The Coronavirus pandemic (COVID-19) caused by the SARS-CoV-2 virus, has severely restricted pulmonary diagnostic testing due to the concern of droplet and aerosol generation by procedures conducted in small test rooms. SARS-CoV-2 infection is characterized by viral shedding from the upper and lower respiratory tracts, additionally, SARS-CoV-2 RNA has been detected in sampled air throughout a hospital, which leads to this concern (1-4). Pulmonary function laboratories are justifiably concerned because test maneuvers involve forceful breathing which may generate infectious particles. Normal speaking has also been reported to generate small droplet aerosols increasing potential exposure risk in close contact to infected individuals (5-7). Currently, there are no studies evaluating particle generation during pulmonary function tests (PFTs). In order to better understand this risk associated with PFTs, we sought to quantify and characterize the amount of detectable aerosol and droplet generation during routine pulmonary function studies at pre-specified distances. Methods This was a single center prospective study conducted at Mayo Clinic Florida. Five adult volunteer subjects without pulmonary disease consented to perform tidal breathing (VT), normal speaking, forced vital capacity (FVC) and maximum voluntary ventilation (MVV) maneuvers. The Mayo Clinic Institutional Review Board approved this study (20-005544). Particle measurement. A light scattering particle counter (FLUKE® 983; Everett, Washington) was used to simultaneously measure six channels of particle size distribution (0.3, 0.5, 1, 2, 5, 10 micrometers), temperature, and humidity while each maneuver was being

Pulmonary arterial hypertension (PAH) is a devastating disease with significant morbidity and mortality. There are many psychosocial and financial implications of this disease; however, little is known how this affects the treatment of PAH patients. A questionnaire-based prospective cohort study was performed on 106 PAH patients from a Pulmonary Hypertension Center and the Pulmonary Hypertension Association national conference in 2018. The demographic, treatment, psychosocial, employment, financial impact on treatment data was obtained. The majority of patients had cardiopulmonary symptoms despite treatment. The symptoms affected their social and work lives, with about one in three applying for disability because of their PAH. The majority of PAH patients had insurance coverage, but still noted a significant financial burden of the disease, with nearly a half who needed financial assistance to pay for their PAH medications. Thirty (28.3%; 95% CI, 20.6–37.5%) patients mentioned they changed their medication regimen, with some skipping doses outright (28 [26.4%; 95% CI, 19–35.6%]) in order to save money. PAH continues to cause significant psychosocial and financial burden on patients despite advances in medications. This impact ranged from dissatisfaction with quality of life, to unemployment, to altering their medication regimen to save money.

Cardiopulmonary exercise training is associated with improvements in health-related quality-of-life, physical function, and overall mortality rates in patients with cardiovascular or pulmonary disease. 1,2 Currently, many structured cardiopulmonary exercise training programs are running at limited operational capacity or are closed due to an increased concern of possible spread of severe acute respiratory syndrome coronavirus 2 through droplet and aerosol generation that could occur with exercise. 2,3 In the community, many gyms are reopening, given the lack of evidence of potential aerosol generation during exercise. 4 This lack of evidence is a concern because of potential coronavirus disease 2 transmission from asymptomatic or presymptomatic individuals in these settings. 4 Presently, we sought to quantify and characterize particle generation associated with healthy adults performing exercise of different intensities. MethodsThis was a single-center study conducted at Mayo Clinic Florida and was approved by the institutional review board. Four adult volunteers free of cardiorespiratory, musculoskeletal, and metabolic disease consented and performed staged exercise.

Background: The coronavirus disease 2019 (COVID-19) has been identified in over 110 million people with no studies comparing pre-infection pulmonary function to post-infection. This study's aim was to compare preinfection and post-infection pulmonary function tests (PFT) in COVID-19 infected patients to better delineate between preexisting abnormalities and effects of the virus. Methods: This was a retrospective multi-center cohort study. Patients were identified based on having COVID-19 and a pre-and post-infection PFT within one year of infection during the time period of March 1, 2020 to November 10, 2020. Findings: There was a total of 80 patients, with an even split in gender; the majority were white (n = 70, 87¢5%) and never smokers (n = 42, 52¢5%). The majority had mild to moderate COVID-19 disease (n = 60, 75¢1%) with 25 (31¢2%) requiring hospitalization. There was no difference between the pre-and post-PFT data, specifically with the forced vital capacity (FVC) (p = 0¢52), forced expiratory volume in 1 s (FEV1) (p = 0¢96), FEV1/FVC(p = 0¢66), total lung capacity (TLC) (p = 0¢21), and diffusion capacity (DLCO)(p = 0¢88). There was no difference in the PFT when analyzed by hospitalization and disease severity. After adjusting for potential confounders, interstitial lung disease (ILD) was independently associated with a decreased FEV1 (-2¢6 [95% CI, -6¢7 to -1¢6] vs. -10¢3 [95% CI, -17¢7 to -2¢9]; p = 0¢03) and an increasing age (p = 0¢01) and cystic fibrosis (-1¢1 [95% CI, -4¢5 to-2¢4] vs. -36¢5 [95% CI, -52¢1 to -21¢0]; p < 0¢01) were associated with decreasing FVC when comparing pre and post infection PFT. Only increasing age was independently associated with a reduction in TLC (p = 0¢01) and DLCO (p = 0¢02) before and after infection. Interpretation: This study showed that there is no difference in pulmonary function as measured by PFT before and after COVID-19 infection in non-critically ill classified patients. There could be a relationship with certain underlying lung diseases (interstitial lung disease and cystic fibrosis) and decreased lung function following infection. This information should aid clinicians in their interpretation of pulmonary function tests obtained following COVID-19 infection.

PurposeDespite its growing popularity and clinical utility among hospital-based physicians, there are no formal competency requirements nor training standards for United States based Internal Medicine Residencies for learning point-of-care ultrasonography (POCUS). The purpose of this investigation was to study the impact and effectiveness of a novel POCUS curriculum for an Internal Medicine (IM) residency program.Patients and methodsThis was a Single-Group Educational Quasi-Experiment involving Categorical and Preliminary Internal Medicine Residents in Post-Graduate Years 1 through 3 at a single United States academic tertiary center. The study period was from January 1, 2017, through June 30, 2017, during which time the residents participated in monthly modules including didactics and hands-on ultrasound scanning skills with live models. Participants completed a comprehensive knowledge examination at the beginning and end of the six-month period. Participants were also tested regarding hands-on image acquisition and interpretation immediately before and after the hands-on skills labs. The primary outcome measure was performance improvement in a comprehensive medical knowledge assessment.ResultsIn total, 42 residents consented for participation. The residents’ monthly rotations were adjusted in order to accommodate the new educational process. Among 29 participants with complete data sets for analysis, the mean (SD) comprehensive knowledge examination score improved from 60.9% before curriculum to 70.2% after curriculum completion (P<0.001). Subgroup analysis determined that improvement in medical knowledge required attending at least 2 out of the 6 (33%) educational sessions. Attendance at hands-on skills labs correlated significantly with improvement; didactics alone did not.ConclusionA longitudinal POCUS curriculum consisting of both didactic sessions and hands-on skills labs improves knowledge, image acquisition, and interpretation skills of residents. Having this curriculum span at least 6 months provides learners the opportunity to attend multiple classes which strengthens learning through repetition while also providing learners flexibility in schedule.

Pulmonary arterial hypertension (PAH) is a progressive disease that requires validated biomarkers of disease severity. While PAH is defined hemodynamically by right heart catheterization (RHC), brain natriuretic peptide (BNP) is recommended by guidelines to assess disease status. Retrospectively collected data in 138 group 1 PAH patients were examined for the correlation of BNP levels to simultaneously obtained right heart catheterization (RHC). Patients were mostly Caucasian women, with functional class III symptoms, mean BNP of 406 ± 443 pg/mL, and an average right atrial pressure (RAP) of 9.9 ± 5.7 mm Hg and mean pulmonary artery pressure (mPAP) of 47.3 ± 14.7 mm Hg. Significant correlation was demonstrated between BNP and RAP (p = 0.021) and mPAP (p = 0.003). Additional correlation was seen with right heart size on echocardiography: right atrial (RAE; p = 0.04) and right ventricular enlargement (p = 0.03). An increased BNP level was an independent predictor of mortality (p < 0.0001), along with RAP (p = 0.039) and RAE (p = 0.018). Simultaneous collection of BNP at the time of RHC confirmed the correlation of BNP with right heart hemodynamics. The current results reinforce the use of BNP level as a continuous variable to assess disease severity in group 1 PAH.

Objectives: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are the most commonly prescribed antihypertensives, with prior studies identifying a possible association between long-term use and increased rates of lung cancer. This study evaluated this potential association in a large population using propensity matching.Methods: This was a population-based cohort study in a large healthcare system in three regions of the United States. Pairwise propensity score matching was performed using demographics and comorbidities. All of the adult patients in the healthcare system from January 1, 2000 to April 30, 2018 with at least 1 year of follow-up were included.Results: In total, 3,253,811 patients with a median age of 59 (range 18-103) years were included. The ACEI group had a higher freedom from lung cancer versus controls at 15 years (98.47%, 95% confidence interval [CI] 98.41-98.54) versus 98.26%, (95% CI 98.20-98.33), whereas ARBs had similar rates versus controls at all time points. For patients diagnosed as having lung cancer, median all-cause survival was significantly higher in the ACEI (34.7 months, 95% CI 32.8-36.6) and ARB (30.9 months, 95% CI 28.1-33.8) groups than the control group (20.6 months,.Conclusions: This study showed lower rates of lung cancer with ACEI use and no difference in risk with ARBs. In addition, use of these medications was found to be associated with increased survival in those diagnosed as having lung cancer. This study supports the continued use of these medications without concern for increasing the risk of lung cancer.

Background:The Coronavirus pandemic has a high mortality rate in patients that are mechanically ventilated, which has led to an ever increasing interest in noninvasive forms of oxygenation. The use of these devices has the theoretical risk of increased exposure risk because of possible particulate generation. This study aimed to quantify the particulate generation associated with different oxygen devices. Methods: This was a prospective single center study conducted during September 2020 using ten healthy adult volunteers. Testing was conducted in a negative pressure hospital room using a light scattering particle counter. The oxygen devices used were a nasal cannula, an OxyMask™, a non-rebreathing mask, and a high flow system. Particle measurements were obtained at baseline in the room and then with each oxygen delivery device and prespecified oxygen flow rates. These measurements were obtained different distances from the volunteer with their mouth open. A Wilcoxon/Kruskal-Wallis test was performed on each separate oxygen modality with all flow rates as one model. Results: The particle concentrations were slightly non-significantly increased with the OxyMask™ and nonrebreathing mask at the closest distance measured. As the distance increased, these counts decreased closer to ambient levels. The nasal cannula and high flow nasal cannula particle counts were not significantly different from ambient measurements at either distance. Conclusion: Nasal cannula, OxyMask™, non-rebreathing mask, and high flow oxygen did not generate any additional aerosols or droplets above a baseline room measurement, but further studies are necessary to determine infectious risk.