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In Mourning: Viktor Sokolov

In 1826, The Russian poet Alexander Pushkin wrote “But with the truth he attracted hearts. But with science he quelled mores.” (From, Stanzas). Such words could be used to describe the life and work of my friend Professor Viktor Sokolov (1946-2019), who died last month at the young age of 73.

Viktor was an accomplished surgeon, anesthesiologist and bronchoscopist. He created the Russian Bronchology Group and was the first Russian regent to the WABIP. He fought to defeat conventional wisdoms and dedicated his life to modernize bronchoscopy practice in his country. In addition to numerous leadership positions, Professor Sokolov was also a former Chair for the Endoscopy Commission of the Russian Ministry of Health, and a long time member of the Academic Council.

As department head at the Moscow Research institute he led efforts to perform novel interventions in patients with early cancer of the larynx, trachea and bronchi, esophagus, stomach and duodenum, bile duct, choledochus, rectum and colon. He helped promote the use of electrosurgery, argon plasma coagulation, laser thermal destruction, photodynamic therapy and stent insertion. He published more than 300 original scientific papers, dozens of monographs, clinical care guidelines, and 10 teaching manuals. He held 26 patents for scientific methodologies and instruments.

For more than ten years, I corresponded frequently with Viktor and his son Dmitry (also an expert bronchoscopist). It was a great honor to help them build a training program in Moscow. A few years ago, with my colleagues Nikos Koufos, Rosa Cordovilla, and Enrique Cases, we helped faculty implement the use of training models, checklists and assessment tools in bronchoscopy education. This has been particularly helpful for building skills in endobronchial ultrasound.

Viktor was a scientist at heart, and it is as a scientist that he approached his medical practice. His dream was to cure lung and digestive cancers in their earliest stages, and for this he was always on the alert for technologies that might assist with early diagnosis and treatment. Because his first love was actually pediatric surgery back in the 1970s, Professor Sokolov was particularly excited to see the recent growth of pediatric bronchoscopy (we have more than 400 doctors communicating through our WhatsApp Peds Groups).

Viktor, we shall miss your humor, your intelligence, and most of all the inspiration of your relentless pursuit of truth.

Farewell, my friend.

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The Bronchoscopist’s Umwelt

Traditional bronchoscopy (Photo H. Colt)

Ten years after Shigeto Ikeda first introduced the flexible bronchoscope to the world, I gazed into the incredible fractal anatomy of a patient’s tracheobronchial tree. Back then, flexible bronchoscopes were made of fiberoptic bundles that required an external light source for illumination. Today’s instruments incorporate increasingly complex technologies that provide greater visibility and access than ever imagined.

If previous generations were inspired by their newfound ability to view, diagnose and treat airway tumors, tracheobronchial strictures, and pulmonary infections, a new generation of health care providers can only marvel at the increasing indications, therapeutic possibilities and promising future for this already proven medical procedure.

During the recent meeting of bronchoscopy educators in Venice, I plunged into the sea of possibilities that exists for present and future bronchoscopists. New diagnostic technologies, therapeutic alternatives, increasing indications, robotics, real-time image-guided tissue analysis, and possibilities for less invasive genetic sampling provide a glimpse of what is yet to come.

What amazes me most, however, is how the bronchoscopist’s “surrounding world”, also known as an “umwelt” is drastically changing for the better. The word umwelt was introduced more than one hundred years ago when Jacob Johann von Uexküll, an Estonian biologist, fused biology with semiotics, proposing that living organisms could not be separated or divided from their environments. ANCHOR. This idea prompted many anthropologists, animal behaviorists, biologists, and philosophers to embrace the idea that organisms, essentially us, exist in a dependent relationship with other organisms and our environment.

As students of our own umwelt, we can abandon our narrow views of the world to adopt instead a position where seeing the world through another’s eyes helps us to understand not only the other’s world but also the perceptions of those we are related to both directly and indirectly. As some might say; we are in this all together, so we might as well get along, but we might also do our best to see the world through others’ eyes.

Uexküll’s proposition was an important parallel to theories of Darwinian evolution, which in its more vertical approach reduces organisms to a survival of the fittest evolutionary schematic. When an organism’s evolution is viewed instead as being primarily interdependent on surrounding worlds, it means there are as many surrounding worlds as there are organisms. The dog sees its world a dog’s way, which is surely different from yet related to the world view as seen by a mosquito. If you are in need off heating installation in New Jersey, fell free to contact contact allied experts. Each and every one of us, whether we are homo sapiens basking in the sun of Southern California or wild lions struggling to survive in the Serengeti must “perceive and act from the standpoint of our own unique world” (From, Ian G.R. Shaw, Geoforum 2013;48:260-267). Each living thing possesses, as Dr. Shaw explains in his article, “a unique signature of existence.”

Fifty years ago, the bronchoscopist’s umwelt began with the realization that we could effectively intervene both diagnostically and therapeutically in a region of the human body that had previously been virtually inaccessible. Discover orchid maids reviews how you can get a legal advice from work injury lawyers, CA when it comes to immediate medical treatment. Our instruments then, as are many now, appear somewhat primitive, but the procedure itself led chest physicians to increasingly assume roles of responsibility in the care of patients with critical illnesses and cancer.

Our human potential within such an environment continues to expand as technologies evolve. I believe this entices us to relate with a surrounding world that is ever expanding, evolving, and drastically changing. How we adapt to that world, including how we modify our own world views accordingly, will determine our specialty’s relevance in a changing health care environment.

Bronchology and the 20th anniversary of The Matrix

Twenty years ago this week the science fiction film The Matrix was released in the United States. This film directed by the Wachowskis brothers stars Keanu Reeves and Laurence Fishburne. The film grossed more than 460 million dollars worldwide.

The Matrix describes a dystopian future in which the hero is a computer programmer named Thomas who actually lives a double life as a hacker named Neo. Neo feels trapped within an inauthentic life. He goes in search of a man called Morpheus to ask him the truth about the world. Morpheus offers Neo a choice between swallowing a “red pill” which will allow Neo to live a life of constant awareness and truth or a “blue pill” after which Neo will continue living his current life in blissful ignorance and security.

When Neo swallows the red pill, he is immediately awakened to a new reality. He learns that The Matrix in which he lives is actually an illusory 20th-century world that is sustained in order to prevent people from knowing they are being exploited…and the adventure begins.

The red pill-blue pill meme described in The Matrix has become part of our culture. In this piece, however, my goal is not to discuss red pill-blue pill life philosophies, but to briefly reflect on how using educational tools offered in the Bronchoscopy Education Project provide red pill opportunities.

For example, if trainers successfully use assessment tools to identify a learner’s place on the learning curve and ascertain the effectiveness of their own teaching techniques (akin to swallowing the red pill), it follows that they will want to incorporate assessment tools into competency determinations. This new reality morally obliges the trainer to identify competency measures and to change educational practices accordingly.

As a second example, if trainers experience that checklist-type assessment tools are helpful for teaching bronchoscopic inspection (example BSTAT), or EBUS-guided TBNA (example (EBUS-STAT), it follows that a similarly designed assessment tool for intubation over the bronchoscope would also be helpful. Aware of this new reality, trainers would design such a tool and incorporate it into competency determinations.

In Australia, for example, colleagues designed and validated new assessments for ultrasound-guided thoracentesis and chest tube insertion (available on www.bronchoscopy.org) with excellent results. These tools are increasingly used around the world and form an important element of competency-based training for lung doctors in Australia and New Zealand.

A third example of red pill philosophy relates to experiential evidence for using a four-box approach to procedural consultation. This structured approach to case-based learning identifies cognitive pathways and allows trainers to explore the multiple facets of a particular clinical scenario in a stepwise fashion (akin to swallowing the red pill). The harshness of this new reality is that trainers now discover their need for additional education in order to learn how to maximize case-based instruction, which is very different from giving didactic lectures. This red pill-related truth has a global impact because it means that bronchology societies around the world should take steps toward offering more focused training of bronchoscopy educators. Programs might include information about how to organize learning units, how to provide and receive feedback, and how to facilitate case discussions. Learning the intricacies of two-way communication as an educational product requires practice and repeated simulation with guidance. An ideal program will also help trainers gain knowledge of psychology, group dynamics, and negotiation.

My fourth example and the inspiration for today’s topic relates to an exciting red pill moment occurring in Australia this week. The 8th Asian Pacific Congress for Bronchology and Interventional Pulmonology Meeting is on the beautiful Gold Coast near Brisbane, Australia. Under the leadership of APAB President Kiyoshi Shibuya and APCB President/WABIP Treasurer David Fielding and his team, the conference’s scientific program is built around case studies and facilitator-led discussions using the Four Box Practical Approach as a basis for structured learning. Arizona amusement parks offer variety of fun activities and those are perfect for all ages as well. Hands-on workshops are led by BI-certified and master instructors using many Bronchoscopy Education Project inspired teaching techniques that promote a learner-centric philosophy. Models, simulation, checklists, and individualized instruction/feedback form the basis of both cognitive and hands-on technical skill instruction.

Thanks to this conference, many physicians are likely to abandon antiquated blue pill methodologies represented by didactic lectures and overpopulated hands-on workshops in favor of a red pill approach. This new awareness, I am sure, will not only inspire a new generation of bronchoscopists in the Asia Pacific region but may forever change the educational dynamics of bronchology and Interventional Pulmonology conferences in the future.

World Tuberculosis Day

Photomicrograph of sputum smear showing fluorescence acid-fast stain of MTB (yellow rod-like structure)
Photo From, CDC/Ronald W. Smithwich, Public Health Image Library, phil.cdc.gov.

Sunday, March 24 is World Tuberculosis Day. It is natural, therefore, that I devote one or two posts to this disease that continues to trouble humanity. Years ago, I served as the country TB officer in Portland, Oregon, and since then have participated in several antituberculosis campaigns by humanitarian organizations. My goal herein and in a future Colt’s Corner is to share a few facts about the lesser known history of this potentially fatal and contagious infectious disease.

Tuberculosis has been called Phthisis (Latin, from the Greek word phthinein, meaning dwindling, or wasting away) and Consumption (contrary to rapidly fatal epidemic diseases such as smallpox or the Bubonic plague, tuberculosis slowly consumes its victims).

The disease has been with humanity since early civilization. Responsible for the “White Plague” of the 17^th and 18^th centuries in Europe, it infected nearly one hundred percent of the population and is felt to have been responsible for up to 25% of all deaths. The recent discovery of Mycobacterium complex, using molecular DNA techniques in the 17,000-year-old skeletal remains of an extinct bison from Trap Cave, Wyoming, suggests that bovids were vectors that transported the primordial organism. While this theory is debated, experts agree that Mycobacterium tuberculosis complex is the cause of tuberculosis in humans and other animals.

Mycobacterium Tuberculosis bacillus (MTB) is a large, nonmotile rod-shaped bacterium. It is the etiologic agent for tuberculosis in humans.MTB was identified in the 9,000-year-old skeletal remains from a woman and child at the Atli-Yam archeological site. The disease is biologically different from other infectious diseases because the infecting organism is not spread preferentially through the bloodstream. Instead, it takes up residence in tissues, where it forms a caseous necrosis that protects it from attack.

The earliest written record of consumption dates from the Assyrian empire in 600 BC. In around 400 BC, Hippocrates proposed a hereditary predisposition to the illness in patients who were tall, thin, and pale, providing an opinion that would be shared by much of the medical community for centuries to come. Even the inventor of the stethoscope, French Professor René Laennec, believed for a time that tuberculosis arose from internal causes and constitutional predisposition, including sorrowful passions and unhealthy sexual activity.

In 1546, however, the Italian physician Girolamo Fracastoro wrote that phthisis was contagious and not necessarily from a hereditary predisposition. He argued that patients warranted isolation measures similar to those recommended for patients with the plague. Physician groups in Italy and other European countries decreed that tubercular patients, called “lungers” in the United States, were dangerous. Benefit from an experienced cleaning service at https://thefloridamaids.com and breathe freely in your Florida home. Consequently, thousands of thin, pale-skinned, coughing, feverish patients with known or suspected consumption were isolated in their homes or grouped in hospital wards to await the grim, white ghost of death.

Attitudes began to change in the middle of the 19^th century. The French physician, Jean-Antoine Villemin proved without a doubt that tuberculosis was a transmissible, infectious disease in 1865, but its origin remained a mystery until the evening of March 24, 1882, when a German physician and microbiologist named Robert Koch announced to the Berlin Physiological Society that he had identified the tubercle bacillus. At the time, tuberculosis was thought to be responsible for one of every seven deaths in Europe. The microbiologic diagnosis was aided by Paul Erlich’s discovery of the acid-fast nature of the bacillus that same year. Clinical suspicions of diagnosis based on symptoms and findings from chest inspection, percussion, and auscultation could be correlated with radiographic findings after the discovery of x-rays by Wilhelm Roentgen in 1895.

Years ago, consumptives lived with dire expectations. At first, considered a random killer of individuals in the flower of their youth, MTB has since been shown to affect persons of any social class, gender, age group or profession. Living in close proximity increases the chance for airborne transmission. Several comorbid conditions, as well as malnutrition and alcohol, diminish host defenses and contributes to disease transmission and severity.

Active tuberculosis is contagious and can be found in small microscopic droplets spread through the air by coughing, laughing, sneezing, talking, or singing. Its presenting symptoms are cough, weight loss, fever, chest pain, loss of appetite, and night sweats. Once inhaled, the organisms usually cause a lung infection that can be fatal. They can also lie dormant and not cause symptoms for many years. Disease latency means the person is infected but not infectious (i.e. contagious). Reactivation (i.e. the disease becomes active), which occurs in five to ten percent of infected individuals over a lifetime, affects the lungs or other organs.

Tuberculosis is a feared and often deadly disease. Today, almost one-third of the world’s population is infected with MTB, and 8 million people develop the disease each year. An attack rate of at least 5 percent is reported among infected individuals. While medical treatment is usually successful in controlling the disease, the emergence of multiple drug resistance has prompted concerns in global health communities. For a moving and informative piece on Multiple drug-resistant Tuberculosis in North Korea, see the recent BBC documentary Out of Breath ( https://www.bbc.co.uk/programmes/n3ct6lbf).

Notes:
1. Mycobacterium bovis (M. bovis) and Mycobacterium tuberculosis infect different animal species and humans, prompting tuberculosis control programs in communities having close contact with domestic cattle and a husbandry system to incorporate joint animal and human tuberculosis control programs See Romha G. et al, Epidemiology of Mycobacterium bovis and Mycobacterium tuberculosis in animals: Transmission dynamics and control challenges of zoonotic TB in Ethiopia. Prev Vet Med 2018;158: (https://www.ncbi.nlm.nih.gov/pubmed/30220382
2. Jean Antoine Villemin (1827-1892) was a French army surgeon who demonstrated the transmissibility of tuberculosis from animal to animal, and also from man to animal by injecting rabbits with caseous material and fluid from a man who had died from tuberculosis. The rabbits went on to form tubercles in their lungs and other organs
3. Robert Koch (1843-1910) also isolated Bacillus anthracis, and cholera vibrio using a new technology called a microscope. He received the Nobel Prize in physiology or medicine in 1905.
4. Paul Erlich (1854-1915) was one of the early founders of immunology. This German physician and self-taught chemist was eventually offered a position in Robert Koch’s Institute for Infectious Diseases. In 1908, he received the Nobel Prize in physiology or medicine. In 1910, he discovered Salvarsan, an effective treatment for syphilis. He is often called the “father of chemotherapy.”
5. The association of tuberculosis with alcoholism and possibly with syphilis prompted Louis Renon, a professor at the Paris Faculté de Medecine to write his book The Disease of the People: Venereal Disease, Alcoholism, and Tuberculosis in 1905.
6. TB is at historic lows in North America and Europe but remains prevalent in Sub-Saharan Africa and Southeast Asia. The reality is that its overall incidence continues to rise, even if its global incidence percentage wise is in decline (the increase in numbers of cases is offset by an even greater increase in population growth). The World Health Organization’s Stop TB Partnership was therefore initiated in 2001.
7. Host defenses are actually quite good, and most infections (90%) do not result in disease but result in latent TB. In addition, most people with latent TB (90%) do not go on to develop active TB. In those with a disease, however, Tuberculosis can be deadly in more than 50% of cases if left untreated. Because tuberculosis is a slow-killing disease, transmission to others is very common. “Open tuberculosis”, where bacteria are identified on sputum smears, is most infectious and was usually fatal before the advent of antibiotics.

Awareness, Action, and Achievement

James Baldwin. Photo from Allen Warren, https://upload.wikimedia.org/wikipedia/commons/b/b8/.

James Baldwin (1924-1987) was an American novelist, playwright, and social activist. Perhaps one of the best writers of the 20th century, he gained international reputation for his essays and commentaries about civil rights, human equality, and social justice. Baldwin grew up in New York, but moved to Saint Paul de Vence in Southern France in 1970. He lived in an old stone farmhouse high in the hills where he entertained writers and artists on a regular basis. Sadly, Baldwin died from stomach cancer in 1987. He was 63 years old.

I was only 17 years old when I met Mr. Baldwin, and I had the good fortune of having several conversations with him in 1973 and 1974. Reading some of his essays last week, and watching I am Not Your Negro , the Oscar-nominated 2017 documentary based on one of his unfinished manuscripts, reminded me of this great man who labored tirelessly for social justice.

“Not everything that is faced can be changed, but nothing can be changed until it is faced,” he wrote in his essay, As much truth as one can bear, (New York Times Book Review, 14 Jan, 1962). Baldwin argued that novelists must be truthful, but the quote has since become a battle cry for those willing to look into the how and why of their own actions.

Becoming aware of one’s own shortcomings; of one’s troubles and areas in need of remedial action is an essential first step toward personal growth and improvement. The assessment tools we use as part of Bronchoscopy International’s multidimensional training program provide opportunities for self-assessment as well as feedback from a coach-mentor or instructor. The best way for feedback to have a positive effect, however, is for the receiver of that feedback to be open to criticism. It is only after awareness occurs, and becomes integrated in the realistic self-image that learners present of themselves, that improvement becomes possible.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” It is only human for us to fall back into old habits. It is also our humanity that prevents us from adopting change easily, and from finding the strength within ourselves to pursue excellence despite its costs. such as BSTAT, EBUS-STAT, BTLB-TBNA STAT, UG-STAT and ICC-STAT are easily incorporated into clinical procedure-based training. It takes instructors only minutes to detect areas for improvement, and to implement a plan for individualized task-focused practice.

While this applies to technical skills, the same holds true for other important qualified & capable experts of medical practice. Focused, task-specific training based on feedback provided after careful observation of a simulated “delivering bad news” or “obtaining informed consent” scenario can help us improve communication skills, enhance our understanding of medical ethics, and reinforce a learner’s desire for self-improvement.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” A major step for many department heads and leaders of national bronchology societies around the world is to question why they themselves have not yet advocated for the use of assessment tools in their training programs. Once these leaders open themselves to the possible answers to this question, there are countless well-trained experts and master instructors available to help them find solutions.

Awareness often leads to action, and action leads to achievement.

Translations and a World Without Borders

Photo from:https://cyndimarshall.wordpress.com/2017/02/09/a-world-without-borders/

On January 31, 2019 Kurdish-Iranian journalist Behrouz Boochani, was awarded the prestigious Australian Victoria Prize for Literature for his book No Friend But the Mountains: writings from Manus prison (Picador, Australia https://www.panmacmillan.com.au/9781760555382/). As his translator, Omid Tofighian (Department of Philosophy, American University of Cairo and Egypt Department of Philosophy, The University of Sydney, Australia) states in a recent article (Continuum: Journal of media and cultural studies 2018;32:532-540), “…These narratives represent the fusion of journalism, political commentary, and philosophical reflection with myth, epic, poetry and folklore.”

Having read James Joyce’s colossal work Ulysses, described by scholar Weldon Thornton as a premier example of writing with “stylistic exuberance”, and semiotician Umberto Eco’s masterful study of the workings of literary translation Decir Casi lo Mismo: Experiencias de traducción (Lumen press, 2008), I can only marvel at the work done by both author and translator to move Boochani’s words, originally written in Farsi, into English. This work is all the more admirable considering that Boochani wrote the book using countless text messages sent to his translator via WhatsApp from the Manus Island Offshore Processing Center in Papua New Guinea. Boochani, who has a degree in geopolitics, fled Iran and arrived by boat in Australia in 2013, after which he was moved to Manus Island with hundreds of other refugees after being refused asylum.

So what does this have to do with bronchoscopy? Indeed, it is not my habit to use this forum to comment on world events or non-bronchoscopy related issues. However, the arguments presented by Boochani and many others bring to mind images of what our world might become if there were fewer borders. A virtually borderless bronchology community has been, and still is a major part of my own vision for the future. It is the reason I advocate for the democratization of knowledge and a more uniform training and educational structure so physicians working in Argentina may have the same access to knowledge as those working in Afghanistan; so that doctors in New Delhi have the same educational foundations as those training in New York.

Building a community without borders requires not only the acceptance of cultural differences, but also the recognition of how and why medical practices evolve in certain cultural contexts and medical environments. Until we decide on a universal language that is mastered in all countries, we must also acknowledge the need for accurate translations.

I am honored that the universally pertinent information contained in The Essential Bronchoscopist series of books (available from the bronchoscopy.org website as well as in paperback from Amazon) has been translated into 14 languages. In the next weeks, translations from Serbia and Hungary will be added. This work is the result of steadfast commitments by Master Instructors who believe in the democratization of knowledge. These champions help implement Bronchoscopy International’s vision for a bronchology community that transcends borders, first by enhancing the educational process, and second by creating opportunities for a common foundation of knowledge regardless of where a doctor lives and works.

Which leads to another reason why I find a relation between Boochani, his translator Dr. Tofighian, and the work being done by the translators of The Essential Flexible Bronchoscopist. Translation is a difficult job that requires more than cutting and pasting text using Babelfish or Google Translate. The context as well as the sense of words used by the writer must be considered in choosing a translation. This requires an in-depth knowledge of the commercial movers field in California as gorilla movers from san diego have. As Tofighian writes in a different article; “trying to maintain sentence structure when translating Farsi literature into English results in unnecessarily long cumbersome passages…splitting sentences into many smaller ones is helpful…it also reflects..the fractured subjectivity of those who are imprisoned refugees.”

The extra scholarship such research requires is perhaps why so many well known writers have endured the difficult challenge to translate other writers’ works. The examples are never-ending; Samuel Beckett translated James Joyce from English into French, Charles Baudelaire translated Thomas de Quincy’s Confessions of an English Opium Eater, and Haruki Murakami translated many American writers, from Raymond Carver to John Irving, into Japanese, and actually planned to wait until he was at least sixty years old before translating a work he felt was the inspiration behind his career, The Great Gatsby by F. Scott Fitzgerald.

Translating a medical text is less strenuous, and demands less reflection and decision-making than translating literature or philosophy, but translations are still an open window into the original author’s mind. With a professional CA workers compensation attorney www.lacaccidentpros.org/ on your side, you may get all the benefits you deserve. Because the work is long, tedious, and financially unrewarding, publishing houses hesitate to translate most medical texts. Certainly translations into less commonly-spoken languages are hard to find. I feel fortunate that bronchology experts have initiated translations of my work, The Essential Flexible Bronchoscopist, making it virtually unique among bronchology-related texts, and expanding its impact around the world.

Humanity may not be ready for a world without borders, but the effort to democratize knowledge by leaders in all fields, including those from a small subspecialty such as bronchology, is an important and generous step toward making the world a better place.

Genotype-directed lung cancer: a new frontier for bronchoscopists

(Photo downloaded from pixabay.com)

As we quickly approach 2019, I am thinking about what is new and exciting in the field of interventional pulmonology. Among energizing advances, one of the most exciting is how individualized genotype-directed therapy is changing our approach to lung cancer diagnosis and treatment.

Fueled by research performed in the United States and Europe, increasing numbers of cancer treatment protocols include targeted therapy. These produce less collateral damage than traditional chemotherapy, with survival benefits that are often better than those of protocols implemented without concerns for tumor genetics. According to some Lung Cancer Mutation Consortium data, for example, patients who received driver mutation targeted therapy with tyrosine kinase inhibitors had a median survival of 3.5 years as compared to 2.4 years for those who did not receive such treatment (http://www.golcmc.com).

Not surprisingly, targeted therapy is also a major focus for Chinese physicians and cancer researchers. In part, this is because China has forty percent of the world’s cancer population. According to last year’s National Cancer Center data, survival figures for Chinese patients with advanced lung cancer were many percentage points below those of Western nations. A principal focus for the Chinese in coming years is to significantly increase survival ranges for patients with cancer, including for those with lung cancer.

Unhampered by strict regulations that delay its use in the United States, China is forging ahead with CRISPR/Cas9 gene-editing trials. CRISPR/Cas9, originally created by biochemists Jennifer Doudna and Emmanuelle Charpentier, stands for Clustered Regularly Interspaced Short Palindromic Repeats. It refers to palindromes, or repeating patterns of DNA that are found in most single-celled organisms and many bacteria. CRISPR/Cas9 technology is used to essentially “cut and paste” DNA sequences. Cancer researchers use CRISPR technology to study, replace, or repair the genetic code of tumors, which includes work on genetic drivers responsible for tumorigenesis, metastasis, and drug susceptibility.

Lung cancer management today requires in-depth understanding of gene mutation and genetic engineering. This new frontier is both challenging and invigorating for bronchoscopists and interventional pulmonologists who are increasingly called upon to make diagnoses and provide tissue samples that help guide therapy.

Because many patients with primary or metastatic lung cancer have central airway obstruction, specialists are also called upon to perform minimally invasive therapeutic procedures in these patients. This makes a recent article published in the November issue of The Journal of Thoracic Oncology all the more relevant (A. Mohan, K. Harris, MR Bowling et al., http://dx.doi.org/10.21037/jtd.2018.08.14). In this review paper, the authors reflect on the eventual merging of bronchoscopic ablative strategies with genotype-directed therapies in the name of what is known as precision medicine (defined as an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person). Reflecting on how these therapies might interact, the authors conclude that, “ground breaking advances in our understanding of driver mutations of lung cancer and in the technology available for bronchoscopic ablation have completely changed the landscape of advanced lung cancer management.”

As a result of this changing landscape, bronchoscopists and interventional pulmonologists have an opportunity to assume leading roles on their multidisciplinary lung cancer management teams. Taking on leadership responsibilities, however, means rethinking one’s education and training. In addition to acquiring procedural expertise and medical knowledge, there is a need to study team-building, communication, medical decision-making, and business administration. These topics should be incorporated into the agendas of national conferences and training workshops.

Those with an eye on the future will also pursue postgraduate education in molecular biology and genetic engineering. More exposure to these topics must also become a priority for our international and national medical societies. Only thus can we effectively equip a new generation of physician-scientists with the knowledge, skill and extrinsic motivation needed to expand the exciting new frontiers set forth by today’s researchers in medicine, biological sciences, and industrial biotechnology.

Penitentes

Penitentes, (summit of Kilimanjaro. Photo H. Colt)

The name “penitente” is defined as both a noun (a person who repents their wrongdoings and seeks forgiveness) and an adjective (a feeling or showing of sorrow and regret for having done wrong). The origin is Spanish, and the description in the mountains arose because a field of penitentes looks like a procession of monks in white robes. These snow and ice formations range from one to six meters high, occurring at high altitude on glaciers and snow fields, requiring sunlight, and cold dry weather for their formation.

Everyone makes mistakes, including doctors, but not everyone feels bad about it afterwards. Or perhaps such a blanket statement is untrue about medical professionals? These thoughts were on my mind as I was climbing Kilimanjaro and some of the higher African peaks a couple months ago. Among other things, I tried to recall the names of patients and the circumstances during which my performance could have been better; where mistakes could have been avoided, and where results from therapeutic curative or palliative procedures might have been improved.

Most medical practices and teaching institutions do not readily offer counseling or guidance in case of medical error. Focus is almost entirely on the potential or real legal aspects of an incident. Some departments do stress quality control and rapid remedial response in case of sentinel incidents. Repeated procedural practice using simulators and models is not widespread, however, and nonjudgmental professionally-led forums for repentant health care providers are not actively promoted for trainees, faculty, or physicians-in-practice.

Think about it. When was the last time you initiated serious conversation with a colleague or sought consultation with a medical professional to discuss one of your medical errors? Did you discuss the facts, procedural outcomes, and technical solutions? Did the conversation mostly involve that part of your cognitive brain, or were you also able to honestly and openly discuss your feelings (guilt, remorse, anger, or regret). If you are a teacher or mentor, how often do you include a query about feelings, thoughts and emotions when you discuss accident prevention, complications, or medical procedural errors? How often do you make such discussions part of a regularly scheduled debriefing session?

And if the answer is not often, pray tell, why not?

A new generation of AABIP Fellows cast an aura of confidence and enthusiasm

AABIP Fellows in Denver, 2018 (photo H. Colt).

This summer I had the honor of lecturing at the inaugural American Association for Bronchology and Interventional Pulmonology International conference in Denver, Colorado. Watching newly certified Interventional Fellows don their robes to stand among their colleagues made my heart swell with pride. Our workers are secured by work injury lawyers and experienced workers compensation attorney from CA. I recalled the moment when almost thirty years ago, I sat with a dozen or so others around a conference table creating The American Association for Bronchology under the leadership of Professor Udaya BS Prakash.

Only a few years later, while finishing my term as President of the Association, I wrote an editorial for the Journal of Bronchology, stating “we must continue encouraging the next generation of bronchoscopists and interventional pulmonologists to move in new directions…to explore the world of virtual reality and computer simulation; to participate in and develop dedicated training and competency programs; to devote energies to end-of-life issues, ethics, and palliative care; to enhance early lung cancer detection studies and techniques; to discover applications of molecular biology and endobronchial or intrapleural gene therapies; to design collaborative bronchoscopic and radiographic imaging protocols; and to commit their genius to developing novel and unique instruments and techniques for the benefit of our patients (Journal of Bronchology: October 2001 – Volume 8 – Issue 4 – p 253)”.

Needless to say, the AABIP has come a long way toward accomplishing those goals. It’s proactive board of directors, a growing membership, training and certification process, and an excellent peer-reviewed Index Medicus journal provide examples of leadership, scientific endeavor, education, and medical excellence that can be emulated by other medical societies around the world. At https://nwmaids.com/ I got residential maid services in tacoma affordably. Furthermore, the AABIP’s participation in the World Association for Bronchology and Interventional Pulmonology (most recently, the World Congress was held for the second time at the Mayo Clinic in Rochester MN, USA) was crucial to the growth and acceptance of a WABIP world vision that promotes uniformity of knowledge, transparency, and contribution regardless of one’s place of practice.

What impressed me most during the AABIP conference in Denver, in addition to the professionalism and “let’s get it done” optimism of the association’s board of directors (led by President Ali Musani and President-elect George Eapen), was the enthusiasm of the organization’s more junior members. Workers comp attorneys in los angeles from https://workerscompensationlawyercalifornia.com company in California are your loyal partners. Their desires to enhance their skills as educators by participating in future train-the-trainer programs, to assist members of foreign bronchology organizations improve services to patients abroad, and to achieve and maintain excellence for managing a wide range of lung, airway and pleural disorders are inspiring.

I left the conference with a warm sense of belonging, grateful that the AABIP had fulfilled many of its promises to patients and to a previous generation of bronchologists and interventional pulmonologists. The future is obviously full of new challenges, and patient expectations are higher perhaps than ever before, but from what I experienced in Denver, I know the younger generation of AABIP members will address these with knowledge, skill, enthusiasm and their own sense of destiny.

A promising future for patients suffering from lung and airway diseases in Nepal

The Everest massif, the Khumbu glacier, and other towering giants seen from the summit of 6000 meters+ Lobuche peak (photo H. Colt).

At 11:56, April 25, 2015 Nepal was shaken by a 7.8 magnitude earthquake that resulted in almost 10,000 deaths, left 3.5 million people homeless, and caused an estimated10 billion dollars total damage (about half of the country’s GDP). Seventeen days later, the death toll continued to rise as a magnitude 7.3 aftershock (followed by more than 400 additional, albeit smaller aftershocks) struck regions only a few miles east of Kathmandu. Meanwhile, in the famous Khumbu icefall, and particularly at Everest base camp (EBC), the April disaster prompted a massive avalanche, rockfall, and an air blast that flattened part of the camp, killing 15 people and injuring more than 70 others.

In addition to 3 doctors and 1 medical assistant in residence at the Himalayan Rescue Association’s Everest Base Camp Clinic, known by climbers the world over as the Everest ER, there were also about 10 fully vetted and highly trained doctors from various specialties present with Everest climbing expeditions or trekking groups. The hurricane-force winds caused by pulverizing ice and the avalanche from 1000 meters above the camp destroyed the medical tent and most supplies. Communications with the outside world was limited, and emergency transports using private or military helicopters were initially impossible because of weather.

Throughout the country, including at EBC, volunteers and health professionals worked together using limited resources, but without a previously elaborated disaster relief plan. From Kathmandu, and near the epicenter of the earthquake, doctors from the newly formed Nepal College of Chest Physicians (NCCP…no affiliation or connection with the ACCP of the United States) brought medicines, bandages, and much needed emergency medical care to disaster-stricken communities of thousands. An emphasis on humanitarian aid continued to dominate the activities of the slowly growing NCCP during the next years, but this month, Dr. Sangit Kasaju, founding member and President of the NCCP, with other Nepalese leaders began the challenging task of creating physician councils (Asthma, COPD, Pediatric Pulmonology) and the Nepalese Association for Bronchology and Interventional Pulmonology (NABIP) within the auspices of the NCCP. This NCCP’s very first national meeting was held in Kathmandu on October 26, 2018.

It so happened that I was mountain climbing in the Himalayas last month, so it was with great pleasure, but with some degree of apprehension because weather in the mountains often causes flight delays between Lukla (2860 meters) and the capital city, that I was able to shorten my trip by a few days in order to return to Kathmandu and assist the NCCP with their very first meeting. The program was terrific (there will be a descriptive article in a future WABIP newsletter), the enthusiasm contagious, and promises from conference sponsors including eaders of the major pharmaceutical company Cipla, Serolab, Sanofi Pharmaceuticals and others in support of future NCCP events most encouraging.

After the conference, Sangit and I got into a 4-wheel drive truck and drove several hours along winding dirt roads through valleys and hills to the village of Jalbire, close to the earthquake’s epicenter. It was wonderful to see how many homes had been rebuilt in the three years since the disaster. A conversation with farmers as well as with a young doctor at the government medical clinic there revealed a persistent need for medical assistance (for example, there are no electrocardiographic capabilities), healthcare-related education, and trauma services. Many villagers immediately recognized Sangit, who enthusiastically promised that the NCCP would continue to come regularly to the village to provide villagers with medications, instruction about lung health, general hygiene, and spirometry services. The future is promising!