 hours a day and spends half of that time in REM sleep. This high fraction of sleep in the human infant has led to the hypothesis that REM is important in brain maturation.

Sleep takes up one third of the human life and has always been a subject of fascination for human beings. In the past century, significant progress has been made in the study of sleep. Sleep is defined as a reversible state of decreased responsiveness to the environment. It has been historically thought to be a passive state of inactivity; however, electrical recordings of brain waves have shown that the brain remains very active during sleep, but that this activity is distinctively different from the wake state. Sleep is divided into two main states, non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. The latter is thought to be the state where the most vivid dreams occur. Different brain regions and groups of neurons in the brain are responsible for the generation of each of these two states. Human fetuses have been shown to display sleep brain waves as early as 28 weeks of gestation. The question of “why do we sleep?” has been occupying scientists for some time and a clear answer has yet to be accepted by all. Many hypotheses exist. The evolutionary adaptation hypothesis claims that sleep evolved to protect the organism by making it quiescent during times where activity would be dangerous (exposure to predators or injury), while also saving energy during those times. More recent evidence suggests that, during sleep, the brain regenerates energy that has been depleted by wakefulness. Other studies also suggest that sleep enhances learning and memory formation.

PURPOSE OF REVIEW Idiopathic pulmonary fibrosis is a progressively fatal interstitial lung disease associated with pathological findings of usual interstitial pneumonia. Its pathogenesis is unknown, and there are no proven effective therapies. Familial cases account for 0.5-2% of idiopathic pulmonary fibrosis. Familial idiopathic pulmonary fibrosis occurs as an autosomal dominant disorder with variable penetrance. The clinical characteristics of familial idiopathic pulmonary fibrosis are indistinguishable from sporadic idiopathic pulmonary fibrosis. These marked similarities support the hypothesis there may, in part, be a genetic basis for idiopathic pulmonary fibrosis. RECENT FINDINGS Many investigations have evaluated genetic polymorphisms and idiopathic pulmonary fibrosis. Candidate genes include cytokines and surfactant protein genes. To date, no gene has been consistently identified to be associated with idiopathic pulmonary fibrosis. Recent studies in familial idiopathic pulmonary fibrosis have demonstrated a strong association with surfactant protein C gene mutations in one large kindred. SUMMARY The pathogenesis of both idiopathic pulmonary fibrosis and familial idiopathic pulmonary fibrosis remains unclear. A consistent genetic basis has not yet been demonstrated in all cases. Other factors, including variable gene expression, co-carriage of other modifying genes and environmental stimuli, particularly cigarette smoke, significantly contribute to disease expression.