Purpose To provide an updated review of the diagnosis and pharmacotherapy of nontuberculous mycobacteria pulmonary disease (NTM-PD) and summarize guideline recommendations for an interdisciplinary treatment approach. Summary A systemic approach was taken in which all articles in English in MEDLINE and PubMed were reviewed. The US National Library of Medicine's DailyMed database was used to assess drug package inserts. Analysis of NTM treatment guidelines is summarized in the article with a focus on medications, dosing, interactions, and medication monitoring. Conclusion It is critical to manage patients with NTM with a multidisciplinary team approach. Treatment is prolonged and expensive, and the potential for drug toxicity, adverse effects, and drug interactions requires monitoring. Clinical pharmacists play a role in the management of NTM.

Infection and trauma are the most common causes of acute respiratory distress syndrome (ARDS). However, ARDS has a lengthy differential diagnosis and rare etiologies must be considered when more common causes are excluded or with atypical clinical presentations.

Wieland and colleagues regarding the redesign of their residency program to a 50/50 alternating ambulatoryinpatient schedule.1 Interestingly, patient continuity decreased from both a provider and patient perspective, and there was no change in resident or faculty satisfaction with the clinic restructuring.We implemented a similar system in the last academic year (AY 2012(AY -2013. We intended to add a stronger emphasis on ambulatory care. We were also addressing what we felt was a common problem in the traditional model of residency-that staffing residents to cover inpatient needs with restricted duty hours occurred at the expense of canceling or changing continuity clinic days. This led to a steady increase in patient cancellations and rescheduling.Based on survey and clinic data, our experience with the transition to a 50/50 block schedule mostly mirrors the experience described by Wieland et al. Our residents did note an overall higher satisfaction with the new system. They noted less of a burden of continuity clinic compared to the traditional model, a more positive ambulatory experience, and felt more engaged in their inpatient rotations. Additionally, our rescheduling rate was reduced by 33 %, our clinic no-show rate declined by 10 %, and overall we had an increase in patient visits by 38 %. Like Wieland et al., we also observed a perceived drop in continuity of care.Another aspect of restructuring to a block model is the ability to implement longitudinal curriculum. This allowed us to implement a longitudinal quality and safety curriculum culminating in residents developing improvement projects in both the inpatient and outpatient setting. Whether incorporating residents into improvement initiatives will have a positive impact on patient outcomes is unknown, but certainly is a point of emphasis for the ACGME's Next Accreditation System. 2Although we feel we have had an overall positive experience transitioning to a block model, the question remains whether this is an effective way to train internists, or simply a reaction to restrictions in resident duty hours. It would be interesting to see research comparing the relative merits of different models of block scheduling (50/50, 4:1 week or 4:2 week) to the traditional model of training. Nonetheless, the work by Wieland et al. is the start of a systemic look at the restructuring of residencies to enhance educational and clinical opportunities for the internal medicine resident.

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Background: Bedside percutaneous tracheostomy (PT) placement in critically ill patients is performed in a variety of ways, largely driven by institutional preference. We have recently transitioned to primarily extubating the patient and placing a laryngeal mask airway (LMA) before tracheostomy insertion in lieu of retracting the endotracheal tube (ETT) in place. This allows for lower sedative use and provides a superior view of the operative field. Here, we seek to describe the safety and efficiency of that approach.Methods: This is a single-center cross-sectional study from 2014 to 2016 comparing patients who underwent PT with the ETT in place retracted to the proximal larynx versus those who were extubated and had a LMA placed. Procedural length, sedative totals, and safety outcomes were recorded.Results: In total, 125 patients underwent PT during the study period, 75 via a LMA and 50 via existing ETT. There was no difference in procedural duration (LMA: 53.5 ± 21.4 min vs. ETT: 50.4 ± 16.8; P = 0.41), total complications (LMA: 29.3% vs. 16%; P = 0.09) or major complications (4% in both groups). Cisatracurium use was significantly lower in the LMA arm (LMA: 1.0 ± 3.6 mg vs. ETT: 11.5 ± 5.9 mg; P < 0.01). Conclusion:Replacing the ETT with an LMA before PT is equally safe, does not increase total procedural duration, and all but eliminates the need for paralytic agents.