The future of pediatric pulmonology: A survey of division directors, assessment of current research funding, and discussion of workforce trends

Adequacy of the US workforce in pediatric pulmonology has been a source of serious concern within the field for some time, as it has been for several pediatric subspecialties. Contributing factors have been thought to include low fill rates of fellowship training programs, aging, and retirement rates of the subspecialist population, and the perception of insufficient numbers of specialists in some regions to meet clinical care needs. Several approaches to assessing workforce needs have already been described, and stakeholder groups are currently working on additional analyses. Although the recent report by Harris et al. captured a broad snapshot of workforce perceptions of 485 pediatric pulmonologists, this study (reporting data collected in 2014) did not address the future scope of practice

Application of assessment metrics for an academic department faculty development program

Faculty development is increasingly seen as a cornerstone of career sustainability in academic medicine, pediatrics, and other disciplines. Many current senior academic medical faculty developed their careers in systems that are distinctly different from current paradigms. Multiple internal and external variables have caused the academic environment to transform. These variables include rapidly changing technology, the opening of the academy to public scrutiny, external rankings, changes in the opportunities for academic advancement (including the increasing predominance of non–tenure track faculty), sharp reductions in protected time for teaching, increased pressure to meet measurable benchmarks for academic and financial productivity, and an increased emphasis on multidisciplinary team science to more rapidly advance biomedical research. Faculty must also become adept at assessing learning outcomes, and engaging in collaborative projects that couple scholarly expertise with the local, national, or international communities. The increasing incidence of burnout and other sequelae of chronic stress among medical faculty is well documented and has led to recommendations for more formalized institutional attention to these threats to the academic medical enterprise

A controlled study of adenoviral-vector–mediated gene transfer in the nasal epithelium of patients with cystic fibrosis

Cystic fibrosis is a monogenic disease that deranges multiple systems of ion transport in the airways, culminating in chronic infection and destruction of the lung. The introduction of a normal copy of the cystic fibrosis transmembrane conductance regulator (CFTR) gene into the airway epithelium through gene transfer is an attractive approach to correcting the underlying defects in patients with cystic fibrosis. We tested the feasibility of gene therapy using adenoviral vectors in the nasal epithelium of such patients. An adenoviral vector containing the normal CFTR complementary DNA in four logarithmically increasing doses (estimated multiplicity of infection, 1, 10, 100, and 1000), or vehicle alone, was administered in a randomized, blinded fashion to the nasal epithelium of 12 patients with cystic fibrosis. Gene transfer was quantitated by molecular techniques that detected the expression of CFTR messenger RNA and by functional measurements of transepithelial potential differences (PDs) to assess abnormalities of ion transport specific to cystic fibrosis. The safety of this treatment was monitored by nasal lavage and biopsy to assess inflammation and vector replication. The adenoviral vector was detected in nasal-lavage fluid by culture, the polymerase chain reaction (PCR), or both in a dose-dependent fashion for up to eight days after vector administration. There was molecular evidence of gene transfer by reverse-transcriptase PCR assays or in situ hybridization in five of six patients treated at the two highest doses. However, the percentage of epithelial cells transfected by the vector was very low (<1 percent), and measurement of PD across the epithelium revealed no significant restoration of chloride transport or normalization of sodium transport. At the lower doses of vector, there were no toxic effects. However, at the highest dose there was mucosal inflammation in two of three patients. In patients with cystic fibrosis, adenoviral-vector–mediated transfer of the CFTR gene did not correct functional defects in nasal epithelium, and local inflammatory responses limited the dose of adenovirus that could be administered to overcome the inefficiency of gene transfer. Cystic fibrosis is a recessive genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The normal CFTR gene codes for a protein (CFTR) that plays a key part in epithelial transport of salt and water. Mutations in CFTR result in abnormal secretions that obstruct and ultimately damage epithelium in many areas of the body. The principal cause of death among patients with cystic fibrosis is lung disease. Patients who are homozygous for mutations in the CFTR gene have defective cyclic AMP (cAMP)–regulated secretion of chloride8,9 and elevated absorption of sodium

Bronchoscopy-Derived Correlates of Lung Injury following Inhalational Injuries: A Prospective Observational Study

Background: Acute lung injury (ALI) is a major factor determining morbidity following burns and inhalational injury. In experimental models, factors potentially contributing to ALI risk include inhalation of toxins directly causing cell damage; inflammation; and infection. However, few studies have been done in humans. Methods: We carried out a prospective observational study of patients admitted to the NC Jaycees Burn Center who were intubated and on mechanical ventilation for burns and suspected inhalational injury. Subjects were enrolled over an 8-month period and followed till discharge or death. Serial bronchial washings from clinically-indicated bronchoscopies were collected and analyzed for markers of cell injury and inflammation. These markers were compared with clinical markers of ALI. Results: Forty-three consecutive patients were studied, with a spectrum of burn and inhalation injury severity. Visible soot at initial bronchoscopy and gram negative bacteria in the lower respiratory tract were associated with ALI in univariate analyses. Subsequent multivariate analysis also controlled for % body surface area burns, infection, and inhalation severity. Elevated IL-10 and reduced IL-12p70 in bronchial washings were statistically significantly associated with ALI. Conclusions: Independently of several factors including initial inhalational injury severity, infection, and extent of surface burns, high early levels of IL-10 and low levels of IL-12p70 in the central airways are associated with ALI in patients intubated after acute burn/inhalation injury. Lower airway secretions can be collected serially in critically ill burn/inhalation injury patients and may yield important clues to specific pathophysiologic pathways

Official American thoracic society clinical practice guidelines: Diagnostic evaluation of infants with recurrent or persistent wheezing

Background: Infantile wheezing is a common problem, but there are no guidelines for the evaluation of infants with recurrent or persistent wheezing that is not relieved or prevented by standard therapies. Methods: An American Thoracic Society-sanctioned guideline development committee selected clinical questions related to uncertainties or controversies in the diagnostic evaluation of wheezing infants. Members of the committee conducted pragmatic evidence syntheses, which followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The evidence syntheses were used to inform the formulation and grading of recommendations. Results: The pragmatic evidence syntheses identified few studies that addressed the clinical questions. The studies that were identified constituted very low-quality evidence, consisting almost exclusively of case series with risk of selection bias, indirect patient populations, and imprecise estimates. The committee made conditional recommendations to perform bronchoscopic airway survey, bronchoalveolarlavage,esophagealpHmonitoring,andaswallowing study.Italsomadeconditionalrecommendationsagainstempiricfood avoidance, upper gastrointestinal radiography, and gastrointestinal scintigraphy. Finally, the committee recommended additional research about the roles ofinfantpulmonaryfunction testingand food avoidance or dietary changes, based on allergy testing. Conclusions: Although infantile wheezing is common, there is a paucity of evidence to guide clinicians in selecting diagnostic tests for recurrent or persistent wheezing. Our committee made several conditional recommendations to guide clinicians; however, additional research that measures clinical outcomes is needed to improve our confidence in the effects of various diagnostic interventions and to allow advice to be provided with greater confidence

Pediatric Pulmonology year in review 2017: Part 3

Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. We here summarize the past year's publications in our major topic areas, in the context of selected literature in these areas from other journals relevant to our discipline. This review (Part 3 of a 5-part series) covers selected articles on asthma, physiology/lung function testing, and respiratory infections. © 2018 Wiley Periodicals, Inc