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Introduction: This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral bronchopleural fistulae (BPF) using minimally invasive techniques. In this study, we present a previously healthy 14-year-old male hospitalized with 2009 H1N1 influenza and methicillin-resistant Staphylococcus aureus coinfection complicated by severe acute respiratory distress syndrome and multifocal necrotizing pneumonia, with significant lung tissue damage requiring prolonged extracorporeal membrane oxygenation (ECMO) support., Methods: The development of multiple BPFs precluded lung recruitment necessary to wean from ECMO. Treatment options were very limited and endobronchial valves were considered. However, localizing single airleaks with a fogarty balloon is normally the technique to determine appropriate location to place the valves. With multiple fistulae, this technique would be ineffective. Therefore, the patient was brought to interventional radiology and bronchography was performed for selective fistula mapping. With this precise localization, the multiple fistulae were ultimately controlled using image-guided embolization and the placement of multiple endobronchial valves. The success of this intervention enabled positive pressure ventilator support and rehabilitation required for weaning from ECMO support., Conclusion: This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral BPFs using minimally invasive techniques.

Study Design: Prospective, cohort study., Objectives: To evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI)., Setting: Academic tertiary care center, USA., Methods: Overall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months., Results: Overall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL., Conclusions: Despite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Context: Spinal cord injury commonly results in neuromuscular weakness that impacts respiratory function. This would be expected to be associated with an increased likelihood of sleep-disordered breathing., Objective: (1) Understand the incidence and prevalence of sleep disordered breathing in spinal cord injury. (2) Understand the relationship between injury and patient characteristics and the incidence of sleep disordered breathing in spinal cord injury. (3) Distinguish between obstructive sleep apnea and central sleep apnea incidence in spinal cord injury. (4) Clarify the relationship between sleep disordered breathing and stroke, myocardial infarction, metabolic dysfunction, injuries, autonomic dysreflexia and spasticity incidence in persons with spinal cord injury. (5) Understand treatment tolerance and outcome in persons with spinal cord injury and sleep disordered breathing., Methods: Extensive database search including PubMed, Cochrane Library, CINAHL and Web of Science., Results: Given the current literature limitations, sleep disordered breathing as currently defined is high in patients with spinal cord injury, approaching 60% in motor complete persons with tetraplegia. Central apnea is more common in patients with tetraplegia than in patients with paraplegia., Conclusion: Early formal sleep study in patients with acute complete tetraplegia is recommended. In patients with incomplete tetraplegia and with paraplegia, the incidence of sleep-disordered breathing is significantly higher than the general population. With the lack of correlation between symptoms and SDB, formal study would be reasonable. There is insufficient evidence in the literature on the impact of treatment on morbidity, mortality and quality of life outcomes.

Objective: To evaluate a strategy of home-based testing to diagnose sleep-disordered breathing and nocturnal hypercapnia in individuals with spinal cord injury (SCI)., Design: Case series., Setting: Referral center., Participants: Adults with C1-T6 SCI (N=81). Individuals were eligible if ≥ 18 years old, with SCI of ≥ 3 months' duration, living within 100 miles of the study site, and not meeting exclusion criteria. Of the 161 individuals recruited from the SCI Model System database who were not enrolled, reasons were not interested in participating, change of location, prior positive pressure ventilation use, or medical contraindication. Ten individuals did not complete the study., Interventions: Performance of an unsupervised home sleep apnea test combined with transcutaneous partial pressure of carbon dioxide/oxygen saturation by pulse oximetry monitoring., Main Outcome Measures: Prevalence of sleep-disordered breathing and nocturnal hypercapnia. Clinical and physiological variables were examined to determine which, if any, correlate with the severity of sleep-disordered breathing., Results: Obstructive sleep apnea (OSA) was found in 81.3% of individuals, central sleep apnea (CSA) was found in 23.8%, and nonspecific hypopnea events, where respiratory effort was too uncertain to classify, were present in 35%. Nonspecific hypopnea events correlated strongly with CSA but weakly with OSA, suggesting that conventional sleep apnea test scoring may underestimate central/neuromuscular hypopneas. Nocturnal hypercapnia was present in 28% and oxygen desaturation in 18.3%. Neck circumference was the primary predictor for OSA, whereas baclofen use and obstructive apnea/hypopnea index weakly predicted CSA. Awake transcutaneous partial pressure of carbon dioxide and CSA were only marginally associated with nocturnal hypercapnia., Conclusions: Unsupervised home sleep apnea testing with transcutaneous capnography effectively identifies sleep-disordered breathing and nocturnal hypercapnia in individuals with SCI., (Copyright © 2016 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Intensive care units (ICUs) are an essential and unique component of modern medicine. The number of critically ill individuals, complexity of illness, and cost of care continue to increase with time. In order to meet future demands, maintain quality, and minimize medical errors, intensivists will need to look beyond traditional medical practice, seeking lessons on quality assurance from industry and aviation. Intensivists will be challenged to keep pace with rapidly advancing information technology and its diverse roles in ICU care delivery. Modern ICU quality improvement initiatives include ensuring evidence-based best practice, participation in multicenter ICU collaborations, employing state-of-the-art information technology, providing point-of-care diagnostic testing, and efficient organization of ICU care delivery. This article demonstrates that each of these initiatives has the potential to revolutionize the quality of future ICU care in the United States.

Objective: To determine the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco(2)) monitoring/oxygen saturation by pulse oximetry (Spo(2)) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders., Design: Retrospective case series analyzed consecutively., Setting: Multidisciplinary neuromuscular respiratory failure (NMRF) clinic at an academic institution., Participants: Subjects (N=35, 68.6% men; mean age, 46.9y) with spinal cord injury (45.7%) or other neuromuscular disorders underwent overnight tests with tc-Pco(2)/Spo(2) monitoring. Fifteen (42.9%) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV)., Interventions: A respiratory therapist brought a calibrated tc-Pco(2)/Spo(2) monitor to the patient's home and provided instructions for data collection during the subject's normal sleep period. Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco(2) (ET-Pco(2)) were recorded at a clinic visit before monitoring., Main Outcome Measures: Detection of NH (tc-Pco(2) ≥50mmHg for ≥5% of monitoring time). Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo(2) ≤88% for ≥5% of monitoring time), FVC, BMI, or daytime ET-Pco(2) could predict the presence of NH., Results: NH was detected in 18 subjects (51.4%), including 53.3% of those using BiPAP or TV. NH was detected in 43.8% of ventilator-independent subjects with normal daytime ET-Pco(2) (present for 49.4%±31.5% [mean ± SD] of the study period), and in 75% of subjects with an elevated daytime ET-Pco(2) (present for 92.3%±8.7% of the study period). Oxygen desaturation, BMI, and FVC were poor predictors of NH. Only 3 attempted monitoring studies failed to produce acceptable results., Conclusions: Home-based, unsupervised monitoring with tc-Pco(2)/Spo(2) is a useful method for diagnosing NH in NMRF., (Copyright © 2013 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Plasminogen activation to plasmin protects from lung fibrosis, but the mechanism underlying this antifibrotic effect remains unclear. We found that mice lacking plasminogen activation inhibitor-1 (PAI-1), which are protected from bleomycin-induced pulmonary fibrosis, exhibit lung overproduction of the antifibrotic lipid mediator prostaglandin E2 (PGE2). Plasminogen activation upregulated PGE2 synthesis in alveolar epithelial cells, lung fibroblasts, and lung fibrocytes from saline- and bleomycin-treated mice, as well as in normal fetal and adult primary human lung fibroblasts. This response was exaggerated in cells from Pai1-/- mice. Although enhanced PGE2 formation required the generation of plasmin, it was independent of proteinase-activated receptor 1 (PAR-1) and instead reflected proteolytic activation and release of HGF with subsequent induction of COX-2. That the HGF/COX-2/PGE2 axis mediates in vivo protection from fibrosis in Pai1-/- mice was demonstrated by experiments showing that a selective inhibitor of the HGF receptor c-Met increased lung collagen to WT levels while reducing COX-2 protein and PGE2 levels. Of clinical interest, fibroblasts from patients with idiopathic pulmonary fibrosis were found to be defective in their ability to induce COX-2 and, therefore, unable to upregulate PGE2 synthesis in response to plasmin or HGF. These studies demonstrate crosstalk between plasminogen activation and PGE2 generation in the lung and provide a mechanism for the well-known antifibrotic actions of the fibrinolytic pathway.

Background and Objectives: As part of our family medicine clerkship seminar on the patient-physician relationship, third-year students write about an illness episode within their own families., Methods: Using a grounded research approach, we examined 260 student narratives to extract the most significant meanings., Results: Significant themes that emerged include the role of family members in illness episodes, specific influences resulting from the family's ethnicity or religion, experiences with socially unacceptable illnesses, experiences with death, appreciation of the moral trajectory of illness, and situations that display the fallibility and limitations of medicine., Conclusions: Writing exercises can help students recognize the centrality of narrative and of cultural values in medicine so they are better able to understand their patients and provide more patient-centered medical care.

Background and Objectives: Management of upper respiratory infection (URI) was examined in a family practice clinic to determine evidence-based practices, specifically for medication choice. Scientific evidence supports the use of decongestants and perhaps decongestant/antihistamine combinations in adolescents and adults and antipyretics in all age groups. The use of cold preparations for children younger than age 5 is not evidence based., Methods: Data on demographics, medications prescribed, and over-the-counter medications recommended were collected from patient charts for 293 URI visits over a 6-month period. The cost of evidence-based URI treatment was compared with the cost of nonevidence-based treatment., Results: Thirty-three percent of patients younger than age 5 were given a prescription; 96% of the prescription cost in this age group was nonevidence based. Twenty-six percent of all patients seen were given unnecessary and potentially harmful medication. These unnecessary medications accounted for almost 60% of the total prescription cost. Various combinations of antihistamines, decongestants, and antitussives were most commonly prescribed., Conclusions: Few medications have been shown to effectively alleviate the symptoms of the generally self-limited, benign common cold. Medications are often overprescribed, escalating health care costs and, in some cases, exposing the patient to dangerous side effects. Family physicians and educators are encouraged to reexamine their treatment and teaching practices for the common cold.

A survey of adolescents living in rural southwestern towns demonstrated their knowledge of the basic transmission routes of Acquired Immune Deficiency Syndrome (AIDS). Nevertheless, misconceptions and attitudes, which may interfere with adopting safe behaviors, persist. Significant differences in knowledge did exist between the ethnic groups surveyed. Further, American Indian and black adolescents were more likely to express attitudinal biases against people who have AIDS. We conclude that current media efforts have been successful in communicating basic information regarding transmission, but there may exist a need for ethnically specific programs that focus on the misconceptions and attitudes surrounding AIDS.

Little attention is given in the medical school curriculum to providing care for the 5-10% of the population that is homosexual. An elective course was developed to promote more positive attitudes among doctors-in-training towards homosexual patients. The format was primarily small group discussion between students and articulate homosexual people around societal biases towards homosexuals and issues of health care delivery. Students from this seminar and a control group from another elective completed an attitude questionnaire before and after the course. The study group became more accepting towards homosexual lifestyles significantly in 12 of 15 measures while no difference was found in the control group. Students' reaction to this learning experience was highly positive: they appreciated the opportunity to learn about same-sex life-styles in a personal and nonthreatening way, thus enabling them to accept and better care for homosexual people.

Saipan, one of many islands of the Pacific Trust Territory, depends on the United States for its medical care. The limited resources on the island have resulted in little medical attention for adolescents. This study surveyed 519 Saipan adolescents to determine their health practices, problems, and needs. Although these teenagers rarely saw physicians, they commonly reported health problems such as headaches, abdominal pain, and dental cavities. In the psychosocial arena, their problems involved parents, girlfriends/boyfriends, school, and suicidal thoughts. The health topics found to be of most interest included sex education, jobs, suicide prevention, drugs, and birth control. The most popular methods for learning about these subjects were books, movies, films, and school classes. There were high reported incidences of drug and alcohol problems among boys, and thoughts about suicide in all respondents.