Faculty Bibliography

This article describes the curricular milestones and entrustable professional activities for trainees in pulmonary, critical care, or combined fellowship programs. Under the Next Accreditation System of the Accreditation Council for Graduate Medical Education (ACGME), curricular milestones compose the curriculum or learning objectives for training in these fields. Entrustable professional activities represent the outcomes of training, the activities that society and professional peers can expect fellowship graduates to be able to perform unsupervised. These curricular milestones and entrustable professional activities are the products of a consensus process from a multidisciplinary committee of medical educators representing the American College of Chest Physicians (CHEST), the American Thoracic Society, the Society of Critical Care Medicine, and the Association of Pulmonary and Critical Care Medicine Program Directors. After consensus was achieved using the Delphi process, the document was revised with input from the sponsoring societies and program directors. The resulting lists can serve as a roadmap and destination for trainees, program directors, and educators. Together with the reporting milestones, they will help mark trainees' progress in the mastery of the six ACGME core competencies of graduate medical education.

BACKGROUND: The objective was to develop high-quality and comprehensive evidence-based guidelines on the diagnosis and management of lung cancer. METHODS: A carefully crafted panel of lung cancer experts, methodologists, and other specialists was assembled and reviewed for relevant conflicts of interest. The American College of Chest Physicians guideline methodology was used. Population, intervention, comparator, outcome (PICO)-based key questions and defined criteria for eligible studies were developed to inform the search strategies, subsequent evidence summaries, and recommendations. Research studies, systematic reviews, and meta-analyses, where they existed, were assessed for quality and summarized to inform the recommendations. RESULTS: Each recommendation was developed with supporting evidence and the consensus of the writing committees. Controversial recommendations were identified for further consultation by the entire panel, with anonymous voting to achieve consensus. CONCLUSIONS: The final recommendations can be trusted by health-care providers, patients, and other stakeholders since they are based on the current evidence in these areas and were developed with trustworthy processes for guideline development.

BACKGROUND: This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer. METHODS: The current guidelines and medical literature applicable to this issue were identified by computerized search and were evaluated using standardized methods. Recommendations were framed using the approach described by the Guidelines Oversight Committee. RESULTS: The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV1 and the diffusing capacity for carbon monoxide (Dlco). Predicted postoperative (PPO) lung functions should be calculated. If the % PPO FEV1 and % PPO Dlco values are both > 60%, the patient is considered at low risk of anatomic lung resection, and no further tests are indicated. If either the % PPO FEV1 or % PPO Dlco are within 60% and 30% predicted, a low technology exercise test should be performed as a screening test. If performance on the low technology exercise test is satisfactory (stair climbing altitude > 22 m or shuttle walk distance > 400 m), patients are regarded as at low risk of anatomic resection. A cardiopulmonary exercise test is indicated when the PPO FEV1 or PPO Dlco (or both) are < 30% or when the performance of the stair-climbing test or the shuttle walk test is not satisfactory. A peak oxygen consumption (V O2peak) < 10 mL/kg/min or 35% predicted indicates a high risk of mortality and long-term disability for major anatomic resection. Conversely, a V O2peak > 20 mL/kg/min or 75% predicted indicates a low risk. CONCLUSIONS: A careful preoperative physiologic assessment is useful for identifying those patients at increased risk with standard lung cancer resection and for enabling an informed decision by the patient about the appropriate therapeutic approach to treating his or her lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment of this disease.

INTRODUCTION: Ulcerative colitis (UC) has a rare, but well-documented, association with pulmonary disease. We present a case of a patient with progressive bronchiectasis due to ulcerative bronchitis following colectomy. CASE PRESENTATION: A female 50 year old former smoker initially presented with new onset UC. Her disease was poorly controlled with immunosuppressive agents, and she underwent a total colectomy. Two years later, she presented with cough, shortness of breath, and wheeze. Obstructive dysfunction was detected and bronchodilator therapy was initiated with partial relief of symptoms. Chest CT was notable for centrilobular nodules, mild bronchiectasis, and peribronchial wall thickening. The patientas clinical and respiratory status progressively worsened. Sputum cultures grew Mycobacterium avium-complex (MAC), and therapy with clarithromycin, ethambutol, and rifampicin was initiated. Cultures converted negative, but following an initial period of radiographic and clinical improvement, the patient again began to experience increased cough, SOB, sputum production, as well as constitutional symptoms. Inhaled amikacin and hypertonic saline were added to her regimen. The patientas clinical and respiratory status progressively deteriorated despite clearance of MAC from sputum cultures, and further chest imaging revealed markedly progressed bronchiectasis and bronchial wall thickening with bronchiolitis. Bronchoscopy revealed severe edema, inflammation, and cobblestoning of the trachea and proximal airways. Large and medium airway biopsies showed severe submucosal inflammation, lymphoplasmacytic infiltration, squamous metaplasia, and peribronchial fibrosis. Findings were consistent with ulcerative bronchitis. The patient subsequently underwent wedge resection of her severely bronchiectatic RML. Surgical cultures were negative, and there is a plan to initiate immunosuppressive therapy for treatment of her UC-related lung disease. DISCUSSION: Pulmonary involvement in UC may involve small and l!