EDITORIALS 3 Campaign for tobacco-free kids. Big Tobacco Guilty as Charged [Internet]. [cited 2013 Nov 25]. Available from: http://www. tobaccofreekids.org/what_we_do/industry_watch/doj_lawsuit/ 4 Drummond MD, Upson D. Electronic cigarettes: potential harms and benefits. Ann Am Thorac Soc 2014;11:236–242. 5 Benowitz NL. Emerging nicotine delivery products: implications for public health. Ann Am Thorac Soc 2014;11:231–235. 6 King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010–2011. Nicotine Tob Res 2013;15:1623–1627. 7 Centers for Disease Control and Prevention (CDC). Notes from the field: electronic cigarette use among middle and high school students—United States, 2011–2012. MMWR Morb Mortal Wkly Rep 2013;62:729–730. 8 Vickerman KA, Carpenter KM, Altman T, Nash CM, Zbikowski SM. Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine Tob Res 2013;15:1787–1791. 9 Li J, Bullen C, Newcombe R, Walker N, Walton D. The use and acceptability of electronic cigarettes among New Zealand smokers. N Z Med J 2013;126:48–57. 10 Popova L, Ling PM. Perceptions of relative risk of snus and cigarettes among U.S. smokers. Am J Public Health 2013;103:e21–e23. 11 Adkison SE, O’Connor RJ, Bansal-Travers M, Hyland A, Borland R, Yong H-H, Cummings KM, McNeill A, Thrasher JF, Hammond
What We Talk about When We Talk about Intensive Care Unit Strain The intensive care unit (ICU) is an inherently stressful place. The patients are sick and their diseases are complex. Emergencies intrude at all hours, frequently with lives on the line. The gamut of human emotions is on display, with weighty decisions about death unfolding on a daily bases. And, increasingly, all of this happens in the setting of resource constraints—not enough beds, not enough staff, and not enough time in the day to get the work done. Collectively, these pressures and tensions have become known as ICU strain. ICU strain imposes adverse consequences on our well-being and the well-being of our patients. Burnout, a psychological syndrome characterized by emotional exhaustion and a diminished sense of professional satisfaction, is highly prevalent among intensivists and is strongly associated with overall workload (1). Strain can also affect the education of our trainees, with patient care responsibilities infringing on our ability to teach students and residents the practice of critical care (2). For our patients, new evidence suggests that higher clinician workload is associated with at least small elevations in risk-adjusted mortality (3, 4). The problem is clear. Less clear is what to do about it. Strain is an amorphous concept—we know it when we see it, but it is difficult to define. We also lack a good understanding of the different elements of ICU workload that influence strain, and thus we have no clear targets for mitigating its effects. For example, an effort to limit the number of patients seen each day by an individual intensivist would do little to reduce strain if the major cause of strain is not the total number of patients but the total number of new admissions or how sick those new patients are. Without more granular information into the determinants of strain, clinicians are “flying blind,” forced to cope with the stresses of the ICU without empirical data on how to reduce that stress (5). Editorials
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D, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med 2013;44: 207–215. Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health 2013;103: 923–930. Lee S, Grana RA, Glantz SA. Electronic-cigarette use among Korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking. J Adolesc Health (In press) Kotler P. A framework for marketing management, 10th ed. [Internet]. [cited 2013 Nov 25]. Upper Saddle River, New Jersey: PrenticeHall, Inc; 2001. Available from: http://dl.ueb.edu.vn/bitstream/1247/ 2250/1/Marketing_Management_-_Millenium_Edition.pdf Bates C. E-cigs and regulation: what do investment analysts think? [Internet]. The counterfactual [accessed 2013 Nov 5]. Available from: http://www.clivebates.com/?p=1618 Cressey D. Regulation stacks up for e-cigarettes. Nature 2013;501: 473.
Copyright © 2014 by the American Thoracic Society
A new article in this issue of AnnalsATS (pp. 167–172) takes an important first step toward addressing this knowledge gap (6). The authors surveyed front-line ICU physicians and ICU nurse managers in a busy academic ICU in an attempt to measure their perceptions of daily strain. The survey inquired about the adequacy of key ICU resources (i.e., beds and personnel) to meet that day’s demand, and also asked about their overall perception of strain on that day. Then the authors tested the association between key clinical variables on that day and higher strain, as perceived the by intensivists and nurse managers. Candidate clinical variables include a host of factors that might relate to strain, including total census, average severity of illness, number of new admissions, and the number of transfers from outside hospitals, among others. The study produced several important and surprising findings that have direct implications for practicing clinicians. First, the study found that nurse managers and intensivists perceived strain in fundamentally different ways. Nurse managers tended to consider strain in terms of available nurses, while intensivists tended to consider strain in terms of available beds and support staff. Indeed, high-strain days for physicians were not consistently high-strain days for the nurse managers, and vice versa. This finding not only supports the inherent subjectivity of strain, but also indicates that multidisciplinary approaches are needed to handle strain in ways that address the needs of the entire ICU care team. Actions that might mitigate strain for physicians, such as adding ICU beds, might ultimately worsen strain for nurses, since there may not be available high-quality nurses to cover those beds. Second, the investigators found that the only empirical factor associated with strain perceived by intensivists was daily census. Other factors hypothesized to be important, such as the number of new admissions and the average illness severity of the patients, were not associated with strain. However, for nurse managers, both daily census and average severity of illness, as well as other factors, were associated with perceived strain. This finding may 219
EDITORIALS indicate that nurse mangers possess a more holistic view of ICU workload than intensivists, or may indicate that intensivists are better able to insulate themselves from the effects of strain, perhaps through the nursing staff or through physician trainees. Together, these findings should remind intensivists and hospital administrators that there are many approaches to reducing strain apart from adding ICU beds and hiring clinicians to care for more patients. Indeed, there is evidence that, at least in the United States, there are already too many ICU beds and too few clinicians available to care for critically ill patients (7, 8). Instead, we should be exploring innovative ways to manage the expanding ICU workload, such as technology to improve the efficiency of critical care, and efforts to avoid ICU admissions in the first place by better preventive care and better engagement with patients about their wishes at the end of life (9). A major limitation of this study is that it was conducted in a single academic medical ICU. It seems highly likely that strain is perceived differently in community ICUs, which (unlike academic ICUs) rarely operate at capacity (10). Thus, we should be cautious about generalizing these results. Nonetheless, this study provides real lessons that are important regardless of practice setting. ICU capacity strain is a significant yet nuanced problem, with solutions that are as much about the demand for critical care as its supply. Without a deeper understanding of strain to help us focus on both supply and demand, we may find ourselves ever more stressed out, without the tools to make the ICU survivable for both our patients and ourselves. Author disclosures are available with the text of this article at www.atsjournals.org. Jeremy M. Kahn, M.D., M.S. Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
Is Vitamin D Deficiency the Root of All Pulmonary Evils? Vitamin D has long been known to play a critical role in the maintenance of serum calcium levels and bone health. More recently, there has been a growing appreciation of its potential role in respiratory disease. Vitamin D deficiency results in decreased lung volume in animal models (1), and vitamin D has also been shown to have wide-ranging effects on immune function (2). Recent data suggest that vitamin D deficiency modifies the severity of a variety of lung diseases, including asthma, chronic obstructive pulmonary disease, and pneumonia (3–5). To this list of diseases we can now add cystic fibrosis (CF). In this issue of AnnalsATS, Simoneau and coworkers (pp. 205–210) report an association between vitamin D deficiency and Pseudomonas aeruginosa (Pa) infection (6), while McCauley and colleagues (pp. 198–204) found that vitamin D deficiency is associated with an increased incidence of pulmonary exacerbations (7). Clearly, vitamin D plays an important role in bone mineral metabolism. Vitamin D, whether produced endogenously by the skin or ingested, is hydroxylated by the liver to 25-hydroxy vitamin 220
and Department of Health Policy and Management University of Pittsburgh Graduate School of Public Health Pittsburgh, Pennsylvania
References 1 Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007;175:686–692. 2 Ward NS, Read R, Afessa B, Kahn JM. Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors. Crit Care Med 2012; 40:400–405. 3 Iwashyna TJ, Kramer AA, Kahn JM. Intensive care unit occupancy and patient outcomes. Crit Care Med 2009;37:1545–1557. 4 Gabler NB, Ratcliffe SJ, Wagner J, Asch DA, Rubenfeld GD, Angus DC, Halpern SD. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med 2013;188:800–806. 5 Halpern SD. ICU capacity strain and the quality and allocation of critical care. Curr Opin Crit Care 2011;17:648–657. 6 Kerlin MP, Harhay MO, Vranas KC, Cooney E, Ratcliffe SJ, Halpern SD. Objective factors associated with physicians’ and nurses’ perceptions of intensive care unit capacity strain. Ann Am Thorac Soc 2014;11:167–172. 7 Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EAJ, de Keizer NF, Kersten A, Linde-Zwirble WT, Sandiumenge A, et al. Variation in critical care services across North America and Western Europe. Crit Care Med 2008;36:2787–2793, e1–e9. 8 Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med 2006;34:1016–1024. 9 Kahn JM. The risks and rewards of expanding ICU capacity. Crit Care 2012;16:156. 10 Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med 2013;41:2712–2719. Copyright © 2014 by the American Thoracic Society
D (25OHD). 25OHD reflects endogenous stores and is the metabolite measured clinically to assess vitamin D status. To act as a hormone in bone mineral metabolism, this 25OHD must then be activated by renal 1a-hydroxylase to 1,25(OH)2D, which acts on the intestine to stimulate calcium absorption, on the renal tubules to stimulate calcium reabsorption, and either directly or indirectly on the parathyroids to suppress parathyroid hormone (PTH) secretion (thus down-regulating PTH-mediated bone turnover and urinary phosphate wasting). Overall, 1,25(OH)2D also functions at the level of the bone to promote bone mineral accretion but at supraphysiologic levels appears to promote bone turnover. The physiology of vitamin D transport presents a challenge in designing and interpreting studies of the association between vitamin D status and pulmonary outcomes. Both 25OHD and 1,25OH2D are bound in circulation to vitamin D–binding protein (VDBP) and, to a lesser extent, to albumin. VDBP gene polymorphisms may impact VDBP levels as well as binding of vitamin Ds to VDBP. In fact, specific VDBP gene polymorphisms are more common in African Americans and appear to contribute to lower VDBP levels (and perhaps to lower 25OHD) (8, 9). These AnnalsATS Volume 11 Number 2 | February 2014
What We Talk about When We Talk about Intensive Care Unit Strain The intensive care unit (ICU) is an inherently stressful place. The patients are sick and their diseases are complex. Emergencies intrude at all hours, frequently with lives on the line. The gamut of human emotions is on display, with weighty decisions about death unfolding on a daily bases. And, increasingly, all of this happens in the setting of resource constraints—not enough beds, not enough staff, and not enough time in the day to get the work done. Collectively, these pressures and tensions have become known as ICU strain. ICU strain imposes adverse consequences on our well-being and the well-being of our patients. Burnout, a psychological syndrome characterized by emotional exhaustion and a diminished sense of professional satisfaction, is highly prevalent among intensivists and is strongly associated with overall workload (1). Strain can also affect the education of our trainees, with patient care responsibilities infringing on our ability to teach students and residents the practice of critical care (2). For our patients, new evidence suggests that higher clinician workload is associated with at least small elevations in risk-adjusted mortality (3, 4). The problem is clear. Less clear is what to do about it. Strain is an amorphous concept—we know it when we see it, but it is difficult to define. We also lack a good understanding of the different elements of ICU workload that influence strain, and thus we have no clear targets for mitigating its effects. For example, an effort to limit the number of patients seen each day by an individual intensivist would do little to reduce strain if the major cause of strain is not the total number of patients but the total number of new admissions or how sick those new patients are. Without more granular information into the determinants of strain, clinicians are “flying blind,” forced to cope with the stresses of the ICU without empirical data on how to reduce that stress (5). Editorials
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15
16
D, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med 2013;44: 207–215. Popova L, Ling PM. Alternative tobacco product use and smoking cessation: a national study. Am J Public Health 2013;103: 923–930. Lee S, Grana RA, Glantz SA. Electronic-cigarette use among Korean adolescents: A cross-sectional study of market penetration, dual use, and relationship to quit attempts and former smoking. J Adolesc Health (In press) Kotler P. A framework for marketing management, 10th ed. [Internet]. [cited 2013 Nov 25]. Upper Saddle River, New Jersey: PrenticeHall, Inc; 2001. Available from: http://dl.ueb.edu.vn/bitstream/1247/ 2250/1/Marketing_Management_-_Millenium_Edition.pdf Bates C. E-cigs and regulation: what do investment analysts think? [Internet]. The counterfactual [accessed 2013 Nov 5]. Available from: http://www.clivebates.com/?p=1618 Cressey D. Regulation stacks up for e-cigarettes. Nature 2013;501: 473.
Copyright © 2014 by the American Thoracic Society
A new article in this issue of AnnalsATS (pp. 167–172) takes an important first step toward addressing this knowledge gap (6). The authors surveyed front-line ICU physicians and ICU nurse managers in a busy academic ICU in an attempt to measure their perceptions of daily strain. The survey inquired about the adequacy of key ICU resources (i.e., beds and personnel) to meet that day’s demand, and also asked about their overall perception of strain on that day. Then the authors tested the association between key clinical variables on that day and higher strain, as perceived the by intensivists and nurse managers. Candidate clinical variables include a host of factors that might relate to strain, including total census, average severity of illness, number of new admissions, and the number of transfers from outside hospitals, among others. The study produced several important and surprising findings that have direct implications for practicing clinicians. First, the study found that nurse managers and intensivists perceived strain in fundamentally different ways. Nurse managers tended to consider strain in terms of available nurses, while intensivists tended to consider strain in terms of available beds and support staff. Indeed, high-strain days for physicians were not consistently high-strain days for the nurse managers, and vice versa. This finding not only supports the inherent subjectivity of strain, but also indicates that multidisciplinary approaches are needed to handle strain in ways that address the needs of the entire ICU care team. Actions that might mitigate strain for physicians, such as adding ICU beds, might ultimately worsen strain for nurses, since there may not be available high-quality nurses to cover those beds. Second, the investigators found that the only empirical factor associated with strain perceived by intensivists was daily census. Other factors hypothesized to be important, such as the number of new admissions and the average illness severity of the patients, were not associated with strain. However, for nurse managers, both daily census and average severity of illness, as well as other factors, were associated with perceived strain. This finding may 219
EDITORIALS indicate that nurse mangers possess a more holistic view of ICU workload than intensivists, or may indicate that intensivists are better able to insulate themselves from the effects of strain, perhaps through the nursing staff or through physician trainees. Together, these findings should remind intensivists and hospital administrators that there are many approaches to reducing strain apart from adding ICU beds and hiring clinicians to care for more patients. Indeed, there is evidence that, at least in the United States, there are already too many ICU beds and too few clinicians available to care for critically ill patients (7, 8). Instead, we should be exploring innovative ways to manage the expanding ICU workload, such as technology to improve the efficiency of critical care, and efforts to avoid ICU admissions in the first place by better preventive care and better engagement with patients about their wishes at the end of life (9). A major limitation of this study is that it was conducted in a single academic medical ICU. It seems highly likely that strain is perceived differently in community ICUs, which (unlike academic ICUs) rarely operate at capacity (10). Thus, we should be cautious about generalizing these results. Nonetheless, this study provides real lessons that are important regardless of practice setting. ICU capacity strain is a significant yet nuanced problem, with solutions that are as much about the demand for critical care as its supply. Without a deeper understanding of strain to help us focus on both supply and demand, we may find ourselves ever more stressed out, without the tools to make the ICU survivable for both our patients and ourselves. Author disclosures are available with the text of this article at www.atsjournals.org. Jeremy M. Kahn, M.D., M.S. Department of Critical Care Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
Is Vitamin D Deficiency the Root of All Pulmonary Evils? Vitamin D has long been known to play a critical role in the maintenance of serum calcium levels and bone health. More recently, there has been a growing appreciation of its potential role in respiratory disease. Vitamin D deficiency results in decreased lung volume in animal models (1), and vitamin D has also been shown to have wide-ranging effects on immune function (2). Recent data suggest that vitamin D deficiency modifies the severity of a variety of lung diseases, including asthma, chronic obstructive pulmonary disease, and pneumonia (3–5). To this list of diseases we can now add cystic fibrosis (CF). In this issue of AnnalsATS, Simoneau and coworkers (pp. 205–210) report an association between vitamin D deficiency and Pseudomonas aeruginosa (Pa) infection (6), while McCauley and colleagues (pp. 198–204) found that vitamin D deficiency is associated with an increased incidence of pulmonary exacerbations (7). Clearly, vitamin D plays an important role in bone mineral metabolism. Vitamin D, whether produced endogenously by the skin or ingested, is hydroxylated by the liver to 25-hydroxy vitamin 220
and Department of Health Policy and Management University of Pittsburgh Graduate School of Public Health Pittsburgh, Pennsylvania
References 1 Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 2007;175:686–692. 2 Ward NS, Read R, Afessa B, Kahn JM. Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors. Crit Care Med 2012; 40:400–405. 3 Iwashyna TJ, Kramer AA, Kahn JM. Intensive care unit occupancy and patient outcomes. Crit Care Med 2009;37:1545–1557. 4 Gabler NB, Ratcliffe SJ, Wagner J, Asch DA, Rubenfeld GD, Angus DC, Halpern SD. Mortality among patients admitted to strained intensive care units. Am J Respir Crit Care Med 2013;188:800–806. 5 Halpern SD. ICU capacity strain and the quality and allocation of critical care. Curr Opin Crit Care 2011;17:648–657. 6 Kerlin MP, Harhay MO, Vranas KC, Cooney E, Ratcliffe SJ, Halpern SD. Objective factors associated with physicians’ and nurses’ perceptions of intensive care unit capacity strain. Ann Am Thorac Soc 2014;11:167–172. 7 Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EAJ, de Keizer NF, Kersten A, Linde-Zwirble WT, Sandiumenge A, et al. Variation in critical care services across North America and Western Europe. Crit Care Med 2008;36:2787–2793, e1–e9. 8 Angus DC, Shorr AF, White A, Dremsizov TT, Schmitz RJ, Kelley MA; Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Critical care delivery in the United States: distribution of services and compliance with Leapfrog recommendations. Crit Care Med 2006;34:1016–1024. 9 Kahn JM. The risks and rewards of expanding ICU capacity. Crit Care 2012;16:156. 10 Wunsch H, Wagner J, Herlim M, Chong DH, Kramer AA, Halpern SD. ICU occupancy and mechanical ventilator use in the United States. Crit Care Med 2013;41:2712–2719. Copyright © 2014 by the American Thoracic Society
D (25OHD). 25OHD reflects endogenous stores and is the metabolite measured clinically to assess vitamin D status. To act as a hormone in bone mineral metabolism, this 25OHD must then be activated by renal 1a-hydroxylase to 1,25(OH)2D, which acts on the intestine to stimulate calcium absorption, on the renal tubules to stimulate calcium reabsorption, and either directly or indirectly on the parathyroids to suppress parathyroid hormone (PTH) secretion (thus down-regulating PTH-mediated bone turnover and urinary phosphate wasting). Overall, 1,25(OH)2D also functions at the level of the bone to promote bone mineral accretion but at supraphysiologic levels appears to promote bone turnover. The physiology of vitamin D transport presents a challenge in designing and interpreting studies of the association between vitamin D status and pulmonary outcomes. Both 25OHD and 1,25OH2D are bound in circulation to vitamin D–binding protein (VDBP) and, to a lesser extent, to albumin. VDBP gene polymorphisms may impact VDBP levels as well as binding of vitamin Ds to VDBP. In fact, specific VDBP gene polymorphisms are more common in African Americans and appear to contribute to lower VDBP levels (and perhaps to lower 25OHD) (8, 9). These AnnalsATS Volume 11 Number 2 | February 2014
