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PROBLEM: Minimal formal training exists in teaching invasive bedside procedures during Internal Medicine (IM) residency despite the large role trainees have in instructing junior colleagues. OBJECTIVE AND METHODS: We investigated if using a Procedural Objective Structured Teaching Encounter (PrOSTE) to disseminate a novel method for teaching procedures would improve supervising residents’ (n = 7) ability to teach ultrasound-guided peripheral IV’s (USGIV) to incoming interns (n = 67) at a single, large academic IM residency. Supervising residents were assigned to receive the PrOSTE training versus standard procedure training, and then, both groups instructed incoming interns. The impact of the PrOSTE was measured by participant surveys, observed changes in teacher behavior, and performance of incoming interns on a USGIV blinded assessment station. MEASUREMENT AND MAIN RESULTS: PrOSTE-trained residents reported high levels of satisfaction with the session and demonstrated increased desirable behaviors when teaching procedures. There was no statistical difference in incoming intern performance when placing USGIVs between intervention and standard groups (81.0% vs 74.8% items correct; difference 6.2; SD = 12.4; p = 0.22). CONCLUSION: The PrOSTE is a feasible, well-received tool for training supervising residents in our novel teaching framework, as demonstrated in this pilot study. Despite not showing a difference in learner performance, qualitative data suggests the impact of the PrOSTE would be even greater in a more controlled teaching environment. Using a PrOSTE to deliver this teaching framework has broad applicability to any IM residency, and the tenets can be used with any bedside invasive procedure with an effective task trainer. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s40670-020-00972-7) contains supplementary material, which is available to authorized users.

OBJECTIVES: We investigated whether patients with chronic obstructive pulmonary disease could safely receive noninvasive ventilation outside of the ICU. DESIGN: Retrospective cohort study. SETTING: Twelve states with ICU utilization flag from the State Inpatient Database from 2014. PATIENTS: Patients greater than or equal to 18 years old with primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease and secondary diagnosis of respiratory failure who received noninvasive ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Multilevel logistic regression models were used to obtain hospital-level ICU utilization rates. We risk-adjusted using both patient/hospital characteristics. The primary outcome was in-hospital mortality; secondary outcomes were invasive monitoring (arterial/central catheters), hospital length of stay, and cost. We examined 5,081 hospitalizations from 424 hospitals with ICU utilization ranging from 0.05 to 0.98. The overall median in-hospital mortality was 2.62% (interquartile range, 1.72–3.88%). ICU utilization was not significantly associated with in-hospital mortality (β = 0.01; p = 0.05) or length of stay (β = 0.18; p = 0.41), which was confirmed by Spearman correlation (ρ = 0.06; p = 0.20 and ρ = 0.02; p = 0.64, respectively). However, lower ICU utilization was associated with lower rates of invasive monitor placement by linear regression (β = 0.05; p < 0.001) and Spearman correlation (ρ = 0.28; p < 0.001). Lower ICU utilization was also associated with significantly lower cost by linear regression (β = 14.91; p = 0.02) but not by Spearman correlation (ρ = 0.09; p = 0.07). CONCLUSIONS: There is wide variability in the rate of ICU utilization for noninvasive ventilation across hospitals. Chronic obstructive pulmonary disease patients receiving noninvasive ventilation had similar in-hospital mortality across the ICU utilization spectrum but a lower rate of receiving invasive monitors and probably lower cost when treated in lower ICU-utilizing hospitals. Although the results suggest that noninvasive ventilation can be delivered safely out- side of the ICU, we advocate for hospital-specific risk assessment if a hospital were considering changing its noninvasive ventilation delivery policy. (Crit Care Med 2019; XX:00–00)

Proning awake patients with COVID-19 is associated with lower mortality and intubation rates. However, these studies also demonstrate low participation rates and tolerance of awake proning. In this study, we attempt to understand barriers to proning. Medical and dental students surveyed nonintubated patients to understand factors affecting adherence to a proning protocol. Only patients who discussed proning with their medical team attempted the practice. Eight of nine patients who were informed about benefits of proning attempted the maneuver. Discomfort was the primary reason patients stopped proning. Addressing discomfort and implementing systematic patient education may increase adherence to proning.

Background. The United States (US) is experiencing a growing shortage of critical care medicine (CCM) trained physicians. Little is known about the exposures to CCM experienced by internal medicine (IM) residents or factors that may influence their decision to pursue a career in pulmonary/critical care medicine (PCCM). Methods. We conducted a survey of US IM residency program directors (PDs) and then used multivariable logistic regression to identify factors that were predictive of residency programs with a higher percentage of graduates pursuing careers in PCCM. Results. Of the 249 PDs contacted, 107 (43%) completed our survey. University-sponsored programs more commonly had large ICUs (62.3% versus 42.2%, p=0.05), primary medical ICUs (63.9% versus 41.3%, p=0.03), and closed staffing models (88.5% versus 41.3%, p<0.001). Residents from university-sponsored programs were more likely to pursue specialty fellowship training (p<0.001) overall but equally likely to pursue careers in PCCM as those from community-sponsored programs. Factors predictive of residencies with a higher percentage of graduates pursuing training in PCCM included larger ICUs (>20 beds), residents serving as code leaders, and greater proportion of graduates pursuing specialization. Conclusions. While numerous differences exist between the ICU rotations at community- and university-sponsored IM residencies, the percentage of graduates specializing in PCCM was similar. Exposure to larger ICUs, serving as code leaders, and higher rates of specialization were predictive of a career choice in PCCM.

This quality improvement study compares COVID-19 testing throughput, personal protective equipment use, and cost per test before vs after the introduction of high-efficiency particulate air–filtered, positive-pressure Hexapod personal protection booths at a hospital in Boston, Massachusetts.

Background Benzodiazepine-based protocols offer a standard of care for management of alcohol withdrawal, though they may not be safe or appropriate for all patients. Phenobarbital, a long-acting barbiturate, presents an alternative to conventional benzodiazepine treatment, though existing research offers only modest guidance to the safety and effectiveness of phenobarbital in managing alcohol withdrawal syndrome (AWS) in general hospital settings. Methods To compare clinical effectiveness of phenobarbital versus benzodiazepines in managing symptoms of alcohol withdrawal, we conducted a retrospective chart review of 562 patients admitted over a 2-year period to a general hospital and treated for AWS. The development of AWS-related complications (seizures, alcoholic hallucinosis, and alcohol withdrawal delirium) post-treatment initiation was the primary outcome examined in both treatment groups. Additional outcomes measured included hospital length of stay, intensive care unit (ICU) admission rates/length of stay, medication-related adverse events, and discharge against medical advice. Results Despite being significantly more likely to have a history of prior complications related to AWS (including seizures and delirium), patients initiated on phenobarbital (n = 143) had overall similar primary and secondary treatment outcomes to those in the benzodiazepine treatment protocol (n = 419). Additionally, a subset of patients (n = 16) initially treated with benzodiazepines displayed signs of treatment nonresponse, including significantly higher rates of AWS-related delirium and ICU admission rates, but were well-managed following transition to the phenobarbital protocol. Conclusion The data from this retrospective chart review lend further support to effectiveness and safety of phenobarbital for the treatment and management of AWS. Further randomized controlled trials are warranted.

Simulation training may improve proficiency at and reduce complications from central venous catheter (CVC) placement, but the scope of simulation's effect remains unclear. This randomized controlled trial evaluated the effects of a pragmatic CVC simulation program on procedural protocol adherence, technical skill, and patient outcomes.Internal medicine interns were randomized to standard training for CVC insertion or standard training plus simulation-based mastery training. Standard training involved a lecture, a video-based online module, and instruction by the supervising physician during actual CVC insertions. Intervention-group subjects additionally underwent supervised training on a venous access simulator until they demonstrated procedural competence. Raters evaluated interns' performance during internal jugular CVC placement on actual patients in the medical intensive care unit. Generalized estimating equations were used to account for outcome clustering within trainees.We observed 52 interns placing 87 CVCs. Simulation-trained interns exhibited better adherence to prescribed procedural technique than interns who received only standard training (P = 0.024). There were no significant differences detected in first-attempt or overall cannulation success rates, mean needle passes, global assessment scores, or complication rates.Simulation training added to standard training improved protocol adherence during CVC insertion by novice practitioners. This study may have been too small to detect meaningful differences in venous cannulation proficiency and other clinical outcomes, highlighting the difficulty of patient-centered simulation research in settings where poor outcomes are rare. For high-performing systems, where protocol deviations may provide an important proxy for rare procedural complications, simulation may improve CVC insertion quality and safety.

Background Residency training is charged with improving resident teaching skills. Utilizing simulation in teacher training has unique advantages such as providing a controlled learning environment and opportunities for deliberate practice. Objective We assessed the impact of a simulation-based resident-as-teacher (RaT) program. Design A RaT program was embedded in an existing 8-case simulation curriculum for 52 internal medicine (IM) interns. Residents participated in a workshop, then served as facilitators in the curriculum and received feedback from faculty. Methods Residents' teaching and feed back skills were measured using a pre- and post-program self-assessment and post-session and post-curriculum evaluations by intern learners. Setting/participants Forty-one second- and third-year residents participated in the study August 2013 to October 2013 at a single center. Results Pre- and post-program teaching skills were assessed for 34 of 41 resident facilitators (83%) participating in 3.9 sessions on average. Partaking in the program led to improvements in resident facilitators' self-reported teaching and feedback skills across all domains. The most significant improvement was in teaching in a simulated environment (2.81 to 4.16, P Conclusions Our simulation-based RaT program offered a unique opportunity for deliberate practice of teaching skills in a controlled environment and led to improvements in resident facilitators' teaching and feed back skills. The simulation curriculum, facilitated by residents, was well received by the intern learners. Our program design may serve as a model for the development of simulation curricula and RaT programs within IM residencies.

IMPORTANCE: The July Effect refers to adverse outcomes that occur as a result of turnover of the physician workforce in teaching hospitals during the month of June.OBJECTIVE: As a surrogate for physician turnover, we used a multivariable difference-in-difference approach to determine if there was a difference in outcomes between May and July in teaching versus non-teaching hospitals.DESIGN: We used prospectively collected observational data from United States hospitals participating in the Get With The Guidelines(®)-Resuscitation registry. Participants were adults with index in-hospital cardiac arrest between 2005-2014. They were a priori divided by location of arrest (general medical/surgical ward, intensive care unit, emergency department). The primary outcome was survival to hospital discharge. Secondary outcomes included neurological outcome at discharge, return of spontaneous circulation, and several process measures.RESULTS: We analyzed 16,328 patients in intensive care units, 11,275 in general medical/surgical wards and 3790 in emergency departments. Patient characteristics were similar between May and July in both teaching and non-teaching hospitals. The models for intensive care unit patients indicated the presence of a July Effect with the difference-in-difference ranging between 1.9-3.1%, which reached statistical significance (p0.20 for all models).CONCLUSIONS: There may be a July Effect in the intensive care unit but the results were mixed. Most survival models showed a statistically significant difference but this was not supported by the secondary analyses of return of spontaneous circulation and neurological outcome. We found no July Effect in the emergency department or the medical/surgical ward for patients with in-hospital cardiac arrest.

Many prior nursing studies regarding family members specifically of neuroscience intensive care unit (neuro-ICU) patients have focused on identifying their primary needs. A concept related to identifying these needs and assessing whether they have been met is determining whether families explicitly report satisfaction with the care that both they and their loved ones have received. The objective of this study was to explore family satisfaction with care in an academic neuro-ICU and compare results with concurrent data from the same hospital's medical ICU (MICU). Over 38 days, we administered the Family Satisfaction-ICU instrument to neuro-ICU and MICU patients' families at the time of ICU discharge. Those whose loved ones passed away during ICU admission were excluded. When asked about the respect and compassion that they received from staff, 76.3% (95% CI [66.5, 86.1]) of neuro-ICU families were completely satisfied, as opposed to 92.7% in the MICU (95% CI [84.4, 101.0], p = .04). Respondents were less likely to be completely satisfied with the courtesy of staff if they reported participation in zero formal family meeting. Less than 60% of neuro-ICU families were completely satisfied by (1) frequency of physician communication, (2) inclusion and (3) support during decision making, and (4) control over the care of their loved ones. Parents of patients were more likely than other relatives to feel very included and supported in the decision-making process. Future studies may focus on evaluating strategies for neuro-ICU nurses and physicians to provide better decision-making support and to implement more frequent family meetings even for those patients who may not seem medically or socially complicated to the team. Determining satisfaction with care for those families whose loved ones passed away during their neuro-ICU admission is another potential avenue for future investigation.

BACKGROUND Internal Medicine (IM) residency graduates should be able to manage hospital emergencies, but the rare and critical nature of such events poses an educational challenge. IM residents' exposure to inpatient acute clinical events is currently unknown. OBJECTIVE We developed an instrument to assess IM residents' exposure to and confidence in managing hospital acute clinical events. METHODS We administered a survey to all IM residents at our institution assessing their exposure to and confidence in managing 50 inpatient acute clinical events. Exposures assessed included mannequin-based simulation or management of hospital-based events as a part of a team or independently in a leadership role. Confidence was rated on a five-point scale and dichotomized to "confident" versus "not confident." Results were analyzed by multivariable logistic regression to assess the relationship between exposure and confidence accounting for year in training. RESULTS A total of 140 of 170 IM residents (82%) responded. Postgraduate year 1 (PGY-1) residents had managed 31.3% of acute events independently vs 71.7% of events for PGY-3/4 residents (P < .0001). In multivariable analysis, residents' confidence increased with level of training (PGY-1 residents were confident to manage 24.9% of events vs 72.5% of events for PGY-3/4 residents, P < .0001) and level of exposure, independent of training year (P = .001). Events with the lowest levels of exposure and confidence for graduating residents were identified. CONCLUSIONS IM residents' confidence in managing inpatient acute events correlated with level of training and clinical exposure. We identified events with low levels of resident exposure and confidence that can serve as targets for future curriculum development.

Purpose We hypothesize that intensive care unit (ICU) families frequently perceive that they have received inconsistent information from staff about their relatives and that these inconsistencies influence abilities to make medical decisions, as well as satisfaction. Materials and Methods We performed a prospective cohort study in the neurosciences and medical ICU at a university hospital. One hundred twenty-four family members of adult patients surviving to ICU discharge completed a questionnaire regarding perceptions of inconsistent information. Results Of 193 eligible patients, 64.2% had family complete the survey. Thirty-one respondents (25.0%; 95% confidence interval, 7.7) reported at least 1 instance of inconsistent information during their family member's admission, with no difference between the neurosciences ICU (21.5%; 9.3) and the medical ICU (31.1%; 14.1; P = .28). Of those who did receive inconsistent information, 38.7% (95% confidence interval, 18.2) reported multiple episodes and 74.2% (16.3) indicated that episodes occurred within the first 48 hours of admission. These episodes had an adverse effect, with 19.4% (14.7) indicating that they affected satisfaction and 9.7% (11.0) indicating that they made decision making difficult. Conclusions Episodes involving inconsistent information from staff as perceived by families may be quite prevalent and may influence decision-making abilities and satisfaction.

Effective communication between intensive care unit (ICU) providers and families is crucial given the complexity of decisions made regarding goals of therapy. Using video images to supplement medical discussions is an innovative process to standardize and improve communication. In this six-month, quasi-experimental, pre-post intervention study we investigated the impact of a cardiopulmonary resuscitation (CPR) video decision support tool upon knowledge about CPR among surrogate decision makers for critically ill adults.We interviewed surrogate decision makers for patients aged 50 and over, using a structured questionnaire that included a four-question CPR knowledge assessment similar to those used in previous studies. Surrogates in the post-intervention arm viewed a three-minute video decision support tool about CPR before completing the knowledge assessment and completed questions about perceived value of the video.We recruited 23 surrogates during the first three months (pre-intervention arm) and 27 surrogates during the latter three months of the study (post-intervention arm). Surrogates viewing the video had more knowledge about CPR (p=0.008); average scores were 2.0 (SD 1.1) and 2.9 (SD 1.2) (out of a total of 4) in pre-intervention and post-intervention arms. Surrogates who viewed the video were comfortable with its content (81% very) and 81% would recommend the video. CPR preferences for patients at the time of ICU discharge/death were distributed as follows: pre-intervention: full code 78%, DNR 22%; post-intervention: full code 59%, DNR 41% (p=0.23).

Background The use of high-fidelity medical simulation in cognitive skills training within internal medicine residency programs remains largely unexplored. Objective To design a pilot study to introduce clinical decision-making training using simulation into a large internal medicine residency program, explore the practicability of using junior and senior residents as facilitators, and examine the feasibility of using the program to improve interns' clinical skills. Methods Interns on outpatient rotations participated in a simulation curriculum on a voluntary basis. The curriculum consisted of 8 cases focusing on acute clinical scenarios encountered on the wards. One-hour sessions were offered twice monthly from August 2010 to February 2011. Internal medicine residents and simulation faculty served as facilitators. Results A total of 36 of 75 total interns volunteered to participate in the program, with 42% attending multiple sessions. Of all participants, 88% rated the sessions as “excellent,” 97% felt that the program improved their ability to function as an intern and generate a plan, and 81% reported improvement in differential diagnosis skills. Conclusions Simulation training was well received by the learners and improved self-reported clinical skills. Using residents as facilitators, supervised by faculty, was well received by the learners and enabled the implementation of the curriculum in a large training program. Simulation can provide opportunities for deliberate practice, and learners perceive this modality to be effective.

Pulmonary alveolar proteinosis (PAP) is a rare condition in which pulmonary macrophages fail to clear surfactant, resulting in the alveolar accumulation of lipoproteinaceous debris. The histopathology of PAP is typified by diffuse filling of terminal airways with eosinophilic, PAS/diastase (PAS/D)-positive acellular material. We present five patients who showed histopathological changes in the lungs consistent with mild PAP. However, these cases were notable for the abundance of degenerating alveolar macrophages, weak PAS staining of lipoproteinaceous material and paucity of lamellated bodies on ultrastructural examination. Only one patient showed the CT finding of mosaiform 'crazy-paving' and the opalescent bronchoalveolar lavage fluid characteristic of PAP. In one case, therapeutic lung lavage based on a presumptive diagnosis of PAP exacerbated respiratory distress. Three patients showed partial or near-complete resolution of disease in response to high-dose corticosteroid therapy, a treatment approach that is generally ineffective in PAP. We conclude that distinguishing 'variant alveolar lipoproteinosis' from classical PAP is clinically important. Despite the otherwise typical appearance of lipoproteinaceous alveolar material in lung biopsies, the presence of degenerating foamy macrophages and atypical histochemical, ultrastructural and radiographic features suggest a steroid-responsive form of proteinosis that is likely pathogenetically distinct and may not be amenable to whole-lung lavage.

Background Procedural skill is predicated on knowledge. We used a previously validated test to evaluate the impact of a web-based education program on medical residents' knowledge of 2 advanced medical procedures. Methods We enrolled 210 internal medicine residents at 3 residency programs in a randomized, controlled, educational trial. Study participants completed a 20-item, validated online test of their knowledge of central venous and arterial line (CVL and AL, respectively) placement at baseline and after performing their next 2 procedures (test 1 and test 2). Between test 1 and test 2, participants were randomized to online educational material for CVL insertion, AL insertion, both, or neither. The primary outcome of the study was the difference in test scores between test 1 and test 2 by randomization group. Results Though residents in the baseline cohort were confident about their knowledge of procedural technique, their mean test scores were low (62% and 58% in the CVL and AL tests, respectively). Baseline test score correlated with the number of prior procedures performed. Sixty-five residents completed all 3 CVL tests, and 85 residents completed all 3 AL tests. Access to the web-based procedure education was associated with a significant improvement in scores for both the CVL test (effect size, d = 0.25, P = .01) and AL test (d = 0.52, P Conclusions Web-based procedure training improves knowledge of procedures to a significantly greater extent than performing the procedure alone. Web-based curricula can effectively supplement other methods of skill development.

radwin l.e., ananian l., cabral h.j., keeley a. & currier p.f. (2010) Effects of a patient/family-centered practice change on the quality and cost of intensive care: research protocol. Journal of Advanced Nursing 67(1), 215–224. Abstract Aim. This paper is a description of a protocol for studying the impact of a patient/family-centered, evidence-based practice change on the quality, cost and use of services for critically ill patients at the end of life. Background. International attention currently is focused on the quality and cost/use of intensive care services. Empirical literature and expert opinion suggest that early, enhanced communication among the clinical team and the patient and family results in higher quality and less costly care at the end of life. Design. Our Medical Intensive Care Unit practice change involves three components: teaching sessions for all Registered Nurses and physicians assigned to the unit; patient/family meetings held in 72 hours of the patient’s admission to the unit; and formal documentation to support communication among clinicians. Ethical approval was obtained in April 2009. A two-group post-test design is used, with one group comprising patients hospitalized before the practice change and their families, and the second group of patients/families after the practice change. Data comprise medical record information and families’ responses to surveys. Final analytic models will result from multivariable regression techniques. Discussion. The study represents translational research in that interventions are brought to the bedside to reach the people for whom the interventions were designed. The practice change is likely to endure after the study because our research team is composed of both clinicians and scientists. Also, direct care clinicians endorse and are responsible for the practice change.

Objective: To determine whether polymorphisms of the surfactant protein B gene may be associated with increased mortality in patients with the acute respiratory distress syndrome. Design: A prospective cohort study. Setting: Four adult intensive care units at a tertiary academic medical center. Patients: Two hundred fourteen white patients who had met criteria for acute respiratory distress syndrome. Interventions: None. Measurements and Main Results: Patients were genotyped for a variable nuclear tandem repeat polymorphism in intron 4 of the surfactant protein B gene and the surfactant protein B gene 1580 polymorphism. For the variable nuclear tandem repeat surfactant protein B gene polymorphism, patients were found to have either a homozygous wild-type genotype or a variant genotype consisting of either a heterozygous insertion or deletion polymorphism. Logistic regression was performed to analyze the relationship of the polymorphisms to mortality in patients with acute respiratory distress syndrome. In multivariate analysis, the presence of variable nuclear tandem repeat surfactant protein B gene polymorphism was associated with a 3.51 greater odds of death at 60 days in patients with acute respiratory distress syndrome as compared to those patients with the wild-type genotype (95% confidence interval 1.39‐8.88, p 0.008). There was no association found between the 1580 variant and outcome (p 0.15). Conclusions: In this study, the variable nuclear tandem repeat surfactant protein B gene polymorphism in intron 4 is associated with an increased 60 day mortality in acute respiratory distress syndrome after adjusting for age, severity of illness, and other potential confounders. Additional studies in other populations are needed to confirm this finding. (Crit Care Med 2008; 36: 2511‐2516)

High-fidelity medical simulation has gained widespread use in medical education because it allows learners an opportunity to actively engage in experiential learning and deliberate practice in a safe learning environment. This resource is a six-case simulation curriculum that focuses on decision-making training in critical care clinical scenarios, designed for medical interns at the end of the first year of training. To our knowledge, this is the first such curriculum implemented within an internal medicine training program. The materials enclosed include individual case protocols and teaching handouts for each of the six cases, as well as a guide for the implementation of the curriculum. The critical care curriculum was implemented based on our experiences and lessons learned with the general medicine curriculum at our institution. The case protocols include information necessary for facilitators to conduct the simulation sessions including learning objectives, a description of the case narrative and progression, an instructor guide, and appendices including laboratory data, radiographic images, and electrocardiograms. The teaching notes, which are one-to-two page documents paired with each of the cases, review the most vital diagnostic and management principles to be learned from the case. While they were created as an independent study resource for the learners (to be distributed after each session), they can also serve as an additional preparation tool for the case facilitators prior to the sessions. The curriculum is delivered through three 1-hour sessions, covering two cases per session. We find that the learning is maximized when two-to-three intern learners work through the cases on one high-fidelity manikin. The cases are designed to be facilitated by two individuals, one acting as the manikin operator and the other as the nurse. Each scenario runs for approximately 15 minutes, followed by a 15-minute debriefing. Debriefings are conducted by one or two facilitators using a learner-centered model of debriefing.

Residency training is charged with improving resident teaching skills. Utilizing simulation in teacher training has unique advantages such as providing a controlled learning environment and opportunities for deliberate practice.We assessed the impact of a simulation-based resident-as-teacher (RaT) program.A RaT program was embedded in an existing 8-case simulation curriculum for 52 internal medicine (IM) interns. Residents participated in a workshop, then served as facilitators in the curriculum and received feedback from faculty.Residents' teaching and feed back skills were measured using a pre- and post-program self-assessment and post-session and post-curriculum evaluations by intern learners.Forty-one second- and third-year residents participated in the study August 2013 to October 2013 at a single center.Pre- and post-program teaching skills were assessed for 34 of 41 resident facilitators (83%) participating in 3.9 sessions on average. Partaking in the program led to improvements in resident facilitators' self-reported teaching and feedback skills across all domains. The most significant improvement was in teaching in a simulated environment (2.81 to 4.16, P0.001). Interns rated the curriculum highly (81% "excellent," 19% "good") and reported that resident facilitators frequently utilized debriefing techniques covered in the RaT program.Our simulation-based RaT program offered a unique opportunity for deliberate practice of teaching skills in a controlled environment and led to improvements in resident facilitators' teaching and feed back skills. The simulation curriculum, facilitated by residents, was well received by the intern learners. Our program design may serve as a model for the development of simulation curricula and RaT programs within IM residencies.

Several studies have suggested that olfactory ensheathing glia (EG) can form Schwann cell (SC)-like myelin. Because of possible misinterpretation attributable to contaminating SCs, the capacity of EG to produce myelin needs to be explored further. Therefore, we compared the abilities of adult EG, purified by immunopanning with p75 antibody, and adult SCs to produce myelin when cocultured with purified dorsal root ganglion neurons (DRGNs) in serum-free and serum-containing media. In both media formulations, the number of myelin sheaths in SC/DRGN cultures was far higher than in EG/DRGN cultures; the number of sheaths in EG/DRGN cultures was equal to that in purified DRGN cultures without added cells. The latter result demonstrates that myelination by a few SCs remaining in purified DRGN cultures may occur, suggesting that myelin in EG/DRGN cultures could be SC myelin. Striking differences in the relationship of EG and SC processes to axons were observed. Whereas SCs displayed relatively short, thick processes that engulfed axons in small bundles or in individual cytoplasmic furrows and segregated larger axons into one-to-one relationships, EG extended flattened sheets that partitioned or only partially encircled fascicles of axons, sometimes spanning the entire culture. SCs exhibited behavior typical of SCs in peripheral nerves, whereas EG exhibited characteristics resembling those of EG in olfactory nerves. In sum, p75-selected EG from adult animals did not exhibit an SC-like relationship to axons and did not form myelin.

Purpose Prior studies of anxiety and depression among families of intensive care unit patients excluded those admitted for less than 2 days. We hypothesized that families of surviving patients with length of stay less than 2 days would have similar prevalence of anxiety and depression compared with those admitted for longer. Materials and methods One hundred six family members in the neurosciences and medical intensive care units at a university hospital completed the Hospital Anxiety and Depression Scale at discharge. Results The 106 participants represented a response rate of 63.9% among those who received surveys. Fifty-eight surveys (54.7%) were from relatives of patients who were discharged within 2 days of admission, whereas 48 (45.3%) were from those admitted for longer. No difference in anxiety was detected; prevalence was 20.7% (95% confidence interval, 10.4) among shorter stay families and 8.3% (7.8) among longer stay families (P = .10). No difference was also seen with depression; prevalence was 8.6% (7.2) among shorter stay families and 4.2% (5.7) among longer stay families (P = .45). Conclusions Families of surviving patients with brief length of stay may have similar prevalence of anxiety and depression at discharge to those with longer length of stay.

Mouse hepatitis virus strain A59 (MHV-A59) encodes within the 22-kb gene 1 a large polypretain containing three proteinase domains with proven or predicted cysteine catalytic residues. E64d, a specific, irreversible inhibitor of cysteine (thiol) proteinases, inhibits the processing of the gene 1 polyprotein. Specifically, E64d blocks the carboxy-terminal cleavage of p65, E64d also inhibits replication of MHV-A59 in murine DBT cells in a dose-dependent manner, resulting in reduced virus titers and viral syncytia formation. This inhibition of replication is associated with a rapid shutoff of new viral RNA synthesis, in a manner similar to that seen in the presence of cycloheximide. The E64d-associated inhibition of RNA synthesis likely results from E64d-specific inhibition of processing of the gene 1 polyprotein, resulting in inactive proteinase or replicase proteins. These results indicate that processing of the MHV-A59 gene 1-encoded polyprotein is required throughout infection to sustain RNA synthesis and virus replication.

Pulmonary alveolar proteinosis (PAP) is a rare condition in which pulmonary macrophages fail to clear surfactant, resulting in the alveolar accumulation of lipoproteinaceous debris. The histopathology of PAP is typified by diffuse filling of terminal airways with eosinophilic, PAS/diastase (PAS/D)-positive acellular material. We present five patients who showed histopathological changes in the lungs consistent with mild PAP. However, these cases were notable for the abundance of degenerating alveolar macrophages, weak PAS staining of lipoproteinaceous material and paucity of lamellated bodies on ultrastructural examination. Only one patient showed the CT finding of mosaiform 'crazy-paving' and the opalescent bronchoalveolar lavage fluid characteristic of PAP. In one case, therapeutic lung lavage based on a presumptive diagnosis of PAP exacerbated respiratory distress. Three patients showed partial or near-complete resolution of disease in response to high-dose corticosteroid therapy, a treatment approach that is generally ineffective in PAP. We conclude that distinguishing 'variant alveolar lipoproteinosis' from classical PAP is clinically important. Despite the otherwise typical appearance of lipoproteinaceous alveolar material in lung biopsies, the presence of degenerating foamy macrophages and atypical histochemical, ultrastructural and radiographic features suggest a steroid-responsive form of proteinosis that is likely pathogenetically distinct and may not be amenable to whole-lung lavage.

This chapter provides an overview of pulmonary embolism (PE) and deep vein thrombosis (DVT) – the history of their clinical recognition and treatment, pathogenesis, epidemiology, risk factors, prognosis, and current therapy. Many of these topics will be addressed in detail in other chapters. PE and DVT will be referred to together as venous thromboembolism (VTE).

This chapter will focus on thrombolytic and anticoagulant therapy for pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH). It will examine the physiologic basis and pharmacologic aspects of various approaches and examine clinical data based on traditional, current, and emerging treatments of the diseases. Other pharmacologic treatments and surgical or procedurally based treatment for PE or CTEPH are explored elsewhere in this book.

This paper is a description of a protocol for studying the impact of a patient/family-centered, evidence-based practice change on the quality, cost and use of services for critically ill patients at the end of life.International attention currently is focused on the quality and cost/use of intensive care services. Empirical literature and expert opinion suggest that early, enhanced communication among the clinical team and the patient and family results in higher quality and less costly care at the end of life.Our Medical Intensive Care Unit practice change involves three components: teaching sessions for all Registered Nurses and physicians assigned to the unit; patient/family meetings held in 72 hours of the patient's admission to the unit; and formal documentation to support communication among clinicians. Ethical approval was obtained in April 2009. A two-group post-test design is used, with one group comprising patients hospitalized before the practice change and their families, and the second group of patients/families after the practice change. Data comprise medical record information and families' responses to surveys. Final analytic models will result from multivariable regression techniques.The study represents translational research in that interventions are brought to the bedside to reach the people for whom the interventions were designed. The practice change is likely to endure after the study because our research team is composed of both clinicians and scientists. Also, direct care clinicians endorse and are responsible for the practice change.

BACKGROUND AND AIM: Knowledge of core medical procedures is required by the American Board of Internal Medicine (ABIM) for certification. Efforts to improve the training of residents in these procedures have been limited by the absence of a validated tool for the assessment of knowledge. In this study we aimed to develop a standardized test of procedural knowledge in 3 medical procedures associated with potentially serious complications. METHODS: Placement of an arterial line, central venous catheter, and thoracentesis were selected for test development. Learning objectives and multiple-choice questions were constructed for each topic. Content evidence was evaluated by critical care subspecialists. Item test characteristics were evaluated by administering the test to students, residents and specialty clinicians. Reliability of the 32-item instrument was established through its administration to 192 medical residents in 4 hospitals. RESULTS: Reliability of the instrument as measured by Cronbach's α was 0.79 and its test-retest reliability was 0.82. Median score was 53% on a test comprising elements deemed important by critical care subspecialists. Increasing number of procedures attempted, higher self-reported confidence, and increasing seniority were predictors of overall test scores. Procedural confidence correlated significantly with increasing seniority and experience. Residents performed few procedures. CONCLUSIONS: We have successfully developed a standardized instrument to assess residents' cognitive competency for 3 common procedures. Residents' overall knowledge about procedures is poor. Experiential learning is the dominant source for knowledge improvement, but these experiences are increasingly rare. Journal of Hospital Medicine 2009;4:430–432. © 2009 Society of Hospital Medicine.

Traditionally, medical education has used live patients to teach medical procedures. This carries a significant risk to patients. As learning technology advances, the early integration of computer-aided medical simulations into medical training before patient contact is becoming an ethical imperative, yet development costs are constraining. In this paper, we describe the use of a gaming engine to create rapidly a game-like interactive simulation for medical training at a low cost. Our process model, driven by the simulation storyboard provided by the instructors, allows for easy simulation refinements and permits an early evaluation of the educational outcome. We also describe its initial integration into the existing matrix of low-tech simulation (procedures practiced on mannequins) and an educational platform (e-learning system) used to support and track novice physicians within a large academic training center.