Anderson, Connecticut, United States
Anderson, Connecticut, United States

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Parsons E.C.,Pulmonary and Critical Care Section | Mattox E.A.,Pulmonary and Critical Care Section | Beste L.A.,General Medicine Service | Beste L.A.,Veterans Affairs Puget Sound Health Care System | And 8 more authors.
Annals of the American Thoracic Society | Year: 2017

Rationale: Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access. Objectives: The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C.Wedescribe the feasibility of an ECHO program for sleep medicine. Methods: ECHO creates a virtual learning community through video-teleconferencing, combining didacticswith individualized clinical case review.We invited multidisciplinary providers to attend up to 10 stand-alone, 1-hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self-reported changes in practice and comfort with managing sleep complaints.We surveyed participation barriers among invitees with low/no attendance. Measurements and Main Results: Of the 39program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfortmanaging sleep complaints, especially sleep-disordered breathing, insomnia, and sleep in post-traumatic stress disorder (80% of respondents each). A follow-up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers. Conclusions: Participants in a pilot sleep medicine VA-ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers. © Copyright 2017 by the American Thoracic Society.


Demaria S.,New York University | Pikarsky E.,Hebrew University of Jerusalem | Karin M.,University of California at San Diego | Coussens L.M.,University of California at San Francisco | And 12 more authors.
Journal of Immunotherapy | Year: 2010

Cancers often arise as the end stage of inflammation in adults, but not in children. As such there is a complex interplay between host immune cells during neoplastic development, with both an ability to promote cancer and limit or eliminate it, most often complicit with the host. In humans, defining inflammation and the presence of inflammatory cells within or surrounding the tumor is a critical aspect of modern pathology. Groups defining staging for neoplasms are strongly encouraged to assess and incorporate measures of the presence of apoptosis, autophagy, and necrosis and also the nature and quality of the immune infiltrate. Both environmental and genetic factors enhance the risk of cigarette smoking, Helicobacter pylori, hepatitis B/C, human papilloma virus, solar irradiation, asbestos, pancreatitis, or other causes of chronic inflammation. Identifying suitable genetic polymorphisms in cytokines, cytokine receptors, and Toll-like receptors among other immune response genes is also seen as high value as genomic sequencing becomes less expensive. Animal models that incorporate and assess not only the genetic anlagen but also the inflammatory cells and the presence of microbial pathogens and damage-associated molecular pattern molecules are necessary. Identifying micro-RNAs involved in regulating the response to damage or injury are seen as highly promising. Although no therapeutic strategies to prevent or treat cancers based on insights into inflammatory pathways are currently approved for the common epithelial malignancies, there remains substantial interest in agents targeting COX2 or PPARγ, ethyl pyruvate and steroids, and several novel agents on the horizon. Copyright © 2010 by Lippincott Williams & Wilkins.


Akgun K.M.,Pulmonary and Critical Care Section | Akgun K.M.,Yale University | Crothers K.,University of Washington | Pisani M.,Yale University
Journals of Gerontology - Series A Biological Sciences and Medical Sciences | Year: 2012

Pulmonary disease prevalence increases with age and contributes to morbidity and mortality in older patients. Dyspnea in older patients is often ascribed to multiple etiologies such as medical comorbidities and deconditioning. Common pulmonary disorders are frequently overlooked as contributors to dyspnea in older patients. In addition to negative impacts on morbidity and mortality, quality of life is reduced in older patients with uncontrolled, undertreated pulmonary symptoms. The purpose of this review is to discuss the epidemiology of common pulmonary diseases, namely pneumonia, chronic obstructive pulmonary disease, asthma, lung cancer, and idiopathic pulmonary fibrosis in older patients. We will review common clinical presentations for these diseases and highlight differences between younger and older patients. We will also briefly discuss risk factors, treatment, and mortality associated with these diseases. Finally, we will address the relationship between comorbidities, pulmonary symptoms, and quality of life in older patients with pulmonary diseases. © 2011 The Author.

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