Linkage Between Poverty and Smoking in Philadelphia and Its Impact on Future Directions for Tobacco Control in the City.

Poverty is linked to negative health consequences and harmful health behaviors such as smoking. Despite this established correlation, few comparative studies have investigated the relationship between local poverty rates and smoking in urban settings through a Social Ecological Model framework. The authors sought to examine the linkage between local poverty rates in Philadelphia, Pennsylvania and adult smoking rates by scrutinizing existing patterns and potential mediating factors via publicly accessible data in established planning districts. The authors determined several individual, interpersonal, organizational, community, and environmental factors, varying across these districts, that impact smoking in Philadelphia. Poverty rates influence the resources, demographic makeup, and number of tobacco retailers a district has, which have downstream effects. The authors recommend that further investment is allocated to planning districts in order to mitigate the risk of smoking

Retrospective Review of Fluoroscopic Swallowing Studies and Outcomes at an Academic Health Center

Introduction: Aspiration is often associated with underlying medical conditions and can cause pneumonia or death. Aspiration risk can be assessed via video fluoroscopic swallowing study (VFSS) or barium swallow (BaSw). We aimed to assess the diagnoses and clinical course of patients who were evaluated for potential aspiration through VFSS or BaSw to determine if there is a degree of aspiration that increases the risk of developing pneumonia and/or death. Methods: We conducted a retrospective chart review of 374 patients in TJUH who were evaluated via VFSS or BaSw from January 1 to June 30, 2017. We recorded the degree and contents of aspiration, the underlying diagnoses, and evidence of subsequent pneumonia. We then collected data for any future admissions concerning for pneumonia. Results: Of the 374 patients, 165 had swallowing studies positive for laryngeal penetration or aspiration. Of the 165 patients, 78 patients (47.2%) had evidence of clinical and radiological pneumonia, and 18 of those 78 patients (23.1%) died. We found that 61 of 165 exhibited laryngeal penetration. Of those 61, 23 patients (37.7%) showed clinical and radiological signs of pneumonia, and 7 of the 23 (30.4%) died of aspiration pneumonia. Discussion: The incidence of pneumonia was considerable in persons with an abnormal swallow and the mortality rate was substantial. Minimally abnormal swallows with laryngeal penetration, but no true aspiration, still had serious consequences. While the incidence of pneumonia was lower (37.7%), there was a substanitial mortality rate (30.4%)

Improvements on the Inhaler

Background: Inhalers are a commonplace in American health care and deliver crucial drugs to patients with COPD and asthma. Inhaler use has been shown to be unsatisfactory among patients resulting in ineffective medication delivery. The goal of this project was to improve the inhaler design for increased effectiveness and ease of use. Methods: Our team first interviewed a Pulmonologist regarding patient inhaler use. Dr. Harry Kane demonstrated the proper use of an inhaler as well and described errors in inhaler use are due to patient technique. A variety of inhalers currently available were examined and were compared for ease of use. Results: Interview with attending physician revealed numerous patient errors that impede effectiveness of inhaled medication. Two common mistakes were identified: patients inhaling too rapidly and patients dispensing the medication too late. Inhaling too rapidly decreases the fraction of drug that reaches the lungs, decreasing effectiveness. Dispensing the medication after a patient reaches total lung capacity (TLC) prevents the drug from reaching their lungs, decreasing effectiveness. Conclusions: We conclude that inhalers could be used more effectively by addressing patient education and feedback mechanisms. Possible solutions discuss audible feedback to help coordinate patient breath with optimal dispersal timing. Future work includes prototyping a design and eliciting patient feedback

Improving the Inhaler

Background: Inhalers used to dispense various pharmacological agents play an important role in the care of patients with pulmonary disease. These pharmacological agents can be very effective, however, many patients that use inhalers often deliver these drugs incorrectly or in a sub-optimal manner. Our project aims to improve the design of the inhaler in order to increase the effectiveness of drug delivery and also ease of patient use. Methods: We interviewed a critical care pulmonologist regarding patient inhaler use and compliance. This physician offered information about proper inhaler use and described common errors that patients encounter when attempting to dispense drugs via inhalers. Both steroidal and albuterol inhalers that are currently being prescribed were allocated for our examination and use to help develop a more user friendly model. Results: The pulmonologist illustrated several errors that patients will commonly make which can degrade the efficacy of the inhaled drug delivery. One frequently encountered error was that drug is dispensed by the patient once they had already reached their total lung capacity, or inhaled fully. This sort of error leads to the drug being dispensed into the throat and failure to reach the intended target, the lungs. Additionally, the physician noted that patients often forget to administer their inhaled drugs because the inhaler does not fit comfortably into the patient’s pocket and so it is not optimally portable. Conclusion: Our research suggests that inhaler design could be improved in order to increase the effectiveness of drug delivery and patient compliance. We are considering incorporating audible actuation clues that will alert the patient when to dispense the drug, and also provide electronic feedback to the patient’s mobile device. This would help educate the patient on how to coordinate their breathing with actuation of the device to dispense the medication

Reviews

A Sword between the Sexes?: C.S. Lewis and the Gender Debates. Mary Stewart Van Leeuwen. Reviewed by Joe R. Christopher. The Cambridge Companion to C.S. Lewis. Edited by Robert MacSwain and Michael Ward. Reviewed by Gregory Bassham. The Law and Harry Potter. Jeffrey E. Thomas and Franklin G. Snyder, eds. Reviewed by Douglas C. Kane. Merlin: Knowledge and Power through the Ages. Stephen Knight. Reviewed by Harley J. Sims. Tolkien\u27s The Lord of the Rings: Sources of Inspiration. Ed. by Stratford Caldecott and Thomas Honegger. Reviewed by Charles A. Huttar. One Earth, One People: The Mythopoeic Fantasy Series of Ursula K. Le Guin, Lloyd Alexander, Madeleine L\u27Engle and Orson Scott Card. By Marek Oziewicz. Reviewed by Donna R. White. War of the Fantasy Worlds: C.S. Lewis and J.R.R. Tolkien on Art and Imagination. Martha C. Sammons. Reviewed by David Bratman

A Just-in-Time Video Primer on Pneumothorax Pathophysiology and Early Management

Audience: Emergency medicine residents (interns, junior residents), medical students, and mid-level providers (physician assistants, nurse practitioners). Introduction: Pneumothorax refersto the presence of gas within the pleuralspace and is a relatively common clinical entity in the emergency department Traumatic pneumothorax results from blunt or penetrating trauma to the thorax. Iatrogenic pneumothorax is a risk inherent to a number of invasive procedures and represents a significant cause of preventable morbidity. Specifically, central venous catheterization (43.8%), thoracentesis (20.1%), and barotrauma due to mechanical ventilation (9.1%) are the most frequent causes. A feared complication of pneumothorax is the development of tension pneumothorax, which involves the compression of mediastinal structures by increased pressures within the pleural space, leading to hemodynamic compromise. As tension pneumothorax is an emergent, life-threatening condition, the management of pneumothorax and the insertion of chest tubes are skills required of physicians involved in the care of injured patients, including general surgeons, intensivists, and emergency medicine physicians.5 The process of correcting pneumothorax is not without complication. Complications following chest tube insertion in trauma patients occur in 19% of cases,6 and are commonly a result of chest tubes placed by resident physicians.7 The authors believe that a web-based learning module addressing topics related to pneumothorax (pathophysiology, clinical manifestations, diagnosis, and management) would be beneficial to healthcare providers who are likely to encounter pneumothorax in clinical practice. Specifically, the web-based nature LECTURES 21 of the module would lend itself to convenient viewing and would allow for utilization as a just-in-time training modality. Presenting these topics in an animated format may also be a useful way of capturing the complex and three-dimensional nature of respiratory physiology. Additionally, the web-based format may be particularly appealing to digital native natives, who occupy an increasing percentage of resident physician positions.8 It should be noted that a number of studies have examined the use of computerized modules in medical education, and found them to be at least as useful as traditional instructional methods, and are typically associated with high rates of satisfaction among learners.9–13 Educational Objectives: By the end of this module, participants should be able to: 1) Review the normal physiology of the pleural space 2) Discuss the pathophysiology of pneumothorax 3) Describe the clinical presentation of pneumothorax 4) Identify pneumothorax on a chest radiograph 5) Review treatment options for pneumothorax Educational Methods: This is a video podcast, which conveys information through animated content. It is available to learners on demand and just-in-time for practice. It may be used as a stand-alone educational tool, as a primer to other instructional methods (eg, simulation), or a just-in-time training tool. Research Methods: A small-scale study was conducted to evaluate the efficacy of this module as an educational tool. The learner group consisted of a convenience sample of 11 second-year medical students at the end of their pre-clinical training. All learners were administered the attached assessment form as a pre-test, shown the video, then asked to re-take the assessment as a post-test to assess improvement. Assessments were graded on a 10-pointscale according to the attached answer key. Learners were also given the opportunity to rate the quality of the module as an educational tool, as well as to provide subjective feedback. Results: The average pre-test score across all learners was 34%. The average post-test score across all learners was 82%, representing an improvement of 48%. Learners were asked to rate their agreement with the statements, “This module effectively taught concepts related to pulmonary physiology and pneumothorax,” and, “The animated format of this module was useful for illustrating concepts related to pulmonary physiology and pneumothorax.” All learners responded with “agree” or “strongly agree” for each statement. When given the opportunity to provide subjective feedback regarding the module, learners responded with “This module is a great review! It is well organized, has effective animations, and information is clear,” and “Helpful review that explained the concepts in an accessible way!” Discussion: Results from the pre-test and post-test suggest that this module was effective in teaching concepts related to pulmonary physiology and pneumothorax. All learners reported satisfaction with th

Detection of lung carcinoma arising from ground glass opacities (GGO) after 5 years - A retrospective review

Pure ground glass opacities (GGO) may indicate pre-invasive subtypes of lung carcinoma. These neoplasms typically demonstrate indolent patterns of growth; Fleischner Society guidelines recommend up to five years of serial imaging. Our aim was to determine the frequency of diagnosed carcinoma arising from GGO detected beyond 5 years of surveillance. We reviewed pathologic diagnoses of lung carcinoma (n = 442) between 2016 and 2018 of a tertiary academic hospital and National Cancer Institute-designated cancer center to identify all cancers that arose from ground glass opacities detected on CT scan. Of the 442 cases of lung carcinoma, 32 (7%) were found that arose from pure GGOs and were ultimately diagnosed as cancer. Among the subgroup of GGOs, 78% (n = 25) were diagnosed within five years of surveillance, but up to 22% (n = 7) required between five and twelve years of serial follow up prior to definitive diagnosis. In order to detect 95% of cancers, GGOs would need to be followed for 7.9–12.7 years based upon a Kaplan-Meier estimate (p = 0.05). No patients who had lung carcinoma arising from GGOs died (0/32) within a follow-up time of one to three years. These data suggest that a greater number of lung carcinomas would be detected upon routine follow up of GGOs that extended beyond the current recommendation of five years. The overall survival of the cohort was 100%, consistent with existing data that these cancers are indolent. It is unknown whether a higher detection rate from longer interval follow up would impact overall survival

Predictors and Characteristics of Rib Fracture Following SBRT for Lung Tumors

Background: The utilization of stereotactic body radiation therapy (SBRT) is increasing for primary and secondary lung neoplasms. Despite encouraging results, SBRT is associated with an increased risk of osteoradionecrosis-induced rib fracture. We aimed to (1) evaluate potential clinical, demographic, and procedure-related risk factors for rib fractures and (2) describe the radiographic features of post-SBRT rib fractures. Methods: We retrospectively identified 106 patients who received SBRT between 2015 and 2018 for a primary or metastatic lung tumor with at least 12 months of follow up. Exclusion criteria were incomplete records, previous ipsilateral thoracic radiation, or relevant prior trauma. Computed tomography (CT) images were reviewed to identify and characterize rib fractures. Multivariate logistic regression modeling was employed to determine clinical, demographic, and procedural risk factors (e.g., age, sex, race, medical comorbidities, dosage, and tumor location). Results: A total of 106 patients with 111 treated tumors met the inclusion criteria, 35 (32%) of whom developed at least one fractured rib (60 total fractured ribs). The highest number of fractured ribs per patient was five. Multivariate regression identified posterolateral tumor location as the only independent risk factor for rib fracture. On CT, fractures showed discontinuity between healing edges in 77% of affected patients. Conclusions: Nearly one third of patients receiving SBRT for lung tumors experienced rib fractures, 34% of whom experienced pain. Many patients developed multiple fractures. Post-SBRT fractures demonstrated a unique discontinuity between the healing edges of the rib, a distinct feature of post-SBRT rib fractures. The only independent predictor of rib fracture was tumor location along the posterolateral chest wall. Given its increasing frequency of use, describing the risk profile of SBRT is vital to ensure patient safety and adequately inform patient expectations

Black patients referred to a lung cancer screening program experience lower rates of screening and longer time to follow-up.

BACKGROUND: Racial disparities are well-documented in preventive cancer care, but they have not been fully explored in the context of lung cancer screening. We sought to explore racial differences in lung cancer screening outcomes within a lung cancer screening program (LCSP) at our urban academic medical center including differences in baseline low-dose computed tomography (LDCT) results, time to follow-up, adherence, as well as return to annual screening after additional imaging, loss to follow-up, and cancer diagnoses in patients with positive baseline scans. METHODS: A historical cohort study of patients referred to our LCSP was conducted to extract demographic and clinical characteristics, smoking history, and lung cancer screening outcomes. RESULTS: After referral to the LCSP, blacks had significantly lower odds of receiving LDCT compared to whites, even while controlling for individual lung cancer risk factors and neighborhood-level factors. Blacks also demonstrated a trend toward delayed follow-up, decreased adherence, and loss to follow-up across all Lung-RADS categories. CONCLUSIONS: Overall, lung cancer screening annual adherence rates were low, regardless of race, highlighting the need for increased patient education and outreach. Furthermore, the disparities in race we identified encourage further research with the purpose of creating culturally competent and inclusive LCSPs