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The ability to perform invasive bedside procedures (IBPs) safely and efficiently is a core skill set within critical care medicine. Fellowship training provides a pivotal time for learners to attain baseline proficiency in such procedures to decrease patient complications. The coronavirus disease 2019 pandemic has posed distinct challenges to the traditional model of teaching and supervising IBPs in the intensive care unit, including stewardship of personal protective equipment and limiting health care worker exposure to persons with coronavirus disease 2019. To address these challenges, we piloted a novel method of IBP supervision and teaching using a virtual monitoring system. In this virtual procedural supervision model, the supervising teacher is located outside the patient room, limiting personal protective equipment use and health care worker exposure. An audiovisual monitoring system allowed communication between the teacher and the learner as well as supervisor visualization of the procedural encounter. Virtual supervision was used for central line placement and bronchoscopy in the medical intensive care unit with no complications or instances of the supervisor needing to enter the patient room. Success was felt to depend on camera positioning and preprocedure planning and to be best for advanced learners who would not require tactile feedback. Upper level learners appreciated autonomy granted by this process. Virtual IBP supervision is felt to be a useful tool in specific situations. As with any tool, there are notable strengths and limitations. Success is felt to be optimized when attention is paid to procedural teaching best practices, learner selection, and technological logistics.

Background Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. Research Question How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? Study Design and Methods This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. Results We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. Interpretation Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

Background Competence in ultrasonography is essential for pulmonary and critical care medicine (PCCM) fellows, but little is known about fellow-reported barriers to acquiring this crucial skill during fellowship training. Research Question How do PCCM fellows acquire experience performing and interpreting ultrasonography during their training, what is their perspective on barriers to acquiring ultrasound expertise during fellowship, and what is their comfort with a range of ultrasound examinations? Study Design and Methods A 20-item survey including questions about procedural training and acquisition of ultrasound skills during PCCM fellowship was developed. The survey instrument was sent to PCCM fellowship program directors to distribute to their fellows at program directors’ discretion. Results Four hundred seventy-five responses were received. The most common method of learning ultrasonography was performing it independently at the bedside. Fellows reported that the greatest barrier to acquiring ultrasound skills was the lack of trained faculty experts, followed by lack of a formal curriculum. Fellow comfort was greatest with thoracic ultrasound and least with advanced cardiac ultrasound. Interpretation Significant barriers to ultrasound training during PCCM fellowship exist, and future educational efforts should address these barriers at both program and institutional levels.

Background Faculty supervision of invasive bedside procedures (IBPs) in the ICU may enhance procedural education and ensure patient safety. However, there is limited research on teaching effectiveness in the ICU, and there are no best teaching practices regarding the supervision of IBPs. Research Question We conducted a multi-institutional qualitative study of pulmonary and critical care medicine faculty and fellows to better understand characteristics of effective IBP teachers. Study Design and Methods Separate focus groups (FGs) were conducted with fellows and faculty at four large academic institutions that were geographically distributed across the United States. FGs were facilitated by a trained investigator, audio-recorded, and transcribed verbatim for analysis. Themes were identified inductively and compared with constructs from social and situated learning theories. Data were analyzed between and across professional groups. Qualitative research software (NVivo; QSR International) was used to facilitate data organization and create an audit trail of the analysis. A multidisciplinary research team was engaged to minimize interpretive bias. Results Thirty-three faculty and 30 fellows participated. Inductive analysis revealed three categories of themes among successful IBP teachers: traits, behaviors, and context. Traits included calm demeanor, trust, procedural competence, and effective communication. Behaviors included leading preprocedure huddles to assess learners’ experiences and define expectations; debriefing to provide feedback; and allowing appropriate autonomy. Context included learning climate, levels of distraction, patient acuity, and institutional culture. Interpretation We identified specific traits and behaviors of effective IBP teachers that intersect with the practice environment, which highlights the challenge of teaching IBPs. Notably, FG participants emphasized interpersonal, more than technical, aspects of successful IBP teachers. These findings should inform future curricula on teaching IBPs in the ICU, standardize IBP teaching for pulmonary and critical care medicine fellows, and reduce patient injury from procedural complications.

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.

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.

The coronavirus disease (COVID-19) pandemic has disrupted not only clinical care but also medical education. Physical distancing and shift rearrangements for both trainees and faculty have led to abrupt cancelation of many in-person didactics. These have been replaced by distance learning options, which include both synchronous and asynchronous curricula. Unfortunately, many medical educators have been forced to quickly create distance-learning options for trainees with little prior experience. In this perspective, we review the evidence base for distance learning and discuss practical considerations for transitioning traditional in-person curricula to distance platforms. We review technical aspects of distance learning as well as educational principles essential for success. The goal is for medical educators to optimize distance learning not just during this COVID-19 pandemic but beyond this crisis as well.

It is important for attending physicians to know which behaviors influence learner perceptions. To date, two studies focusing on general medicine attending physicians have been published addressing internal medicine residents' perceptions of attending physicians; there are no data on intensive care unit (ICU) attending physicians.We sought to expand the evidence regarding this topic through a multicenter study at four geographically diverse academic medical centers. Our study focused on identifying the teaching behaviors of ICU physicians that learners observe in attending physicians who they value as effective educators.The study was conducted at Indiana University (Indianapolis, IN), Johns Hopkins University (Baltimore, MD), University of California-San Francisco (San Francisco, CA), and University of Washington (Seattle, WA). Internal medicine residents completed an anonymous online survey rating the importance of behaviors of ICU attending physician role models. We created a 37-item questionnaire derived from prior studies and from the Clinician Teaching Program from the Stanford Faculty Development Center for Medical Teachers. This questionnaire included behaviors, current and past, that residents observed in their ICU attending physicians.A total of 260 of 605 residents responded to the survey (overall response rate of 43%). The five behaviors of attending physicians most commonly rated as "very important" to residents were: (1) enjoyment of teaching; (2) demonstrating empathy and compassion to patients and families; (3) ability to explain clinical reasoning and differential diagnoses; (4) treating nonphysician staff members respectfully; and (5) enthusiasm on rounds. Behaviors that trainees rated as less important were having numerous research publications, having served as chief resident, sharing personal life with residents, and organizing end-of-rotation social events.Our study provides new information to attending physicians striving to influence resident education. Although prior data demonstrated that learners valued attending physicians having served as chief resident and sharing personal information with learners, our study did not replicate this. We confirmed that learners appreciated teachers who are perceived to enjoy teaching. We discovered that behaviors, such as expression of empathy, explanation of clinical reasoning, and qualities of professionalism, were commonly seen in esteemed teaching attending physicians. Our study was limited by lack of correlation to objective performance metrics and a low response rate. Future work may include assessing the impact of faculty development on identified behaviors.

// Anna K. Brady 1 , Jonathan D. McNeill 2 , Brendan Judy 3 , Joshua Bauml 4 , Tracey L. Evans 4 , Roger B. Cohen 4 , Corey Langer 4 , Anil Vachani 5 , Charu Aggarwal 4 1 Department of Medicine, Washington University Medical Center, St. Louis, MO, USA 2 Ruth and Raymond Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA 3 Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA, USA 4 Division of Hematology and Oncology, University of Pennsylvania, Philadelphia, PA, USA 5 Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, PA, USA Correspondence to: Charu Aggarwal, e-mail: Charu.Aggarwal@uphs.upenn.edu Keywords: KRAS, non-small cell lung cancer, bevacizumab Received: May 06, 2015 Accepted: August 24, 2015 Published: September 03, 2015 ABSTRACT Introduction: Mutations (MT) of the KRAS gene are the most common mutation in non-small cell lung cancer (NSCLC), seen in about 20–25% of all adenocarcinomas. Effect of KRAS MT on response to cytotoxic chemotherapy is unclear. Methods: We undertook a single-institution retrospective analysis of 93 consecutive patients with stage IV NSCLC adenocarcinoma with known KRAS and EGFR MT status to determine the association of KRAS MT with survival. All patients were treated between January 1, 2008 and December 31, 2011 with standard platinum based chemotherapy at the University of Pennsylvania. Overall and progression free survival were analyzed using Kaplan-Meier and Cox proportional hazard methods. Results: All patients in this series received platinum doublet chemotherapy, and 42 (45%) received bevacizumab. Overall survival and progression free survival for patients with KRAS MT was no worse than for patients with wild type KRAS. Median overall survival for patients with KRAS MT was 19 months (mo) vs. 15.6 mo for KRAS WT, p = 0.34, and progression-free survival was 6.2 mo in patients with KRAS MT vs. 7mo in patients with KRAS WT, p = 0.51. In multivariable analysis including age, race, gender, and ECOG PS, KRAS MT was not associated with overall survival (HR 1.12, 95% CI 0.58–2.16, p = 0.74) or progression free survival (HR 0.80, 95% CI 0.48–1.34, p = 41). Of note, receipt of bevacizumab was associated with improved overall survival only in KRAS WT patients (HR 0.34, p = 0.01). Conclusions: KRAS MT are not associated with inferior progression-free and overall survival in advanced NSCLC patients treated with standard first-line platinum-based chemotherapy.

A man in his 20s with a history of classical Hodgkin's lymphoma was admitted with fever. His original lymphoma diagnosis was made 3 years prior, when he had presented with lymphadenopathy and a mediastinal mass. He had relapsed disease despite chemotherapy and radiation. As a result, he underwent autologous peripheral blood stem cell transplant (SCT) 6 months prior to current presentation and subsequently allogeneic SCT 2 months prior for added graft vs tumor effect.

The objective of this study was to examine the prevalence of potentially inappropriate medications (PIMs) and potential adverse drug effects (ADEs) in older adults presenting to the emergency department (ED). This was a prospective observational study of a convenience sample of adults 65 years and older presenting to the ED at an urban, tertiary care hospital. Potentially inappropriate medications were defined according to 2003 Beers criteria. Potential ADEs were defined as either (1) a potential drug-drug interaction, (2) alternative medication likely to cause toxicity or drug interactions, or (3) toxic doses of vitamins or minerals. Of 174 eligible patients, 124 were enrolled. The mean number of medications used per patient was 8.6 (range, 0-20). Thirty six patients (29%, 95% confidence interval, 27%-37%) presented to the ED with at least one PIM. Eight PIMs were prescribed in the ED, representing 16% of all prescriptions in the ED. Potential ADEs meeting the defined criteria were found in 26.6% of patients. A subanalysis of a random sample of charts revealed significant discordance between medication lists obtained by the research assistants and that of the health care providers. Older ED patients are at high risk for use of potentially inappropriate medications and ADEs. This problem may be magnified by inaccurate medication lists obtained by ED providers. A larger multicenter study may help to better define the scope of this problem.

7595 Background: KRAS mutations (MT) form a distinct subset of NSCLC, generally considered to have poor prognosis. Although KRAS MT is a well-establised prognostic and predictive marker in colorectal cancer, its role in NSCLC remains ambiguous. Pts with KRAS MT NSCLC do not respond well to epidermal growth factor receptor (EGFR) directed tyrosine kinase inhibitor therapy, but little is known about the ability of KRAS MT to predict outcome after first-line chemotherapy in newly diagnosed advanced or recurrent NSCLC. Methods: We analyzed outcomes of consecutive pts with newly identified Stage IV non- squamous NSCLC treated at University of Pennsylvania (Penn) between 05/2008 and 7/2010 and then compared survival based on KRAS status [MT vs wild type (WT)] using chi square, Kaplan-Meier methods, and Cox regression models. Results: Of 106 consecutive new pts with Stage IV non squamous NSCLC treated at Penn, 49 (46%) underwent molecular analysis for KRAS MT. Fifteen (34%) were KRAS MT. Of 34 KRAS WT pts, 6 were positive for EGFR MT. The median age of all 49 pts was 61 years; 83% were Caucasian, 45% male and 60% had a >10 pack year smoking history. Median duration of follow up is 16.4 mos. Majority of pts (92%) had adenocarcinoma histology. Most pts (88%) had ECOG PS 0-1 at presentation. Forty three pts received first line platinum-based combination chemotherapy (platinum and pemetrexed in 31 pts). KRAS MT was associated with smoking (p=0.04), but not with gender or age. Overall survival (OS) of pts with KRAS MT was similar to KRAS WT pts [median OS 15.6 vs. 19.0 mos; HR 1.24 (95% CI 0.57-2.67)]. Univariate analyses demonstrated superior OS among women compared to men (HR 0.40, 95% CI 0.20-0.85) in the entire pt cohort. Conclusions: In our population of stage IV non squamous NSCLC, pts with KRAS MT had similar OS to those with KRAS WT tumors. OS was slightly higher in KRAS WT pts, but this may have been confounded by the inclusion of 6 EGFR MT pts in this cohort. The potential prognostic or predictive role of KRAS MT in NSCLC pts undergoing chemotherapy requires further prospective study.

Acute myeloid leukemia (AML) is difficult to treat, particularly in the relapsed or refractory setting due to drug resistance. Topo II inhibitors are effectively used to treat AML, and histone deacetylase (HDAC) inhibitors have been used pre-clinically and clinically with some success. We previously reported that vorinostat (SAHA) was effective in combination with topo II inhibitors in AML cells (Proc. AACR, 2009, Abstract 4567). In the present study we evaluate LBH589, a novel class I/II HDAC inhibitor. Since resistance to HDAC inhibitors has not been well described, we hypothesized that LBH589 would be effective in combination with a topo II inhibitor in a doxorubicin-resistant AML cell line that expresses MDR and resistant by MDR-independent mechanism. A sensitive HL60 parent line (S) and the doxorubicin-resistant sub-line (R) were used. Early studies revealed that vorinostat (SAHA) had comparable anti-proliferative effects in S & R cells but the R cells were relatively more resistant to LBH589. This resistance was likely MDR-mediated. We then tested whether sub-lethal doses of SAHA or LBH589, used in combination with sub-lethal doses of etoposide (VP-16), would be effective. S and R cells were treated with VP-16 for 1 h, washed, and re-incubated with SAHA or LBH, or drug-free media, for a total of 144 hours. Cell viability and apoptosis were measured at 72 h and 144 h following treatment. At 72 h and at 144 h, the combination of VP-16 and LBH was significantly more effective (p Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5431.

Abstract 1012 Poster Board I-34 Background: Disparities in survival between black and white patients (pts) exist for many malignancies, including AML. Potential causes include differential access to care; variable aggressiveness of therapy; and biological heterogeneity. Black men with AML have lower complete remission (CR) and overall survival (OS) rates than black women and whites, as shown in a previous Cancer and Leukemia Group B (CALGB) study in which induction therapies were defined, but subsequent treatment compliance and intensity was unknown. We investigated whether differences in post-remission therapy (PRT) might explain disparity in outcome. Methods: All pts with newly diagnosed AML treated with cytarabine-based induction therapy between 1997 and 2008 were included. PRT was defined as either cytarabine-based chemotherapy or bone marrow transplant (autologous or allogeneic) administered to pts achieving a CR and prior to relapse or in the setting of no relapse. PRT was coded according to intensity, in cumulative mg/m2 of cytarabine or mitoxantrone received, with BMT assigned the highest intensity of cytarabine. Data on known prognostic factors (age, white blood cell count (WBC) at diagnosis, pathologic subtype, AML etiology, cytogenetic risk groups (as defined by CALGB 8461)) were collected and controlled for in multivariable analyses. Time to PRT was measured in days from date of discharge after induction chemotherapy to date of PRT initiation, excluding patients with time to PRT >150 days, considered too long to be true consolidation. Comparisons between black and white pts were performed using linear, logistic, and proportional hazard regressions, exploring intensity of and time to PRT, and number of PRT cycles, along with potential interaction terms, controlling for known prognostic factors for outcome. Results: Of 460 pts, 421 had adequate data on PRT. Of these, 379 (90%) were white, 32 (8%) black, 10 (2%) other, and 46% were female. Similar to CALGB data, and compared to whites, blacks were younger (mean age 53.5 vs. 57.5 years, p=.11), had a higher proportion of favorable (18.8% vs. 12.7%) and poor risk (34.4% vs. 24.5%) cytogenetics (p=.28), and were less likely to attain a complete remission (CR, 66% vs. 73%, p=.39), though differences did not reach significance due to sample size. Other baseline characteristics, including reinduction rates, were similar. The 236 pts who received PRT included 18 blacks (56%) and 218 whites (58%, p=.89). In univariate analyses, for blacks vs. whites, median time to PRT initiation was 31 vs. 23 days (p=.33); cytarabine intensity was 66,654 mg/m2 vs. 50,630 mg/m2 (p=.26); and number of cycles was 2.4 vs. 2.1 (p=.41), respectively. Median time to PRT among all men was 24 days, compared to 21 days for all women (p=.09), and for pts =60 years (p=.43). Median survival was 0.72 years in both black and white patients (p=.57). Among those receiving PRT, median survival was 3 years in blacks and 1.4 years in whites (p =.22); for pts not receiving PRT, median survival was.22 years in blacks and.32 years in whites (p =.25). In multivariate analyses, time to PRT was shorter for whites (HR=.25, p=.016), particularly when white men were compared to black men (HR=.12, p=.012), whereas no differences were found for women. Survival differences did not reach significance; nor was there an interaction for male and black race. Conclusions: Time to PRT is shorter for whites compared to blacks with AML, though cycle dose intensity and number are similar. Despite this, overall survival was not different between blacks and whites receiving PRT. In the post-remission setting, blacks and whites appear to receive similar chemotherapy management, and thus differential treatment aggressiveness and compliance are not explanations for varying outcome between races. Disclosures: No relevant conflicts of interest to declare.