[Tezepelumab: a new option for the treatment of severe asthma]

In Latin America, asthma is a public health problem with a significant impact on both patients and health systems. The greater understanding of the pathophysiology and the recognition of the central role that inflammation has in the severity of asthma has favored the development of monoclonal antibodies that have IL-5, IL-4, IL-13 and IgE as therapeutic targets. Although these therapeutic alternatives promote better control of the disease, not all patients respond favorably to these treatments. Therefore, it is of particular interest to explore monoclonal antibodies such as Tezepelumab, directed against thymic stromal lymphopoietin (TSLP), an alarmin (epithelial cytokine) that participates in the initiation and perpetuation of inflammation in Asthma. Therefore, in this review, we will show the clinical efficacy of tezepelumab in reducing the annual rate of exacerbations, improving lung function, and reducing bronchial hyperreactivity, regardless of the patient's baseline biomarker levels. Therefore, this new molecule is a highly effective therapeutic option for patients with severe asthma.

An Integrated Mycobacterium tuberculosis Infection Session: Utilizing an Online Collaborative Platform in a Synchronous Classroom Setting

INTRODUCTION

Tuberculosis (TB) remains a major public health concern worldwide. It is important to provide high-quality instructional sessions to students about the pathogenesis and risk factors of TB, as medical students are likely to encounter TB infections in clinical practice.

METHODS

We describe an interactive instructional session integrating immunology and microbiology concepts of Mycobacterium tuberculosis infection that was presented to first-year medical students in their respiratory organ systems course. The session included a pretest primer followed by a brief review of mucosal immunity with an emphasis on the respiratory system. Using an online collaborative application, learners created a study guide on a shared spreadsheet while faculty provided real-time feedback. Following the cloud-based portion, faculty presented interactive lectures using student-created content. The session concluded with a formative posttest. We evaluated the session with responses to an optional student survey.

RESULTS

One hundred fourteen students (37% male and 63% female) completed the survey across 4 years from 2016 to 2019. The session received high student satisfaction ratings across five questions, with 83% of students indicating they were slightly satisfied to strongly satisfied. The students had an absolute increase in their scores of 31% on the posttest as compared to the pretest mean (p < .001).

DISCUSSION

We developed an interactive TB instructional session that integrates disciplines, contains real-time instructor feedback, and promotes teamwork in a large class setting. The session allows medical students to learn content and create their own study guide using online collaboration technology.

Respiratory Auscultation Lab Using a Cardiopulmonary Auscultation Simulation Manikin

INTRODUCTION

Mastery of respiratory auscultation skills is fundamental for clinicians to develop. We created a case-based educational session utilizing a high-fidelity simulator to teach lung sound auscultation to medical students at our institution. We employed a hypothesis-driven approach and deliberate practice to enhance students' learning experience and retention of acquired skills.

METHODS

We developed the session to teach second-year medical students how to discriminate between normal and pathological respiratory sounds within the context of clinical vignettes. Faculty facilitators, in conjunction with near-peer educators, made use of a high-fidelity auscultation manikin to guide students through case-based problem sets. Students were given the opportunity to auscultate the manikin while being observed and receiving feedback from the faculty.

RESULTS

We introduced the manikin in 2016, with a total of 759 second-year medical students from four class years having participated in the session since then. Students evaluated the session through an end-of-the-week and end-of-unit survey. The survey showed an overall improvement in learner satisfaction over previous years. Survey results and feedback were used to make adjustments to the session.

DISCUSSION

Our respiratory auscultation session was well received overall. Proper faculty development is crucial for implementing the session. Because of the focus on deliberate practice, adequate time must be allotted to hold the session. This program is reproducible with similar high-fidelity simulators.

Management of Acute Pulmonary Embolism With a Pulmonary Embolism Response Team

Despite recent advances in the assessment, risk stratification, and treatment of acute pulmonary embolism (PE), it remains a leading cause of cardiovascular morbidity and mortality in the United States each year. Patient presentation and prognosis are heterogeneous, and a variety of diagnostic and therapeutic instruments have arisen to assist in providing patients with the appropriate level of care and aggressiveness of approach. Fortunately, a growing number of institutions now have pulmonary embolism response teams (PERT) that urgently assist with risk assessment and management of patients with massive and sub-massive PE. In service of providers at the point of contact with acute PE, this review aims to summarize the data pertinent to rapid risk assessment and the interpretation of diagnostics used to that end. The role of PERT and the indications for systemic fibrinolysis and invasive therapies are also discussed.

Cardiopulmonary Arrest and Resuscitation in the Prone Patient: An Adult Simulation Case for Internal Medicine Residents

INTRODUCTION

Acute respiratory distress syndrome (ARDS) is present in approximately 10% of ICU admissions and is associated with great morbidity and mortality. Prone ventilation has been shown to improve refractory hypoxemia and mortality in patients with ARDS.

METHODS

In this simulation, a 70-year-old male had been transferred to the ICU for ARDS and was undergoing scheduled prone ventilation as part of his care when he experienced a cardiopulmonary arrest secondary to a tension pneumothorax. Learners demonstrated how to manage cardiac arrest in a prone patient and subsequently identified and treated the tension pneumothorax that was the cause of his initial arrest. This single-session simulation for internal medicine residents (PGY 1-PGY 4) utilized a prone mannequin connected to a ventilator in a high-fidelity simulation center. Following the simulation, facilitators led a team debriefing and reviewed key learning objectives.

RESULTS

A total of 103 internal medicine residents participated in this simulation. Of those, 43 responded to a postsimulation survey. Forty-two of 43 agreed or strongly agreed that all learning objectives were met, that the simulation was appropriate for their level of training, and that their participation would be useful for their future practice.

DISCUSSION

We designed this simulation to improve learners' familiarity with prone cardiopulmonary resuscitation and to enhance overall comfort with cardiac arrest management. Postsimulation survey results and debriefings revealed that the simulation was a valuable education opportunity, and learners felt that their participation in this simulation would be helpful in their future practice.

Asthma Exacerbation Triggered by Wildfire: A Standardized Patient Case to Integrate Climate Change Into Medical Curricula

INTRODUCTION

Climate change presents unprecedented health threats. It is imperative that medical trainees understand the implications of climate change/planetary health on the physical and mental health and well-being of their patients. Medical professionals generally are not trained to consider climate change impacts in patient encounters. Hence, there is a need to train climate-aware providers who will be at the forefront of patient care in managing these current and emerging health impacts.

METHODS

We created a standardized patient (SP) case enhanced with details of risks and health impacts due to exposure to wildfire smoke. This session was deployed to 11 internal medicine clerkship students as part of a standard OSCE already included in our curriculum to evaluate core clinical and communication skills. Two cohorts, a group activity, and a one-on-one encounter were deployed and followed with a faculty debrief and learner assessments.

RESULTS

Students had increased awareness and knowledge of health impacts of climate change and potential actions for adaptation and mitigation. The improvements were statistically significant for the one-on-one cohort (p = .006). Postsimulation comments were favorable; students were more inclined to consider health impacts, risks, and vulnerabilities exacerbated by climate change.

DISCUSSION

Students had an increased recognition of climate change as a force impacting their patients' health which should be considered in patient care. This format allowed retention of well established curricular content, but also the inclusion of other crucial emerging issues that will impact public health locally and globally and foster the development of climate-aware health care providers.

Improving CPAP Adherence for Obstructive Sleep Apnea: A Practical Application Primer on CPAP Desensitization

INTRODUCTION

Obstructive sleep apnea (OSA) is a common medical condition with well-established morbidity and mortality. Continuous positive airway pressure (CPAP) is a highly effective treatment prescribed to most individuals with OSA that has documented poor adherence rate for a variety of reasons including claustrophobia and discomfort. CPAP desensitization is an effective, simple, and brief treatment shown to improve adherence rates to CPAP.

METHODS

A psychologist specializing in behavioral sleep medicine developed this module focused on teaching medical residents the techniques of CPAP desensitization. The educational activity was an interactive 45-minute seminar which included a didactic component followed by a case presentation and interactive role-play. A postseminar survey was used to evaluate the content of the workshop, as well as growth in awareness and perception of knowledge and skills with a pre- to postworkshop evaluation.

RESULTS

In a survey of 25 primary care and psychiatry residents and sleep medicine fellows, 92% of respondents indicated that the topic of CPAP barriers and CPAP desensitization was important. Ratings of self-reported knowledge and skills improved nearly one-third following the workshop. Qualitative feedback indicated the utility and enthusiasm learners had for this topic.

DISCUSSION

The workshop on CPAP desensitization was a valuable tool that should be disseminated more widely to improve treatment adherence in the significant portion of the population that suffers from OSA which does not use adherence to positive airway pressure therapy. The workshop is applicable to other health professionals including medical students and nursing, social work, or psychology trainees.

Using Near-Peer Teaching to Address Concepts of Cystic Fibrosis in Undergraduate Medical Learners

INTRODUCTION

Cystic fibrosis (CF) is a high-yield undergraduate medical education topic that lends itself to adaptability of content. We used a CF case paired with activities to deliver content in a near-peer teaching session. First-year (M1) and second-year (M2) medical students contributed acquired knowledge of protein structure and obstructive lung disease, respectively, to generate a concept map and address discussion questions.

METHODS

Combined groups of M1 and M2 students reviewed a CF case and a concept map prompt. For 30 minutes, they created a concept map describing connections between molecular biology and clinical manifestations. We summarized by reviewing concept maps and discussion questions. The efficacy of the session was determined by comparing exam performance of class attenders and nonattenders (M2) and performance on questions related and unrelated to the exercise (M1). We also determined students' perception of the session and incorporation of additional core competencies.

RESULTS

M2 students' performance was 3.8% higher (p = .296) and M1 students' performance was 1.8% higher (p = .286) than their respective controls. Students commented positively on the exercise and perceived more than one core competency as part of the session.

DISCUSSION

Although there was no significant improvement in exam performance, this curriculum used near-peer teaching to reinforce previously learned material and apply recently acquired material in an engaging format without detriment to either group. This method can be adapted to different learner groups and provides an opportunity to deliver and assess other core medical competencies.

Antisense oligonucleotide eluforsen improves CFTR function in F508del cystic fibrosis

Background:

Cystic fibrosis (CF) is caused by mutations in the CF transmembrane conductance regulator (CFTR) gene. In this study we assessed the effect of antisense oligonucleotide eluforsen on CFTR biological activity measured by Nasal Potential Difference (NPD) in patients with the most common mutation, F508del-CFTR.

Methods:

This multi-centre, exploratory, open-label study recruited adults with CF homozygous or compound heterozygous for the F508del-CFTR mutation. Subjects received intranasal eluforsen three times weekly for 4 weeks. The primary endpoint was the within-subject change from baseline in total chloride transport (Cl-free+iso), as assessed by NPD. Secondary endpoints included within-subject change from baseline in sodium transport.

Results:

In the homozygous cohort (n = 7; per-protocol population), mean change (90% confidence interval) in Cl-free+iso was −3.0 mV (−6.6; 0.6) at day 15, −4.1 mV (−7.8; −0.4, p = .04) at day 26 (end of treatment) and − 3.7 mV (−8.0; 0.6) at day 47. This was supported by improved sodium transport as assessed by an increase in average basal potential difference at day 26 of +9.4 mV (1.1; 17.7, p = .04). The compound heterozygous cohort (n = 7) did not show improved chloride or sodium transport NPD values. Eluforsen was well tolerated with a favourable safety profile.

Conclusions:

In F508del-CFTR homozygous subjects, repeated intranasal administration of eluforsen improved CFTR activity as measured by NPD, an encouraging indicator of biological activity.

Clinical experience of rigid bronchoscopy in single center

Background

The aim of this study was to analyze clinical situations requiring rigid bronchoscopy and evaluate usefulness of rigid bronchoscopic intervention in benign or malignant airway disorders.

Methods

We retrospectively reviewed 29 patients who underwent rigid bronchoscopy from November 2007 to February 2011 at St. Paul's Hospital, The Catholic University of Korea School of Medicine.

Results

Of the 29 patients, the most frequent underlying etiology was benign stenosis of trachea (n=20). Of those 20 patients, 16 had post-intubation tracheal stenosis (PITS), 2 had tracheal stenosis due to inhalation burn (IBTS) and other 2 had obstructive fibrinous tracheal pseudomembrane (OFTP). Other etiologies were airway malignancy (n=6), endobronchial stenosis due to tuberculosis (n=2), and foreign body (n=1). For treatment, silicone stent insertion was done in 16 cases of PITS and IBTS and mechanical removal was performed in 2 cases of OFTP. In 6 cases of malignant airway obstruction mechanical debulking was performed and silicone stents were inserted additionally in 2 cases. Balloon dilatation and electrocautery were used in 2 cases of endobronchial stenosis due to tuberculosis. In all cases of stent, airway obstructive symptom improved immediately. Granulation tissue formation was the most common complication.

Conclusion

Tracheal stenosis was most common indication and silicone stenting was most common procedure of rigid bronchoscopy in our center. Rigid bronchoscopic procedures, at least tracheal silicone stenting, should be included in pulmonary medicine fellowship programs because it is a very effective and indispensable method to relieve critical airway obstruction which needs training to learn.