The optimal method for teaching procedures is not known. For uncommonly performed procedures such as pediatric airway procedures, practical learning is often supplemented with simulation (sim) or digital platforms. In this study, we compare residents' performance of pediatric bag valve mask (BVM) and endotracheal intubation (ETI) after undergoing training using (1) Standard sim, (2) The Peyton method, or (3) Self-directed learning with free access to sim mannikins.

Sepsis, the systemic response to infection, is a common but potentially life-threatening process that can be difficult to diagnose. In the emergency department (ED), various measures, such as systemic inflammatory response syndrome (SIRS) and q-SOFA criteria, lactate, and procalcitonin, help determine sepsis and whether its source is bacterial. However, there is currently no known marker that results in the ED to confirm diagnosis. While delaying antibiotics for bacterial sepsis results in worse outcomes, giving unnecessary antibiotics is also harmful, so rapid, accurate diagnosis is critical. Group II Secretory Phospholipase A2 (sPLA2-IIA) is a novel biomarker that has shown some promise in small studies as a tool to detect bacterial sepsis. Our objective was to determine if a point-of-care (POC) sPLA2-IIA assay can predict sepsis in patients meeting SIRS/q-SOFA criteria. Adult, non-pregnant patients who met SIRS and/or q-SOFA criteria and received a sepsis workup in a single tertiary academic ED were enrolled from May 2019 to March 2020, when the study was temporarily suspended under IRB guidance to reduce COVID-19 exposure. Each time a lactate was drawn in the ED from an enrolled patient, a separate blood sample was collected simultaneously and run by a trained researcher on a POC machine to measure the sPLA2-IIA value. Patients who were subsequently admitted to the ICU had additional sPLA2-IIA values drawn with lactates. SPLA2-IIA data did not affect patient care, and the medical team was blinded to the results except when the researcher was also the primary physician for that patient in the ED. Our primary endpoints were whether sPLA2-IIA could predict sepsis, bacterial sepsis, and bacteremia. Secondary endpoints were ICU stay, hospital length of stay (LOS), in-hospital mortality, and 90-day mortality. Potential confounders noted included elevated troponin, pancreatitis, antibiotic use at time of ED presentation, immunosuppression, steroid use, and comorbid inflammatory conditions. 226 patients ages 18-101 (mean 66) were analyzed, composed of 184 patients with sepsis (ED impression correct 80.5%), 152 with bacterial sepsis (ED impression correct 70.8%), and 37 with bacteremia. See table for data on the ability of sPLA2-IIA to detect sepsis, bacterial sepsis, and bacteremia. All patients with sPLA2-IIA>201 had a final diagnosis of sepsis, and all patients with sPLA2-IIA>225 had a final diagnosis of bacterial sepsis. No significant difference was found after stratifying for potential confounders. sPLA2-IIA was not found to be predictive of ICU stay, hospital LOS, or mortality. Correlations between sPLA2-IIA and lactate (r=0.2688, p<0.00001) and between sPLA2-IIA and neutrophil-lymphocyte ratio (r=0.2717, p=0.000035) were poor. A moderate correlation was found between sPLA2-IIA and procalcitonin (r=0.4418, p=0.00001). At midpoint analysis, sPLA2-IIA≤20 shows good sensitivity to rule out sepsis, bacterial sepsis, and bacteremia; sPLA2-IIA>200 shows excellent specificity to detect sepsis and bacterial sepsis.

Study Objectives: The need to establish competency in several infrequently performed clinical procedures is recognized by the Emergency Medicine Residency Review Committee. Although the use of laboratory simulation is well accepted and widely employed, there are few data concerning the rate of skill decay after such training sessions. The purpose of this prospective single-blind study was to determine the skill decay at 1, 2 and 18 months after a single didactic and laboratory training session in which all residents were documented to have acquired proficiency in cricothyroidotomy.

A 57-year-old woman with bilateral pneumothoraces secondary to pulmonary metastases from leiomyosarcoma of the uterus was treated successfully by intrapleural instillation of tetracycline.

Five patients with advanced upper airway obstruction due to goiter were identified in our institution. All had symptoms of respiratory insufficiency to such a degree that surgery was clearly indicated. Functional characteristics of this group were compared with prior series of goiter patients who had less severe respiratory symptoms. A peak inspiratory flow less than 1.5 L/sec characterized this group who required surgery.

In a double-blind, 12-week study of corticosteroid-dependent reversible bronchial asthma, 20 of 31 (64.5%) patients receiving triamcinolone acetonide aerosol, 800 microgram daily, were able to discontinue oral steroid therapy. This compares with three of 29 (10.3%) treated with aerosol placebo. At the end of the 12-week period, the mean 8 AM plasma cortisol level had increased from 5.3 +/- 4.1 to 8.6 +/- 5.2 microgram/dl in those receiving triamcinolone acetonide. The mean percent predicted values in the triamcinolone group for forced expiratory volume in the first second rose from 44.8 to 62.4 at two weeks (P less than .005), for forced vital capacity from 64.1 to 79.9 (P less than .005), and for maximum midexpiratory flow rate from 26.7 to 46.7 (P less than .005). The improved pulmonary function values persisted while the oral prednisone equivalent daily dose decreased from a mean of 13.3 to 2.9 mg at 12 weeks. Significant oral candidiasis was detected in two patients. Aerosol triamcinolone acetonide appears to be an effective alternative to beclomethasone dipropionate for use in patients with bronchial asthma.

Two siblings with characteristic clinical and radiologic features of Morquio's disease are presented. Detailed pulmonary function tests, including vital capacity, flow rates, lung volumes, airway resistance, and lung compliance, were performed. The ventilatory studies suggested a restricted pattern due to chest cage dysfunction. Hypoxemia was noted in one patient and was shown to be due to right-to-left shunting, probably related to the microatelectasis as a result of the restricted chest cage.

During a 21/2-year period, studies were done on 14 patients with chronic renal failure to evaluate pleural effusions which we believe were secondary to the uremic process. The patients with uremic pleural effusions closely resembled those in the group with chronic renal failure as a whole with respect to diagnosis and clinical features. Fever and pericarditis were noted in half the patients. The pleural fluid appeared serosanguineous or hemorrhagic in 10 of 14 patients and contained a predominance of lymphocytes more often than of neutrophils. Elevated protein and lactic dehydrogenase (LDH) levels gave the effusion characteristics of an exudate. Pleural tissue obtained by pleural biopsy or autopsy showed chronic fibrinous pleuritis in every patient. With continued dialysis the effusions resolved in 4 to 6 weeks after thoracentesis in 11 patients and recurred in 3 patients.

A patient with superior vena cava syndrome due to an infected benign mediastinal bronchogenic cyst is reported. Although bronchogenic cyst is a rare cause of the superior vena cava syndrome, it should be considered because it is a potentially treatable lesion. Patients with bronchogenic cysts should have elective surgery before major complication develop.

Pulmonary function was evaluated in a patient with myositis ossificans progressiva, a rare disorder characterized by ossification of muscles, fascia, tendons, and ligaments, and associated with congenital digital anomalies. Results showed diminished lung volumes with normal airway dynamics and lung elastic recoil, suggesting a restricted chest cage disorder.